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Mary Shomon

Low TSH Levels May Be Safe for Patients Being Treated for Hypothyroidism

By April 8, 2010

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There is a part of me that wants to look at the above headline, and get a bit snarky and say "Oh, really? This is actually NEWS to endocrinologists?'" (But I won't.)

What I will tell you is that several researchers out of the University of Dundee in Australia made a presentation at the Annual Society for Endocrinology BES meeting, held not long ago in Manchester, England. The upshot of their research was that it may be safe for patients taking thyroxine replacement drugs (i.e., Synthroid, Levoxyl, etc.) to take enough of the medication to have a low -- but not suppressed -- thyroid-stimulating hormone (TSH) level.

"This is the first population-based study to show that having slightly lower TSH levels when taking thyroxine replacement is not detrimental to health," Graham Leese, MD, BMSc, consultant in diabetes and endocrinology and honorary reader at Ninewells Hospital and Medical School, University of Dundee, Australia, said in a press release.

This was a fairly sizeable study population of more than 16,000 patients thyroxine replacement drugs between 1993 and 2001. The patients were categorized as

  • Raised TSH -- TSH above 4.0
  • Suppressed TSH -- TSH less than 0.04
  • Low TSH -- TSH less than 0.3
The had interesting findings. Compared to patients who had a TSH level within the reference range:
  • Patients with raised and suppressed TSH levels had an increased risk for heart disease, heart rhythm disturbances, and bone fractures
  • Patients with low TSH levels did not have an increased risk for heart disease, heart rhythm disturbances or bone fractures
In a press release, study author Graham Leese said: "Our findings confirm that it may be safe for patients with hypothyroidism to take marginally higher doses of thyroxine than our currently recommended."

This latest finding is a more ammunition for patients to take to doctors who think that any treatment -- as long as it gets you somewhere into the old (and actually outdated and insufficient) TSH normal range of .5 to 5.0 -- is all we need.

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Leese, Graham & Flynn, Robert. "Is it safe for patients taking thyroxine to have a low but not suppressed serum TSH concentration?," Endocrine Abstracts (2010) 21 OC5.6, Society for Endocrinology BES 2010, 15 March 2010 - 18 March 2010, British Endocrine Societies. Online

"Low TSH levels may be safe for patients taking thyroxine replacement." Endocrine Today. Posted on March 22, 2010, Online

April 9, 2010 at 3:40 am
(1) Val O'regan says:

There is no “University of Dundee” in Australia.
The city of Dundee is in Scotland, and that is where the University of Dundee is located.
Somebody will need to check the sources of this item.

April 9, 2010 at 4:09 am
(2) June H says:

Ninewells Hospital, Dundee is in SCOTLAND, United Kingdom as is Dundee University. I used to work in Dundee and had a friend at the uni there.

That said the research findings are good news!

April 9, 2010 at 4:23 am
(3) Victoria says:

I don’t feel well unless my TSH is 0.02. I can’t get my Frees high enough or get rid of the symptoms unless it’s that low.

April 9, 2010 at 6:04 am
(4) Amy says:

When will they figure out that the safety focus needs to be on levels of free thyroid hormones.

After years of hearing from my primary physician that my tsh of 0.001 was too low & my thyroid medication was too high, I was thrilled to provide him with yet another DEXA scan showing improvement in my bones! Every DEXA I’ve had since beginning desiccated thyroid hormone shows steady improvement in my bones. He still thinks I”m one in a million.

Thank God I don’t rely on him for my thyroid medication.

April 9, 2010 at 6:13 am
(5) Ciara says:

Like you Mary, I am tempted to say – and this is NEWs?? Well it’s not news to the Endo Registrar (not yet even a consultant at that time) I attended 9 years ago. Maybe he was ahead of his time but he recognised tht I am in the same situation as you Victoria and he found out that it was because I do not metabolise the medication the same way as other (normal!) people. My ‘bar’ for feeling well is just set lower along the TSh line than others. My attitude was – sent me for a Dexa and even and ECG if you feel you must, every 3 years but at least give me some quality if life NOW when I need it. I’ve suffered from palpitations (heart rhythm disturbances) since I started on the OCP 20 years ago so I now see them as normal and like 40% of women who get them, they are harmless and my bones, thanks to weight bearing exercise and pleenty of natural sources of calcium and vit D are in great shape despite what some might see as a “low” TSh.

