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Unresolved Hypothyroidism Symptoms in Treated Patients

What should you do if you’re being treated for hypothyroidism but you still have symptoms?
Unresolved Hypothyroidism Symptoms in Treated Patients
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Hypothyroidism, a common condition characterized by an underactive thyroid gland, can usually be managed with medication to replace the deficient thyroid hormone. While the majority of hypothyroid patients experience an improvement in their symptoms with standard treatment, some patients still have persistent symptoms despite being treated with thyroid medication and normal thyroid function!

If you’re being treated for an underactive thyroid gland, but you still have frustrating hypothyroid symptoms, what could be the reason? What proactive steps can you take to address those symptoms and ensure effective management of your condition? In this article, we explore those questions and provide some practical things you can do to feel your best.

Improper medication absorption

Thyroid hormone replacement medication can be difficult to absorb, affecting your thyroid hormone levels and hypothyroid symptoms. Ideally, these drugs need to be taken on an empty stomach, and various factors can interfere with absorption. These factors include:

  • Other hormones like estrogen and progesterone can bind to thyroid hormone and prevent absorption.
  • The pharmaceutical formulation of your medication can affect absorption. Liquid gel capsules and liquid forms of levothyroxine are best absorbed, while tablets, especially when coated, can slow or impair absorption.
  • Eating too close to taking your thyroid medication can impair absorption. Ideally, take your thyroid medication on an empty stomach and wait at least an hour before eating.
  • The timing of your thyroid medication can also affect absorption. Medication taken at night tends to be better absorbed than medication taken in the morning.
  • You have a gastrointestinal disorder that’s causing malabsorption. Conditions such as celiac disease, gastritis, lactose intolerance, and ulcer (Helicobacter pylori infection) may impede the absorption of levothyroxine, the standard medication for hypothyroidism.
  • Your foods and drinks are interfering with absorption. If you drink coffee too close to your thyroid hormone therapy, it can impair absorption. Wait at least an hour between taking your thyroid drugs and drinking coffee. Other substances that can interfere include calcium-fortified juice, calcium and iron supplements, and proton pump inhibitor (PPI) drugs. These should be taken from 3 to 4 hours apart from thyroid medications.

Dosage too low

If you still have symptoms despite treatment, your dosage of thyroid hormone replacement therapy may be too low. A complete thyroid test panel – including Thyroid Stimulating Hormone (TSH), Free Thyroxine (Free T4), Free Triiodothyronine (Free T3), and Thyroid Peroxidase Antibodies (TPOAb) – can determine whether your dosage needs to be adjusted.

“Normal” but not “optimal”

Normal thyroid levels fall within a reference range based on the average values of a tested population. This reference range has an upper reference limit and a lower limit, and everything within that range is considered “normal.” The levels don’t, however, consider your clinical picture. Instead, it’s an average of other adults in your area. You can have levels within that normal range but still experience symptoms of hypothyroidism because your levels are not optimal. Optimal thyroid function is defined as the level within the normal range where you also have improved – or resolved – symptoms. Learn more about optimal thyroid levels and dose adjustments in this Paloma article.

Not taking medication regularly

Doctors call it non-compliance or non-adherence. But in plain language, it means you’re not taking your daily doses of thyroid medication regularly as directed. Surprisingly, researchers estimate that only 15% to 40% of patients show “high adherence” to their treatment for hypothyroidism and take their medication regularly.

You may miss taking your thyroid medication due to various reasons such as forgetfulness, a change in routine, or being unable to take it with food or other medications. However, it is crucial to take the medication consistently as prescribed, at around the same time daily. Missing doses can lead to a range of undesirable effects and persistent hypothyroidism symptoms. It’s crucial to adhere to your medication schedule and talk with your healthcare provider if you have difficulty in doing so to ensure the effective management of your condition and relief of your symptoms.

Symptoms from other conditions or medications

Many patients with hypothyroidism may also have other chronic conditions, and there may be overlap in the symptoms associated with these conditions. For example, various autoimmune conditions may be associated with symptoms such as fatigue, waking up unrefreshed, cold intolerance, and brain fog. Weight gain can be due to pre-diabetes, insulin resistance, or metabolic syndrome. Low sex drive may be due to the use of certain antidepressant medications. This is why regular and open communication with your healthcare provider is so crucial: They can help determine the best way to assess and resolve persistent symptoms.

T4 to T3 genetic conversion factors

Genetic factors are associated with persistent symptoms in some hypothyroid patients who are receiving treatment. These factors include defects in thyroid hormone supply, thyroid hormone metabolism, transport problems, deiodinase variants, and impaired T4-to-T3 conversion. Genetic testing can help determine if you have any of the genetic factors associated with continued symptoms of hypothyroidism.

