Hypothyroid treatment options: Is Synthroid Your Only Choice?

Ok, so you’ve been diagnosed with Hypothyroidism or Hashimoto’s thyroiditis. 

Perhaps this just happened or maybe you’ve been living with and managing thyroid disease for years or even decades.

What do you do now?

If you’ve had hypothyroidism for years and feel like it’s well managed, you simply need to have a yearly blood check (review the full panel to ask for!) to make sure the medication(s) you are taking are still appropriate and doses don’t need to be adjusted.

If you’re new to this rodeo OR you have had hypothyroidism and are on medication but have never really felt any difference with the treatment you were prescribed, here we go:

What are my treatment options for hypothyroidism/Hashimoto’s?

  1. Medication:

I don’t typically think of thyroid medication as first step therapy, unless a woman is trying to get pregnant or already pregnant or breastfeeding, but I know it’s by far the most common treatment option given so I wanted to discuss your options here first.

The medications available are all, with one exception, replacing the thyroid hormone your body is struggling to make.

Here’s how it works in the body:

Your brain makes TSH (thyroid stimulating hormone) which, aptly named, stimulates the thyroid gland to make mostly T4 and a bit of T3. T4 is then circulated through the bloodstream where it is converted to T3 hormone. 

While both hormones have big actions in the body, T3 hormone is the more active player. It’s important that your body has both.

Both T4 and T3 send signals back to the brain to either turn up the volume on TSH production (which translates to your body needing MORE medication) or to turn it down (which can mean you need LESS medication). 

I like to think of TSH as a volume control. The HIGHER it is, the LOUDER your brain is having to communicate to your SLOW thyroid to make hormone. Your hormone production is SLOW or LOW when TSH is HIGH. And, the MORE thyroid hormone you make or take as medication, the LOWER the TSH will be. It can become too low, which tells your provider that you need LESS medication. 

That can be confusing, but the summary is this:

  • High TSH = low T4 and T3 hormones being made/taken
  • Low TSH = high T4 and T3 hormones being made/taken 

I think it’s important to understand the very basics of thyroid hormone production because it relates to your medication options, which are outlined below.

  1. Levothyroxine = Levothroid = Levoxyl = Synthroid = T4 hormone.

This is, by far, the most common thyroid medication prescribed. It is one of the most common meds prescribed in general, on many Top 5 lists for all pharmaceuticals together. When prescribed correctly and monitored well, it is an extremely safe medication. 

Your body takes in the T4 hormone replacement and should convert it to T3 hormone.

Your body should then tell your brain to make less TSH. 

You should see TSH levels come down to ideal values.

Your Free T4 and Free T3 lab values become ideal.

You should feel better! 

  1. Liothyronine = Cytomel = T3 hormone

I don’t see Cytomel prescribed as frequently by my conventional primary care colleagues in the Seattle area, but I have noticed endocrinologists recommending this med occasionally, and I do as well. 

Why? Some people’s bodies don’t convert T4 hormone to T3 hormone well. 

These folks may be deficient in some nutrients (zinc, selenium) or genetically they may just not be efficient at it.

In these women, using T3 in addition to T4 allows the body to give the proper signals to the brain to lower TSH.

Subsequent lab checks for TSH, Free T4 and Free T3 should show ideal ranges, as previously discussed.

You should feel better!

Bummer: of all the hormone medication options, I see Cytomel (T3) being the most irritating to women’s bodies. Even when labs look good/normal/better, women frequently report heart palpitations and hair loss. I don’t use it much for these reasons. Many women do really well with the addition of Cytomel, I’m just always cautious about adding it. 

In some practices, providers will use higher doses of Cytomel alone. This is called the Wilson’s Protocol. I don’t follow this protocol in my practice for the reasons I mentioned above.

  1. Nature-throid & Armour thyroid & NP thyroid = glandular thyroid 

These are all medications containing both T4 and T3, sourced from pig thyroid glands.

Say what now? It’s true, these are pig gland medications. They are available at your conventional pharmacy. 

Some people believe these are more natural because they come from an animal and are not made in a lab. I don’t think of this medication in this way. It’s still manufactured in a lab. It is still hormone replacement.

So, what’s the difference? The medication contains BOTH T4 and T3 in one pill. That can be great for minimizing the amount of medications you take per day. It also has slightly higher amounts of T3 than T4 and some bodies do really well with that. In my experience, women seem to tolerate the T3 in these gland therapies better than Cytomel. 