April 9, 2010 at 8:03 am
(6) Gina says:

I am commenting on the first post in the responses.

I googled “University of Dundee” in Australia and found that YES, THERE IS A UNIVERSITY OF DUNDEE IN AUSTRALIA.

Don’t take my word for it, simply google it yourself and you will see that there is in fact a U of D in Australia.

April 9, 2010 at 8:58 am
(7) Theresa says:

My doctor panics every time my tsh comes back (the lab flags it as abnormal every time, and it’s been hovering around 0.03 – 0.04). Last spring, just as I was turning 50, he sent me for a bone mineral density scan, and it turns out my bones are as healthy as a 20-year old. Thanks to desiccated thyroid, with its calcitonin!

April 9, 2010 at 9:02 am
(8) Jim says:

A bit more detail can be found at “http://www.endocrinology.org/press/pressreleases/2010-03-16_Thyroxine.pdf”. As you will see the study was from Scotland.

Some interesting quotes in this paper. “Patients who had a slightly low TSH level (0.04-0.4mU/l)”. When was the last time an endo. referred to TSH < 0.4 as "slightly low"?

"patients may be able to take slightly higher doses". They show a clear lack of understanding of the relationship between thyroxine and TSH. Reducing TSH from, say, 0.5 to 0.05 will take a fair amount of thyroxine (maybe 1/3 more) due to the inverse logarithmic relationship between TSH and thyroid hormone levels. They compound this error by referring to "marginally higher doses of thyroxine" later on.

April 9, 2010 at 9:43 am
(9) Alexis says:

My TSH was only 1.54 a couple of months before I went on Armour because I was miserable – it had gone on and gotten worse for so long I didn’t know what normal was anymore! Once I got to a level I felt good at (and also lost weight) my tsh was too low to measure and my free T3 is slightly over range. I have no hyper symptoms and have had Hashi’s for years and also had Graves and WAS hyper from that years ago – hyper does NOT feel good and I know what it’s like. For me TSH is useless! Even my integrative doctor worried a little but finally decided I was right and has always let me dose my way. I had an endo tell me “you FELT hypo” – like all the obvious symptoms that went away were all in my head! And he tested the usual total T3, T4, uptake nonsense – they were all in the MIDDLE of the range but the TSH was below normal so he tried to tell me I was HYPER! He said “don’t worry I won’t lower your dose” – well HE wasn’t the one prescribing – I went to him for something else! I don’t know where I would be now were it not for my great doctor that considers how I feel and says we are treating YOU not lab values!

April 9, 2010 at 10:54 am
(10) Beth says:

AMEN, amen, amen. I have been struggling with hypo for at least four years, and after two miscarriages and starting dessicated porcine thyroid hormone am now 26 weeks pregnant. My obstetrician becomes hysterical every month when my TSH comes back “very suppressed,” at .001 – .06. I stupidly decreased my dose a little to try to appease her, and my Free T4 promptly went into the low range, whereas it had previously been perfectly normal. For the past three months I have been trying to get FT4 back to normal. Last week it was .78 (normal .80). So I increased my dose again. If only this article would have came out last December!!!!!!!

Also of note: my obstetrician several times tried to convince me to go to an endocrinologist, because she obviously didn’t trust my naturopathic thyroid doctor — EVEN THOUGH EVERYTHING MY THYROID DOCTOR HAS SAID HAS TURNED OUT TO BE CORRECT.

Also check out this study on low TSH, normal FT4 in preganancy, where NO DIFFERENCE was found between these women and “normal” pregnant women:


April 9, 2010 at 6:20 pm
(11) Debra says:

I am so thankful for these articles and for the forum. I have been absolutely sick and miserable for years. While I had every single symptom of Hashimoto’s my doctors were telling me that my TSH was normal and that my thyroid was NORMAL. FINALLY I changed doctors and when my TSH came back witin “normal range” at 3.0. I was referred to an endo and at first he was telling me he “doubts” it was my thyroid. He decided “for the heck of it” because Hashimoto’s runs throughout my family, to do the sonogram. I was in SUCH pain in my thyroid area as he touched my neck he became “suspicicious.” He concluded a definitive diagnosis of Hashimotos through the sonogram but said to leave it for now, and wait until my TSH levels indicate need for meds. My primary care, asked me what I thought about low levels of syntrhoid to see if I would feel better. Well,it has taken about 4 months, but I finally feel better! I still have symptoms, but my TSH levels have gone down to 1.9 and I am hoping to see further drop. So much for the standard of what is “normal TSH levels.”

