Maximize Thyroid Medication

Great timing!  I’m giving a free talk on Thyroid Therapy on Wednesday, May 28th at 6:30pm at Mahaya Forest Hill Integrative Health!  Check out this article for details on how to register!

SynthroidDid you know that Synthroid, prescribed for underactive thyroid, is the MOST prescribed drug in Canada?

Incidentally, Crestor and Lipitor (both statin drugs used to lower cholesterol) were number 2 and 3!  Check out another one of my articles for a Cholesterol reality check.

Now back to thyroid medications…

Thyroid dysfunction, particularly hypothyroidism, is incredibly common, yet poorly understood and hardly discussed.  Your thyroid, that little butterfly-shaped gland at the base of your throat, plays a role in metabolism, fertility, hormone balance, mood, digestion, temperature regulation, heart health, and many more important systems.

Shouldn’t we pay a little bit more attention how we treat it?

This article is about the surprisingly few medications available to treat underactive thyroid (aka hypothyroidism) as well as how to optimize treatment whether you are taking thyroid medication or not.  For a bit of background on types of thyroid dysfunction and thyroid testing, check out my previous article on Decoding thyroid testing.

Levothyroxine: the leading lady

Levothyroxine, also known as Synthroid, Eltroxin, and some other trade names, is first line conventional medical therapy for hypothyroidism and the most prescribed medication in Canada.

Levothyroxine provides synthetic T4 (thyroxine), the primary hormone produced by the thyroid gland.  T4 is the precursor to T3 (triiodothyronine) and is converted to T3 by tissues throughout the body.  T3 (as well as several other thyroid hormones) is also produced by the thyroid gland, but in lesser amounts that T4.

Supplementing only T4 provides the initial hormone to be converted and thus depends on conversion to have effect at the tissue level.  This also also provides feedback to the pituitary gland which produces TSH, thus bringing down elevated TSH found in hypothyroidism.

The correct dose of T4 can normalize TSH levels but may not resolve symptoms of hypothyroidism or resolve the autoimmune process present in Hashimoto’s hypothyroid.  Hashimoto’s hypothyroid happens to be the most most common cause of hypothyroidism, so while levothyroxine normalizes some lab values, it does not address the cause of Hashimoto’s hypothyroid.

Given how common underactive thyroid is, it’s highly likely that you or someone you know is using this medication!  A large percentage of my patients take levothyroxine with results that vary between great effect at reducing symptoms to noticing no change in symptoms compared to no medication.

There are several brands of levothyroxine, and changing brands can significantly affect results and appropriate dosing.  I can’t tell you how many times I’ve had patients switch from branded to generic medication (or vice versa) and notice major differences in symptoms and/or adverse effects, not just with thyroid medications.

Before bed dosing is superior!

Patients are nearly always instructed to take levothyroxine in the morning, but in 2007 group of Dutch researchers completed a pilot study (only 12 patients) that demonstrated that “l-thyroxine taken at bedtime by patients with primary hypothyroidism is associated with higher thyroid hormone concentrations and lower TSH concentrations compared to the same l-thyroxine dose taken in the morning.” (1)

They followed up this study with a larger, double-blinded, placebo controlled crossover study that yielded the same results: “Levothyroxine taken at bedtime significantly improved thyroid hormone levels. Quality-of-life variables and plasma lipid levels showed no significant changes with bedtime vs morning intake. Clinicians should consider prescribing levothyroxine intake at bedtime.” (2)

For those taking levothyroxine, this is something to speak to your doctor about and if you change timing of your medication, ensure you follow up with appropriate testing to ensure the right dose is being prescribed.

Liothyronine: the forgotten middle child

Liothyronine, also known as Cytomel, is a much less common medication used to treat hypothyroidism.  It provides synthetic (triiodothyronine) directly rather than via conversion from T4.

Supplementing T3 has a more direct effect at the tissue level and can normalize TSH levels.  This medication is often used in combination with T4 but this combo does not seem to provide better results that T4-only therapy, so it is not very common.