Because all pigs are unique (just like us!), the amount of thyroid hormones in each batch of glandular medication varies. Some bodies do fine with that variability. Others really do not and we can see wild changes in lab results and patients report feeling over or understimulated from batch to batch.  That is certainly not every woman’s experience, but it does happen.

I’ve noticed that all of these medication options are just that: OPTIONS for managing hypothyroid and Hashimoto’s. I have not seen one-size-fits-all with any of these. I respectfully disagree with the providers that believe there is one medication that is best for all women with thyroid disease. 

Because it’s the most simple and well tolerated, I usually have women start Levothyroxine (T4). This allows us to not only see how she feels on the new medication but also to track how her body is converting the T4 to T3. If she needs T3, we can talk about Cytomel or a change to Armour or Nature-throid.

  1. Low dose naltrexone (LDN) 

Last but not least, LDN is a compounded medication that can decrease thyroid antibodies in Hashimoto’s thyroiditis (and perhaps in other autoimmune diseases).  You have to have this prescribed by your provider and made at a special pharmacy in the ultra low doses that are effective (1.5-4.5mg).

Naltrexone in its standard dose of 50mg (or more) is a medication that is used in helping people overcome alcohol and opiate addictions. It is an “opiate antagonist”, which means that it works by blocking the activation of opioid receptors. Instead of controlling withdrawal and cravings, it treats opioid & alcohol use disorder by preventing any opioid drug or alcohol from producing rewarding effects such as euphoria.

In smaller/low doses of Naltrexone, the body’s endorphins are released. These endorphins have an effect on the immune system that decreases inflammation and the production of antibodies against the self. It’s pretty cool! I have a very small handful of women managing their Hashimoto’s on this medication alone.

It can have uncomfortable side effects, so I don’t prescribe it very much. Women report sleep disruption, nightmares and headaches. I work with many perimenopausal and menopausal women who are already struggling with these symptoms and very few are willing to make things potentially worse.

It can also cause nausea and worsen constipation or diarrhea. 

LDN is typically started at 1.5mg and titrated up every 1-2 weeks by 1.5mg until the therapeutic dose of 4.5mg is reached.

  1. Eat well 

In my practice I see diet being less of an issue with pure hypothyroidism versus Hashimoto’s. That said, generally a healthy diet is the best course for any chronic disease management. What’s a healthy diet? I like Michael Pollen’s recommendation, “Eat real food. Not too much. Mostly Plants.”

I am a fan of the Mediterranean Diet and appreciate the food pyramid associated with that style of eating.

Now, with Hashimoto’s, which is driven by an inflammatory process in the body, I find it important to dig a bit deeper. I FREQUENTLY see foods creating inflammatory (re)actions in the body and they may not always be the foods you might think. That said, my recommendation is to follow an anti-inflammatory diet approach like the Whole 30 or Autoimmune Paleo diets and then test thyroid antibodies to see if they’ve changed. How long do you need to follow a diet like this? That varies per person, but I’d wait at least a month, if not 2-3 months.

If these extreme diets seem too extreme, then start with the more common inflammatory food: you guessed it, gluten.  As mentioned in previous posts, if you have Hashimoto’s, you have a higher risk of Celiac disease, the extreme autoimmune intestinal reaction to gluten. Before eliminating gluten from your diet, have your provider screen you for Celiac disease!

  1. Manage your Stress

Part of managing any chronic disease or condition *should* involve a focus on managing stress levels. I encourage women to think about rating their stress regularly, in order to do a self-check: on a scale of 1 – 10, how stressed are you now? If you give yourself a rating higher than a 5, I encourage you to think about what you can change to either lower the demands on you (say “no” more, end toxic friendships/relationships) OR experiment with different stress coping skills until you find ones that work for you to do DAILY. Ideas:

  • Deep breathing for 5 minutes 
  • Guided meditation for 5-10 minutes daily (apps I like: Calm, Shine, Insight Timer, Head Space)
  • Put your devices away & observe what’s around you
  • Play with your kids
  • Take a date night with your partner
  • Craft/draw/knit/sew/paint
  • Relaxing (yin) yoga for 10-20 minutes
  • Warm bubble bath with 10 drops of lavender essential oil
  • Read fiction 
  • Take a walk outside
  • Take a walk with friends
  • Call a close friend or family member

Why is it important to keep stress in check? When your mind and physical body are stressed it creates a cascade of hormonal changes that can slow the thyroid down and make the autoimmune response worse. It can be much harder to manage your thyroid disease when stress is unregulated. Plus, you’ll be more fun to be around!