April 9, 2010 at 7:14 pm
(12) Val O'Regan says:

I am Australian and I live in Australia and I can assure Gina and everybody else that in fact there is DEFINITELY NO UNIVERSITY OF DUNDEE IN AUSTRALIA.
All the google results obtained by googling “University of Dundee in Australia” are based on the same wrong information.
One of them has been corrected and now refers to “University of Dundee in Scotland”.

April 10, 2010 at 10:16 am
(13) doc says:

hey, you messed up the figures!
Originally it reads:
low: 0,04 to 0,4 and
suppressed >0.03

April 10, 2010 at 5:11 pm
(14) rose says:

what is a good thyroid TSH suppose to be? And how dro u read a free t3 and a free t4 blood result?

April 10, 2010 at 10:34 pm
(15) Yvonne Ardith says:

I want to see research that distinguishes between Primary Hypothyroidism (inadequacy of the thyroid gland) & secondary hypothyroidism (indadequacy of the hypothalamic/pituitary mechanism that generates TSH). Doctors who focus ONLY on TSH level ignore that in the rarer illness, as in my case, & for several other commentators here, TSH is not generated normally. How can we push for this distinction? So-called evidence-based medicine takes the opposite approach of lumping all thyroid problems into one Primary category.

April 11, 2010 at 9:58 am
(16) Steff says:

I agree with Yvonne. I need the same info. As i am sure My prob is probably pituitary rather than just thyroid. My doc 3yrs ago did some blood work and said I was fine but I am still suffering and have all the syptoms. I dont know if he did the right test or even read it right cause every doc I go to wont raise my armour or put me back on useless synthroid!

April 12, 2010 at 9:01 am
(17) Brenda B says:

Thank you Yvonne and Steph! I have had the same thoughts for years. Why ISN’T there research in this area? It is definitely worth considering. If you have many people with “normal” TSH and still suffering with hypothyroidism symptoms, there is obviously something that is being overlooked. If we could just figure out where the system is malfunctioning, we could work on the problem area specifically rather than diagnosing the whole endocrine system as either normal or not based on a few ineffective tests.

April 12, 2010 at 10:13 am
(18) sue says:

so glad to hear this. i haven’t been officially diagnosed yet. have had issues for years and complained, but was always “borderline” in numbers, but severly depressed, couldn’t lose weight, hair loss, fatigue etc. in feb my tsh is down to .01 dr. are alarmed., i am not, i feel better. i am so nervous to face this appt. any advice for a newbie?

April 12, 2010 at 11:17 am
(19) Brenda says:

Sue, I would recommend that you do your research on the various thyroid tests available prior to your appointment, and then insist he do all of the tests, including the antibody tests. Ask for a copy of your lab results so that you can study them yourself. Then if nothing is found, ask for a low dose trial of thyroid med’s. I came to this conclusion after 17 years of symptoms and doctors, including some that called themselves endocrinologists, telling me I was fine because my TSH was “normal”. I sought out a doctor who was willing to address my symptoms aside from my bloodwork and I feel much better today as a result. Good Luck.

April 13, 2010 at 8:06 am
(20) Jill says:

I’m a case study for the benefits of low TSH, as I feel my best when my TSH is between 0.02 to 0.09, with no hyper heart palpitations. I don’t want my thyroid to have to work hard at all.

Many years ago, when I was on 75 mcg Synthroid, my TSH was kept between 2 to 3. I was always freezing with bad muscle pains. For many years, I begged various doctors to add T3 Cytomel to lower my TSH, but none would allow it saying that my thyroid was in range. I felt horrid and was later diagnosed with fibromyalgia… really just hypothroidism gone badly undertreated! I’ve always felt that if I’d been switched to Armour, or at least been allowed to add Cytomel to reduce my TSH to less than 0.5, I might have been saved from many years of pain. There were many days when I could hardly walk due to the muscle pains in my upper back and legs.