It is rare that I see patients taking this medication as it is not the typical first-line therapy for hypothyroidism.

Desiccated thyroid: the rising star

Known simply as Thyroid (made by Erfa) in Canada and under several brands available in the United States, desiccated thyroid is the powdered thyroid gland of pigs, providing T4 and T3 as well as additional hormones produced by the thyroid gland (T2, T1, calcitonin).

What’s old is new again!

Desiccated thyroid at one point was the ONLY medication option for underactive thyroid and has been around the longest.

Because it is made from the whole gland, desiccated thyroid is considered a more complete product, providing supplementation of thyroid hormones closest to what would be produced naturally.

Many patients choose this medication after starting with levothyroxine because they prefer a natural product and experience better results in symptom reduction.

Because desiccated thyroid is NOT synthetic and is derived from a natural source that will vary from batch to batch, it is very important to use a reputable brand that is standardized and formulated carefully.  In the United States particularly, there are a lot of products with desiccated thyroid in them, some of which are not standardized and pose a major health risk.

How to maximize thyroid medication

Hypothyroidism is nearly never JUST about the thyroid gland.  Remember how your thyroid is interconnected with so many other systems in your body?  For optimal thyroid health, you must support other key systems:

Immune balance is key

Most hypothyroidism is autoimmune in nature (Hashimoto’s hypothyroid).  In these cases, the immune system is mistakenly damaging the thyroid gland by creating antibodies against it, which impairs thyroid function.

Optimal treatment must include immune support and reduction of this autoimmune process to preserve long-term thyroid function.

Harmonize hormones!

It is common in my practice to see hypothyroidism preceded by years of female hormone imbalance (PMS symptoms, painful periods, irregular periods, fertility challenges, etc).  Many of these hormonal issues are caused by excess estrogen stimulation and estrogen also happens to reduce the efficiency of T4, the major hormone produced by the thyroid gland.

Addressing hormone balance not only prevents many chronic diseases but also improve thyroid function and reduces need for medication.

Adrenal glandsStress less for better adrenal function

There is lots of talk about adrenal glands these days!  Who knew that those little pyramid-like glands that sit on top of your kidneys would ever be so popular?  These little glands are actually powerhouses, producing all kinds of neurotransmitters and hormones that are essential for normal function.

But what most people are interested in is their production of cortisol, the major stress hormone.  Did you know that cortisol decreases T3, the more active thyroid hormone, increases auto-antibody production (the root cause of Hashimoto’s hypothyroid), and interferes with function of the thyroid gland?

Chronic stress means you are constantly flooding your body with cortisol, impeding thyroid function as well as setting you up for lots more disease down the road.  In fact, many hypothyroid symptoms (such as fatigue, depression, low libido, poor memory, weight gain) can ALSO be attributed to poor adrenal function as a result of chronic stress.

Supporting the adrenal glands and reducing stress is therefore a necessary part of any thyroid treatment and can improve the efficacy of medication.

What else can I do?

For more tips on improving thyroid function naturally, check out my article 10 tips for thyroid balance.

Hope to see you my free talk on Thyroid Therapy on Wednesday, May 28th at 6:30pm at Mahaya Forest Hill Integrative Health.  Click here for details on how to register!

Watch my video about how Naturopathic medicine can treat Hashimoto’s Hypothyroidism:


  1. Bolk N, Visser TJ, Kalsbeek A, van Domburg RT, Berghout A. Effects of evening vs morning thyroxine ingestion on serum thyroid hormone profiles in hypothyroid patients. Clin Endocrinol (Oxf). 2007 Jan;66(1):43-8.
  2. Bolk N, Visser TJ, Nijman J, Jongste IJ, Tijssen JG, Berghout A. Effects of evening vs morning levothyroxine intake: a randomized double-blind crossover trial. Arch Intern Med. 2010 Dec 13;170(22):1996-2003.

