Hypothyroidism - why am I not feeling better?

Hypothyroidism occurs when the thyroid gland doesn’t produce enough thyroid hormones, causing symptoms like fatigue, weight gain, depression, and cold intolerance.

While treatment often brings relief to many people, some may continue to struggle with symptoms despite following their prescribed regimen. Dr Abbi Lulsegged, distinguished consultant physician in general medicine, endocrinology, diabetes, and metabolism, explores the reasons why.

What is the treatment for hypothyroidism?

The primary treatment for hypothyroidism is thyroid hormone replacement therapy. The most commonly prescribed medication is levothyroxine, a synthetic version of thyroxine (T4), one of the hormones the thyroid naturally produces. Levothyroxine works to restore hormone levels and alleviate symptoms.

Patients typically notice improvements within 2 to 4 weeks of starting treatment, though some may take several months to feel the full effects. In some cases, patients may experience persistent symptoms.

Why don’t I feel better even after starting treatment?

There are several reasons why you might still feel unwell despite adhering to your prescribed thyroid hormone therapy.

Problems with the gut

The gut is crucial for the absorption of levothyroxine. Conditions such as coeliac disease, inflammatory bowel disease (IBD), or Helicobacter pylori infection can interfere with how your body processes the medication, reducing its effectiveness. Food intolerances such as gluten and dairy can also affect absorption, as can disorders of stomach acid production.

There is increasing recognition of disturbances in the gut microbiome (the balance between “good” and “bad” bacteria) that can contribute to autoimmune conditions as well as persistent symptoms.

Problems with the dose

Finding the right dose of levothyroxine is a delicate process that requires fine-tuning. Too little hormone can leave unresolved symptoms, while too much can lead to side effects like palpitations or anxiety. Additionally, interpreting blood test results can also involve nuances and limitations.

Regular monitoring of TSH (thyroid-stimulating hormone) levels and free hormones are useful to ensure the dosage remains optimal for your current health status, taking into account factors such as age, weight, and other medications.

Associated conditions

Symptoms like chronic fatigue, weight gain, and depression aren’t exclusive to hypothyroidism. Conditions such as anaemia, vitamin D or B12 deficiency, and sleep apnoea can mimic these symptoms or worsen their intensity.

Similarly, recurrent infections, problems with the adrenal axes, and autoimmune conditions like lupus or rheumatoid arthritis often coexist with hypothyroidism and can contribute to ongoing symptoms.

Problems with the medication regime

Even if the dose is correct, issues with the timing and administration of levothyroxine can impact its effectiveness.

Ideally, the medication should be taken on an empty stomach, at least 30 minutes before breakfast or at least 4 hours after the last meal. Calcium supplements, iron tablets, and high-fibre foods can interfere with absorption and should therefore be avoided around the time you take the medication.

In some cases, patients may also not tolerate levothyroxine well. This can occur in people who, for instance, have genetic problems converting T4 to the active, T3. In these situations, alternatives like combination therapy with T4 and T3 (triiodothyronine) or natural desiccated thyroid extract may be considered.

How often should my TSH levels be tested?

When starting treatment or adjusting your dose, TSH levels are typically tested every 6 to 8 weeks until they stabilise. Once your levels are within the target range and you’re feeling well, testing is then recommended every 6 to 12 months.

More frequent testing may be necessary during pregnancy, after significant weight changes, or when starting new medications that could affect thyroid function.

When should I consider changing treatment?

You might want to consider revisiting your treatment plan if you have adhered to your medication regimen but continue to feel unwell after 6 weeks - 3 months.

If you would like to book an appointment with Dr Abbi Lulsegged, head on over to his Top Doctors profile today.