Then 2 years ago, I insisted that my new doctor switch me to Armour. I still have moderate upper back pain and my temp is still low, but I feel much better than when my TSH was high. Last Aug’09, my TSH was 0.09 on 180mg Armour, and I felt fine. Then due to the Armour shortage, I temporarily lowered my dose for 1 month to 120mg Armour, and my TSH was 0.02. Afer I dropped my dose of Armour, I immediately became sick with the flu so I’ll have to get retested. Only Nature-Throid is available in my area, so I asked my doctor to prescribe Nature-Throid. I read on this site that for some people, NT worked better than Armour, but I felt horrid on the lower 130mg dose. Completely drained of energy, I slept 12-16 hours a day, and my average temp dropped below 97. After a week, I increased to 195mg Nature-Throid and now feel fine! I’m sure that my TSH would agree! I intend to keep my TSH to as close to 0.02 as possible!

As for the “normal range” being set too high, that’s easily understandable. When people go to their doctor and complain that they feel freezing cold, tired, depressed, gained weight, the doctors think that’s “normal”, or they prescribe antidepressants and a diet. The same patient’s blood samples may be used in clinical studies to set the normal TSH range. The study wants healthy individuals. Well, if you are relatively fit, you might say on the study questionaire that you are normal and healthy. It might take many years for you to realize that you haven’t quite felt perfectly normal like your friends. In the early stages of thyroid disease, you may even flucctuate between higher hypo TSH and lower hyper TSH. You’re newly hypothyroid, and gave blood to the study that says you are normal, so the “normal” range might be set too high. Many years ago, when I was likely in the early stages of hypothyroid disease, before I was properly diagnosed with Hashimotos, my donated blood might have been used in the clinical study population to determine the normal TSH range. The normal TSH range should be revised to include only the healthiest population.

April 13, 2010 at 9:37 am
(21) steff says:

Do all of you with thyroid problems find it hard to get your doc to test you for sluggish adrenals?

April 16, 2010 at 12:57 pm
(22) David M Odom MD says:

One of the problems with this paper (Endocrine Abstracts 2010 21 OC5.6) are the definitions of “Low TSH” (0.04-0.4 μIU/ml) versus “Suppressed” TSH (≤0.03 μIU/ml). As an MD practicing natural hormone replacement therapy, and having wide experience prescribing both Levothyroxine and Thyroid USP, I know that taking 2 Grains per day of Thyroid USP will result in a “Low TSH” but will not reverse low thyroid symptoms in most patients. Taking 3 Grains per day, or more, will result in a TSH that falls into the category of “Suppressed TSH” but will generally fully reverse low thyroid symptoms. So, the category of “Suppressed TSH” in this paper includes an extremely wide spectrum of patients, including those who have been able to take larger than usual doses of Levothyroxine and also those patients who have had tremendous hyperthyroidism in the past, as in Graves’ Disease, and were placed on Levothyroxine after they descended into post-Graves hypothyroidism. These latter patients are, of course, more likely to develop “cardiovascular disease, dysrhythmias, and fractures.”

This lumping together of patients taking Thyroid USP, larger than usual doses of Levothyroxine, and those with burned out Graves’ Disease, simply because of a suppressed TSH is no less than slander. I say this fully realizing that a combination of ignorance and arrogance is at the core.

I agree with the observations of Amy & Theresa that DEXA’s demonstrate a reversal of bone loss occurring simultaneously with TSH suppression. In addition, my post-menopausal patients are supplementing those hormones producing bone growth during youth, Progesterone, DHEA, D3, and Testosterone. Estradiol prevents further loss of bone. Thyroid rev’s up the process of bone gain in this situation.

In conclusion: Suppression of the TSH is an expected consequence of thyroid supplementation that has no adverse health consequences, moreover the TSH has no specific or reliable correlation with thyroid function. (Meier, Christian, et al, Serum TSH in assessment of severity of tissue hypothyroidism in patients with overt primary thyroid failure, BMJ, vol 326:8Feb2003).

The large majority of medical practitioners follow the system of prescribing synthetic levothyroxine to regulate the TSH, even though this practice has no scientific foundation. Doctors who practice Natural Hormone Replacement Therapy, on the other hand, prescribe Thyroid USP or compounded T4T3 combinations, seeking symptom reversal without regard to the TSH and find success with great benefit for patients.