10 Responses to Maximize Thyroid Medication

  1. Paul January 16, 2018 at 12:16 pm #

    I will leave a reply, there is no “value’s” left in the above article. Knowing Desiccated can vary batch to batch, some people(?) may have the simple problem of non conversion of their T4 to T3. Taking Desiccated can (and does) leave to high of a T4, while T3 is at a level not achieved while taking synthroid (7 adjustment under 2 years)….need to know, how much of each hormone is in 30mg (T1, T2 not included) desiccated thyroid.
    I know the answer is “batch” reliant, however an educated guess would be nice.

    • Dr. Kate Whimster, ND January 22, 2018 at 10:06 am #

      Hi Paul, for information about the levels of T4 and T3 in dessicated thyroid medication you would need to contact the pharmaceutical company directly. In Canada, ERFA is the company that manufactures the only dessicated thyroid product, simply called Thyroid.

  2. Tanya January 19, 2018 at 9:30 pm #

    If one has low functioning adrenals which in turn pull down thyroid …..should both be treated ? I’ve tried treating adrenals alone but my thyroid still remains sluggish which has led to leaky gut, food Sensitivies, insomnia, gut dysbiosis, high cholesterol, stopped period etc. Two years later and still hypo thyroid …..
    My doctor did give me ERFA NDt – BUT I read If adrenals are weak it can be hard to take NDt optimally.

    I worry because I have been hypothyroid for so long that the NDt won’t work or will make me worse.

    Do you have thoughts on this, thank you

    • Dr. Kate Whimster, ND January 22, 2018 at 10:07 am #

      Hi Tanya, treating adrenal dysfunction is frequently helpful in improving thyroid function but it depends on the individual case. I cannot advise on your case as you are not my patient, so I recommend you seek diagnosis and treatment with a Naturopathic Doctor in your area who can address your individual concerns with a personalized treatment plan. Good luck!

  3. Linda February 12, 2018 at 9:26 am #

    Hi Tanya, my doctor prescribed Erfa NDT eight months ago, 30mg . Since starting them l now have hip, knee and back of thigh pain. I also have increase in sweating, sinus headaches. The more she increase my thyroid medicine the more pain. I am unable to take at night because they cause insomnia in me. I eat healthy mostly Paleo.I have ween off thyroid medicine and pain ,sweating goes away, back on them pain back again. Am l missing something here? Have you any suggestions . Thank you.

    • Dr. Kate Whimster, ND April 27, 2018 at 9:19 am #

      Hi Linda, I highly recommend you pick up the book Hashimoto’s Protocol by Isabella Wentz which should provide you with some guidance on how to assess your situation and what medication may be right for you!

  4. Tam Kaczor May 31, 2018 at 6:04 pm #

    Hello. I live in the US and would like to know if I am able to get ERFA NDT from Canada as it is not available here for over 3 months now and it’s the only treatment that works well for me. I had a total thyroidectomy back in 2009 and have been on Synthroid and Levo and they didn’t work well for me. I started on Thyroid 90, increased to 120 and 90 alternating for several years and 12 months ago was increased to 180. Now it’s not available and I am taking Nature Throid for a month. I am already seeing the decline. Thank you very much.

    • Dr. Kate Whimster, ND June 1, 2018 at 7:49 pm #

      Hi Tam, I recommend you speak to your doctor and/or pharmacist about medication options for you in the US. I am not aware whether ERFA Thyroid is available outside of Canada.

      Good luck!

  5. cindy long January 25, 2021 at 11:35 am #

    HI Dr. Kate. I am on 100 mg of ndt med every other day as I had a partal thyroidectomy but the muscle and back pain is intense. my blood levels are perfect but when I lower the dose to every third day I feel so much better. is there anything else you can give me to raise my t4 but not cause back pain if I lower my dose? I am in Ontario Canada

    • Dr. Kate Whimster, ND January 28, 2021 at 8:21 am #

      Hi Cindy, I’m sorry to hear you are having pain! My first recommendation is that you speak to the prescribing doctor to review your labs and symptoms and he or she may recommend adding T4 only medication or changing medication. As an ND I can work with you on optimizing thyroid health with what thyroid tissue remains as well as on your specific health concerns.

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