  1. Use Natural Therapies
  • Nutrients

I encourage women to have their zinc, selenium, iron and vitamin D tested. Supplement if needed to bring values up into the high end of the normal range. If a woman is low in these nutrients, I will often wait to adjust medication doses until the nutrients have normalized. Frequently, thyroid hormone production improves when these nutrients are in ideal ranges.

If you have a pure hypothyroidism (no Hashimoto’s antibodies are present), it’s important for you to avoid goitrogens. Goitrogens are foods that decrease thyroid hormone production by interfering with iodine uptake. When not enough iodine is available, the thyroid cannot produce sufficient levels of thyroid hormones T4 and T3. The brain senses the low T4 hormone and produces more TSH. The thyroid gland responds to TSH by making more hormones, but if it can’t keep up with demand, the thyroid grows bigger. A swollen thyroid gland is called a goiter. 

  • Goitrogenic Foods:
  • RAW Cruciferous vegetables: kale, cabbage, broccoli, turnips, brussel sprouts,radishes, collard greens. NOTE: cooking cruciferous veggies decreases the goitrogenic content. **These are such a healthy veggie family that I encourage you to NOT stop eating them, just cook them a little bit before enjoying them.
  • Cassava, lima beans, sweet potato, sorghum, soy, millet 

Interestingly, new studies show by blocking iodine uptake, goitrogens are actually beneficial to those with hashimoto’s thyroiditis. Lowering iodine levels lowers the antibody activity within the thyroid gland. Goitrogenic foods have also been found to increase levels of the antioxidant glutathione, which lowers oxidative stress in the gland to slow the rate of destruction of the thyroid cells.

  • Iodine 

This essential mineral is vital to proper thyroid hormone production.You need small amounts for normal function, but many of us are deficient.  Your body can’t make it, so you must get it through your diet or supplementation. There aren’t great tests for iodine deficiency, so I’ll recommend women regularly incorporate iodine containing foods into their diet. These include:

  • iodized salt, seasoning mixes with iodized salt and onion salt or garlic salt made with iodized salt
  • seaweed (kelp, nori, kombu, wakami)
  • food additives: carrageen, iodides, alginates, iodate
  • egg yolks
  • most seafood except fresh-water fish

It’s important to get enough iodine but not too much. There are iodine replacing protocols that use milligram (mg) doses of iodine when the body only needs around 200 MICROgrams (mcg). Mega doses of iodine can worsen hypothyroidism and autoimmune Hashimoto’s. Balance is key.

  • Herbal therapy

Ashwagandha: this Ayurvedic stress adaptogenic herb has been shown in at least one study to increase triiodothyronine (T3) and thyroxine (T4) levels by 41.5% and 19.6%, respectively, and reduce serum TSH levels by 17.4% from baseline. That’s significant! The dose in the study was 600mg per day, and I usually recommend this dose. You can safely take up to 1000mg per day. BONUS: taking it at bedtime may improve sleep quality. DOUBLE BONUS: it is an adrenal hormone adaptogen, meaning it normalized your body’s response to the stress hormone, cortisol!

  1. Avoid toxins

More and more research is showing a correlation between common toxins in our environment and disease risk. Hypothyroid is one such condition. The chemicals we know affect the thyroid gland are:

  • Flame retardants = organohalogens
    • Furniture, some children’s clothing, children’s toys
  • Alkylphenols
    • Personal care products (shampoo, lotions, cosmetics), detergents, cleaning products, paints
  • PFAs/PFCs = Poly- and perfluoroalkyl substances and perfluorinated ompounds
    • Found in textiles, food packaging and firefighting foam
  • Phthalates
    • Personal care products (shampoo, lotions, cosmetics), food packaging, soft plastics, vinyl flooring, vinyl products, old toys

WOW. These chemicals are everywhere. What’s a gal to do? Do your best. Reduce your exposures to these chemicals. Use the Environmental Working Group’s wonderful catalogue of databases to help you find safer options for you and your family:

How often should I get tested?

 When you first start thyroid medication and each time you change the dose, you’ll want to get retested again in 6-8 wks. This is the length of time it takes your body to assimilate the medication and for labs to change. 

Once you’re on the best dose of medication or the best natural treatment regimen, you’ll want to get tested at least annually.

Have more questions? Want to work together to optimize your health and thyroid? Call or email the office and schedule a telemedicine visit. If you live in Washington state, your insurance may cover our visit!

Stay well!