Levothyroxine, an inherently unstable drug, markedly affected by light, heat, & humidity. Although on the market for many years, it was not officially approved by the FDA until relatively recently. (The Medical Letter, Vol 46, Issue 1192, 9/27/04) This is because in 1997, inconsistency in the stability and potency of various formulations of Levothyroxine prompted the FDA to reclassify all oral levothyroxine products as new drugs & require New Drug Applications from the manufacturers. (Thyroid 2003, JV Hennessey, 13:279). A further problem with levothyroxine is that the synthetic T4 is difficult to convert into T3 without the supportive stroma found in natural thyroid, thus limiting its effectiveness.

April 17, 2010 at 2:51 am
(23) Patty says:

I went to my doctor and had blood work done and he told me, my thyroid level was high meaning hypothyroidism. He put me on 25milgrams of Synthroid. In 3 months I gained 12 pounds and felt miserable. I had all the side effects of the medicine.

I started researching thyroid problems and I went off of Synthroid and I feel like a new person. I researched what foods make the thyroid work better and they are, fish (at least 3 times a week), walnuts, iodized salt, cheese, eggs, flaxseeds, folic acid, iodine, whole grains, nuts, ice cream. Other things that you can do are, get adequate sun each day, exercise 30 to 60 minutes 3 to 4 time a week, don’t drink tap water.

Stress in all its forms is another culprit of thyroid dysfunction. Poor nutrition is probably the orgin of many thyroid problems, (including low thyroid), and rich nutrition is vital to reversing them, or at least to prevent futher decline. Healthy thyroid function depends on a range of nutrients, especially, selenium, folic acid, and iodine. Consume foods naturally high in b vitamins, such as whole grains, nuts, and seeds, and iodine.

May 27, 2010 at 9:50 am
(24) Leona says:

When my physician would complain about my TSH being .01, he would decrease my dose of natural thyroid, i soon learned to schedule my lab draw appointments first thing in the morning AND DON’T take my thyroid medicine until AFTER the lab draw. So, the last dose of medicine I would have taken was the previous morning…problem solved :) My TSH comes up enough to make my Doctor happy and he quit changing my dose.
Even if your lab draw isn’t until mid morning HOLD your thyroid meds until afterwards…you’ll be fine. In my opinion, fasting (from thyroid meds) before a lab draw is a clearer picture of where your true thyroid levels are anyway.

January 10, 2011 at 7:00 pm
(25) monarch59 says:

I take mine (levothyroxine) at bedtime

there is NO food, beverage interference AND so my blood tests are acurate.

Should You Take Your Thyroid Medication at Night?
By Mary Shomon, About.com
Updated: March 23, 2007
About.com Health’s Disease and Condition content is reviewed by our Medical Review Board

Every thyroid patient has heard the advice that for best results, we should take our medication first thing in the morning, on an empty stomach, and wait at least 30 minutes to an hour before eating.

(And also, that we should wait at least three to four hours before taking calcium or iron, which can interfere with thyroid hormone absorption.)

But research reported in the journal Clinical Endocrinology found that taking the same dose of levothyroxine (i.e., Synthroid) at bedtime, as compared to first thing in the morning, might be better.

The small pilot study was prompted by observation that some patients had improved thyroid hormone profiles improved after they switched from taking their levothyroxine in the morning, to bedtime.

The purpose was to look at the impact on thyroid hormone profiles by changing the time levothyroxine was taken from early morning to bedtime.

They also evaluated the impact of this change on the circadian rhythm of TSH and thyroid hormones and thyroid hormone metabolism.

The study, while small (12 subjects), was fairly conclusive in its findings, which the researchers said were “striking” and which have “important consequences for the millions of patients who take l-thyroxine daily.”

Researchers reported that taking medication at bedtime, rather than the morning, results in “higher thyroid hormone concentrations and lower TSH concentrations.” TSH decreased and Free T4 levels rose in all patients by changing thyroxine ingestion from early morning to bedtime and T3 levels rose in all but one subject. And TSH decreased irrespective of the starting TSH levels, suggesting better absorption of the thyroid medication when taken in the evening.

Interestingly, the researchers found that the circadian TSH rhythm — the typical daily fluctuations of TSH that occur during a 24-hour period — does not vary.

The researchers suggested several explanations for the results:
Even when waiting at least 30 minutes to eat, breakfast may be interfering with the intestinal absorption of levothyroxine thyroxine.
“Bowel motility is slower at night,” which means that it takes longer for the levothyroxine tablet to transit through the intestinal system, resulting in longer exposure to the intestinal wall, and therefore, better uptake of the medication.
The conversion process of T4 to T3 may be more effective in the evening.