T3 levels are too low

Some hypothyroid patients have a relative deficiency of triiodothyronine (T3), the active form of thyroid hormone, despite having normal TSH levels. For these patients, adding a synthetic liothyronine (T3) drug like Cytomel – or a switch to natural desiccated thyroid (also known as desiccated thyroid extract) – may better relieve symptoms. Paloma has a comprehensive article to help you determine if you might benefit from treatment with T3.

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Chronic depression or anxiety

Hypothyroidism can cause depression, low mood, or anxiety. In some thyroid patients, however, the causes of depression and anxiety can be multifaceted, involving a combination of genetic, biological, environmental, and psychological factors. Some of the common causes of depression and anxiety include:

  • Genetic Factors: Having blood relatives who have had depression or anxiety can increase the risk of developing these conditions.
  • Biological Factors: Changes in brain chemistry, disruptions in neurotransmitters, and alterations in the areas of the brain responsible for mood regulation can contribute to depression and anxiety.
  • Environmental Factors: Traumatic or stressful events such as abuse, the death of a loved one, financial problems, or major life changes can be significant triggers for depression and anxiety.
  • Psychological Factors: Personal conflicts, social isolation, and chronic illness can also play a role in the development of depression and anxiety.
  • Other Factors: Gender, age, certain medications, and other chronic illnesses can also influence the risk of developing depression and anxiety.

Lack of sleep

Most healthy adults need at least seven hours of sleep each night for good health. The recommended amount of sleep for adults is in the range of 7 to 9 hours per night. If your persistent symptoms include fatigue, brain fog, and cognitive impairment, you may need the upper end of the range to help resolve these symptoms.

Hashimoto’s or another autoimmune condition

Conditions like Hashimoto’s disease, an autoimmune condition that causes hypothyroidism – as well as other autoimmune diseases – can lead to persistent symptoms despite treatment, including fatigue, weight gain, and constipation. Other common symptoms of various autoimmune diseases include:

  • Joint pain and swelling
  • Skin problems
  • Abdominal pain or digestive issues
  • Dizziness
  • Headaches
  • Anxiety and depression
  • Confusion and difficulty thinking
  • Insomnia
  • Memory issues
  • Muscle aches
  • Redness, heat, pain, and swelling in the body

Your practitioner may conduct additional evaluation and tests, including tests for thyroid antibodies, to rule out the possibility that you have Hashimoto’s or another autoimmune condition.

Out of range iodine levels

Too little or too much iodine can worsen hypothyroidism. Too little iodine can lead to hypothyroidism, while too much iodine can make hypothyroidism worse in people who already have the condition. You can learn more about iodine in this detailed article at the Paloma blog.


Dehydration can exacerbate hypothyroidism symptoms or cause hypothyroidism-like symptoms to worsen. When dehydrated, your body may experience high histamine levels, leading to symptoms such as fatigue, dry skin, temperature sensitivity, and mental health changes, which are similar to those seen in untreated or undertreated hypothyroidism. Additionally, dehydration can cause an increase in cortisol production, which can stress the adrenals and have a negative impact on the thyroid. Research has also shown that hydration status can complicate getting the correct dose of thyroid medication, with TSH levels being higher in those who are dehydrated compared to those with optimal hydration status. Therefore, people with hypothyroidism need to maintain proper hydration to help manage their symptoms effectively.

Hormonal imbalances

Hormonal imbalances can significantly affect hypothyroidism symptoms. For instance, excess cortisol and low thyroid hormones can contribute to symptoms such as obesity. When thyroid hormones are out of balance, you can experience symptoms such as fatigue, changes in weight, altered vision, dry skin, and fluctuations in heart rate. Additionally, lifestyle habits and other hormonal imbalances, such as those affecting sex hormones like estrogen, progesterone, and testosterone, can also impact hypothyroidism symptoms. It’s essential to be aware of these potential effects and work closely with your healthcare provider to manage your condition effectively.

A note from Paloma

The management of hypothyroidism can be complex, with various factors contributing to continuing symptoms. However, as a Paloma Health member, you can benefit from personalized care, comprehensive testing, thyroid hormone therapy, and ongoing support, all essential in optimizing your treatment and resolving persistent symptoms. With Paloma’s patient-centered approach and specialized expertise, you’ll be empowered to take control of your health and well-being, ensuring that you receive the most effective and tailored treatment for hypothyroidism. Don’t let lingering symptoms hold you back – join Paloma Health and take the first step towards a healthier, symptom-free life.

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Cleveland Clinic. Hormonal imbalance: Causes, symptoms & treatment. Cleveland Clinic. Published April 4, 2022.

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Mary Shomon

Patient Advocate

Mary Shomon is an internationally-recognized writer, award-winning patient advocate, health coach, and activist, and the New York Times bestselling author of 15 books on health and wellness, including the Thyroid Diet Revolution and Living Well With Hypothyroidism. On social media, Mary empowers and informs a community of more than a quarter million patients who have thyroid and hormonal health challenges.

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