Email me with questions: perimenopausenaturally@gmail.com

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PMSing through Perimenopause

I wrote before about what’s happening with the two major hormones in a normal monthly menstrual cycle. Estrogen is the Queen of the first two weeks (when the period starts to ovulation), and Progesterone is Queen of the second two weeks leading up to the next period (the classic PMS time). This hormone is the first to get wonky and trigger many perimenopausal symptoms.

Why? Our bodies have a set number of eggs at birth. This number drops steeply at puberty and then decreases each month with ovulation until there are no eggs remaining and a woman is in menopause.

As we age, not only does the number of eggs we have decrease but also the quality of the eggs declines. What does that mean? Remember that we make progesterone after ovulation? If the eggs we are ovulating as we age are less healthy, we make less progesterone. This is one of the first changes in perimenopause. Progesterone levels start to decline in the 2nd half of the menstrual cycle. This creates a natural state of “estrogen dominance”, something many of my patients are curious about. I tell all women over 35 that they are almost positively estrogen dominant. There’s no need to test this in most women; it’s the natural state of affairs in early perimenopause.

This lowered progesterone during this time translates to heightened PMS symptoms for many women. PMS symptoms vary woman-to-woman in intensity and severity and length of time. Most women think of PMS as being the increased emotional sensitivity right before a period, but PMS technically includes ANY symptom that occurs in that 1-2 weeks prior to a period and goes away once the period comes. Common symptoms are breast tenderness, fatigue, headaches, bloating, cramping, intense cravings, insomnia, night sweats, acne. What an awesome way to feel…

PMS tends to increase in length for many women during perimenopause, sometimes starting immediately after ovulation and lasting the full 2 weeks before the next period.

Many women I work with experience most of the symptoms I mentioned for the full 2 weeks of the month– Yuck! These women feel terrible half of the month. Their period starts and PMS symptoms finally go away (hooray!), but then many struggle with extremely heavy bleeding and intense cramping and more headaches. Lots of women I talk to have a few days after their periods in which they feel their best. This is crazy! Many of us only feel well for 1-5 days per month.

Listen, ladies: This is common but is NOT normal! You do NOT have to live like this.

What to do?

  1. Sleep—this is a priority. This is your number one goal. Start your efforts here if you are not getting at least 7 restful hours each night. If so, move on down the list.
  2. Manage your stress—you are more sensitive to stress and it’s impact on another hormone called Cortisol. This hormone is HUGE and deserves it’s own post, so stay tuned.
  3. Eat well—what does that mean? Well, this is another big can of worms and a big part of my healing philosophy so we’ll spend whole posts on it for sure! The big picture: plant-based diet, lots of healthy fats (think avocado, grass-fed butter, coconut oil, nuts & seeds), whole foods, minimal to no processed foods, minimal to no sugar (right when you want them the most, I know, I’m mean), very little if any alcohol, very little if any caffeine.
  4. Are you still reading?
  5. Exercise—more is not always better, but try to move your body daily. Walking, stretching and yoga are perfect starts. Try to find a buddy to make it more enjoyable, keep you motivated and committed, and give you some girlie time to get stuff off your chest. This is an important daily routine, but is also SO helpful during those PMS days. You may find it feels best to go for longer & slower walks, jogs and swims rather than shorter more intense workouts during the PMS phase.
  6. Keep track of your cycles and your symptoms. There are many, many period tracker apps out there. My favorite for simple tracking (not for fertility purposes) is Clue (it’s free!). Look around, though, and find what works for you. The benefit of these apps is that you can start to see patterns and understand if certain symptoms are cyclical or hormonal. They are also excellent for reminding yourself that when you start to feel the PMS symptoms start, they are temporary and will be leaving soon(ish). Many trackers can send you reminders that PMS may be starting, once the app has a good history of the symptoms you enter each month. I cannot downplay the benefit of this knowledge. Many women tell me they feel crazy for days, they don’t know why, they get their period and feel better and then think, in retrospect, “Oh! I had PMS, that’s why I felt terrible!”. Knowing in advance gives you a little bit more control of the situation; this control and knowledge is very powerful and can prevent the PMS from taking over your decision-making processes.

If you’re doing all of these and feeling confident about your efforts and still struggling, or find yourself so stuck in the PMS haze that you can’t find the energy to make the efforts, it may be helpful to try a few supplemental nutrients.