From Mary Shomon: What are the Implications for Thyroid Patients?
Taking medication at bedtime instead of in the morning could have major implications for many thyroid patients.
First, it’s easier, as you don’t have to worry about when to eat breakfast.
Second, it’s easier to avoid medications, supplements and foods, like calcium, iron, and high-fiber foods that can interfere with thyroid medication absorption.
Third, it might offer some improvement in symptoms to people who are just not getting optimal absorption by taking thyroid medication during the day.

While this was a small study, it confirms what many patients anecdotally have been reporting for years — that they feel better if they take their thyroid medication in the evening, rather than the morning.

You may want to talk to your practitioner about changing the time you take your levothyroxine (i.e., Synthroid, Levoxyl, Levothroid, Unithroid, Eltroxin) to bedtime, versus morning. And if you decide to change to taking your thyroid medication in the evening, be sure to have your thyroid levels evaluated — six to eight weeks is a reasonable timeframe — after you’ve made the switch.

The blood test results, along with any improvements or worsening of symptoms, will help you and your doctor to determine if you need to adjust the dosage or timing of your medication.

Note, however, that this study was conducted with levothyroxine — a synthetic form of the long acting T4/thyroxine thyroid hormone. This form of the hormone must first be converted in the body to the active form (T3) and this can take days.

Thyroid drugs that contain T3 — Cytomel, Thyrolar, and the natural desiccated thyroid drugs like Armour can by used directly by the body within hours. These drugs were not evaluated in the study.

Anecdotally, some thyroid patients have reported improvement in symptoms when taking their
T3-based thyroid hormone replacement medications in the evening. But some thyroid patients also find that if they take a medication with T3 later in the day or in the evening, the slight stimulatory effect of the T3 medication can make it difficult to sleep.

So keep in mind that while it’s very possible that if a similar study were conducted with T3 drugs, the results would be similar, there is some chance that it would impact sleep quality. Only make such a change after discussing it with your doctor.

Optimally, some doctors have suggested that patients who take medications with T3 split their doses to take them throughout the day, leaving a dose for bedtime. This approach seems to minimize sleep interference.

Again, if you do make a change to how you take your T3 thyroid medication, you’ll want to have a reevaluation of blood levels and symptoms after several weeks, to determine if you need to adjust the dosage or timing of your medication.

January 14, 2011 at 1:13 pm
(26) Mary says:

I read Mary’s article about taking thyroid medicines at night. While it might make sense for some, I don’t like to take ANYTHING right before bed and probably would not remember anyway so will stick with morning.

I like the idea that if you are feeling well on a dosage that puts TSH at a level your doctor might holler about, not to take the thyroid the morning of blood work. I would not do that if I was not feeling pretty good, though.

For those on Nature-Throid finding it takes more than Armour, try chewing the tablets. I read an article that said the fillers might make it harder to metabolize. The current versions of Armour may fall into that same category so try chewing those tablets and notice what happens for you.

My last TSH was 3.35 and I was still freezing and not just hands and feet. The area between my shoulder blades would get so chilled even with pretty warm clothing.

About 2-3 days before my next doctor appt I went from half of a 65 mg tablet to the full 65 mg and am not getting so cold like before. A new test will be taken in early February, 2011 and I will see what it comes out with.

The doctor did agree with me taking a higher dosage, thank heaven.

I wish the people who come up with “Normal” would realize that normal for me may not be normal for you and everyone else.

April 20, 2012 at 12:10 pm
(27) tina says:

I have been struggling with hypothyroidism and Hashimotos. I found it because, even with healthy eating habits and exercise, I gained 20 pounds. I went to the doctor fatigued and overweight. It has been a very slow process to get my numbers down. I started at 3.9 and am down to 1.9, but still don’t feel any different. I went on an Advocare diet, which many, many claim to lose 10-20+pounds. I did the same exact diet and lost 3 lbs. I am so frustrated and emotional. I have to beg my doctors to continue to increase my Synthroid medication and then, they only increase by very small amounts. I think I will be happier when I am below 1.0. I am so frustrated with this process. I have not noticed any change in the 5 months that I have been treated. I even changed medications and doctors. What can I do?

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