  1. A high quality, food-based multivitamin: All multis are NOT created equal. I recommend the food-based brands like Garden of Life/Vitamin Code, Rainbow Light and New Chapter, because the nutrients are sourced from fruits & veggies (and organic versions are available and preferable). The nutrients from food are readily absorbed and used by the body, minimizing the extra steps needed to activate them or make them useful. This means you actually absorb the vitamins and minerals instead of peeing them out. I recommend finding the Women’s formula specific to your age range, too (that may mean a prenatal).
  2. A high-quality fish or krill oil: I recommend we each get a total of 1000mg per day of EPA and DHA combined per day. More may be better, especially if you struggle with more mood change with PMS.
  3. Magnesium citrate or glycinate: This mineral is amazing! It is needed to relax muscles, it calms the brain, improves sleep, promotes bowel regularity and decreases PMS symptoms. You cannot get a toxic dose orally. If you take too much, your stools will be looser and you may have some abdominal cramping. I recommend taking this to “bowel tolerance”; in other words, take as much as your body can tolerate without causing diarrhea (the glycinate form is easier on more sensitive bellies). This is usually in the range of 300-600mg. Take it at night to promote a blissful slumber.
  4. Vitamin D3: I do recommend having your Vitamin D levels tested. Optimal is to be in the 60-80 range, but normal is above 30. If you live in the Pacific Northwest, I recommend 4000iu daily. You DO want to have levels monitored, as excess levels can increase your risk for kidney stones.
  5. Vitamin B6: This B-vitamin is a necessary precursor or ingredient in making many hormones in the body, including serotonin (the happy brain hormone) and progesterone. Levels are depleted with long-term oral contraceptive use and are often low in women with PMS. Start with 100mg each morning with food; better yet, take it with the other B-vitamins as part of a B-complex. I like the B6-Complex from Pure Encapsulations. You CAN get too much B6, so be careful—it can cause numbness and tingling in the hands and feet.

If you are trying these recommendations and not seeing results after at least 3 months, it’s time to get more aggressive. This could mean lab tests for hormones and nutrient deficiencies, or experimental diets to uncover food sensitivities, or the use of more specific herbal therapies, etc. See your local naturopathic physician for more individualized care recommendations! Find a naturopath in your area here.


No, I don’t have PMS. I’m just a b*tch

Michelle Wolf

 I know that’s a racy way to end this post, but I love the subtext of what Michelle is saying here (she’s a very funny comedian I’ve seen periodically on The Daily Show with Trevor Noah). More often than not, girls and women are taught to be kind, sweet and submissive and we are rewarded for being so. Being bold, aggressive and questioning others is not and the thought is that a woman must have PMS when she behaves this way. Let’s all be b*tches, I say!

Biology of a Cycle, the short-short version

There are major hormone changes happening in perimenopause. Let me back up. There are major hormone changes happening constantly in a woman’s body from puberty through menopause. Our bodies get in to a nice rhythm once periods are regular, sometime in our teens to our early 30’s on average. For most women, periods are a monthly hiccup where the daily routine changes a bit for a few days but we march through and go about our business. Please know that I’m talking about the majority of young women who have normal cycles. I see women every day in clinic that struggle with their cycles; they are a huge upheaval in their lives and a major challenge each month. I’m not talking about these women right now. Most young women find their cycles to be an annoyance and nothing more (and that, perhaps, is a topic for another discussion!).

In a normal cycle, you have two distinct phases. The whole cycle lasts on average about 28 days, with each phase lasting 14 days. There is huge variability here. A normal cycle can be anywhere from 21 to 35 days long, which would make the 2 phases more variable in length. Almost always, the second phase is 12-14 days, which means the first phase is usually the one that is longer or shorter. Anyway, the take-home point is there are 2 phases of a menstrual cycle.

The first phase is called the Follicular phase. Day one of your cycle is the first day you have a normal bleed (spotting doesn’t count!) and the first day of this phase. At the same time you have your period, your ovaries begin again to get ready to ovulate an egg. An egg follicle starts to mature and is typically ovulated or hatched around the 14th day of a normal cycle. Again there’s variability here. A healthy ovulation occurs between days 11 -17 of a cycle and usually depends on how long the full cycle is. Many hormones are involved in the menstrual cycle but the main player here is Estrogen.

Once an egg is ovulated, the 2nd phase begins. It’s called the Luteal phase. The shell of the egg, called the corpus luteum, sticks around for a while and makes a hormone called Progesterone. It’s the main player of the luteal cycle. If there is no pregnancy, the luteum gets smaller and smaller, the body makes less Progesterone and it signals another period to happen. The whole cycle then begins again.

I’ll come back to this biology lesson frequently in future posts. These two phases and the changes that occur with them as we age are key in understanding perimenopause and its symptoms.