I’m on Levothyroxine and My Labs Are Normal – Why Do I Still Feel Terrible?

Beyond the Thyroid – Episode 34: I’m on Levothyroxine and My Labs Are Normal – Why Do I Still Feel Terrible?

Are you on Levothyroxine but still feeling exhausted, foggy, or unwell — even though your labs are “normal”? You’re not alone.

In this episode of Beyond the Thyroid, Dr. Dana Gibbs dives into the reasons why standard thyroid care often leaves patients struggling. She explains how issues like poor T4-to-T3 conversion, inconsistent medication timing, adrenal dysfunction, and other coexisting conditions can keep you from feeling your best.

In this episode, you’ll learn:

• Why TSH alone isn’t enough to measure thyroid health
• How to identify and address T4-to-T3 conversion problems
• The importance of consistent medication timing
• Common nutrient deficiencies and conditions that mimic thyroid symptoms
• How advanced testing can uncover hidden imbalances

Dr. Gibbs also shares details about her upcoming Thyroid Clarity Checkup program — designed to give you the insights and action plan you need to finally feel better.

📑 Join the The Thyroid Clarity Checkup Priority List! 

📲 Follow Dr. Dana Gibbs on the Goodself App!

🩺 Interested in a Discovery Call with Dr. Dana? Click here!

📺 Watch on YouTube

Episode Highlights:

00:00 – Introduction to Persisting Thyroid Symptoms
 01:02 – Host Introduction and Personal Journey
 02:13 – Common Issues with Thyroid Medication
 05:39 – Understanding Thyroid Hormone Conversion
 10:53 – Optimizing Thyroid Medication Timing
 14:20 – Additional Factors Affecting Thyroid Health
 20:21 – Upcoming Program and Final Thoughts

✨ Stop settling for “normal” when you still feel terrible. Tune in now!

Let's connect! 🔔
Facebook - Consultants In Metabolism
Instagram - @danagibbsms
LinkedIn - Dana Gibbs MD
Tiktok - @dana.gibbs.md

✉️ Email Dr. Gibbs at drgibbs@DanaGibbsMD.com or visit https://www.danagibbsmd.com/ for more information.


Thank you so much for listening! Tune in on the next episode.


The medical information provided in this episode is intended for informational purposes only and should not be construed as medical advice. Always consult a qualified healthcare provider regarding any medical questions or concerns.

Transcript

dana-gibbs-md--she-_1_08-06-2025_215234: 0:04

Welcome to episode 34. Today's gonna be a look at persisting symptoms, particularly in people who've already been taking thyroid medication. Because I hear this all the time,"I don't wanna take this medicine. It's not making me feel any better." So, we're gonna take a pretty detailed look at why somebody who really seems to need thyroid medicine, either by labs or symptoms or both, might not feel better on their medication. Usually this is a fixable problem and we aren't just looking for better. I want my patients to feel well. It takes a nuanced approach beyond just TSH and levothyroxine, and that is exactly what I offer to my clients. My methods allow me to get superior results in fixing people's energy levels and their other hypothyroid symptoms quickly, while they also work to get their Hashimoto's Disease antibodies and there are other underlying causes under control. It is much easier to optimize your diet, your habits, your lifestyle, your sleep once you're not exhausted all the time, so let's get started.

1:13

You're listening to the Beyond the Thyroid podcast. I'm your host, Dr. Dana Gibbs. I'm an ENT surgeon and hormone specialist. For years, I struggled with my own unrecognized thyroid problems before and even after I was regularly performing thyroid surgeries. Then, one day, I learned something that turned my health around and opened my eyes to the limits of mainstream medicine in treating more subtle thyroid abnormalities. I spent the next 20 years fine tuning my hormone expertise in disorders like Hashimoto's disease, perimenopause, and stress related illness. Come join me as I share this new approach to hormones that empowers you to take control of your own thyroid and hormone imbalances. Let's dive in.

dana-gibbs-md--she-_5_08-06-2025_220112: 2:06

Welcome friend. It's good to have you back. If you're new here. I'm Dr. Dana Gibbs. I'm an ENT Turn Thyroid Specialist. So if you've started thyroid medication and you've been told, okay, your labs are normal, but you still feel exhausted, cold, brain, fogged, anxious, or like you're barely getting through the day, this episode is for you. Because here's the truth, I see patients every week who are on thyroid medication, maybe have been on several different types or doses, and yet they still don't feel right and they're told,"oh, you just need to eat better, exercise more." Or even that, there's nothing else to be done. And this is assuming that your TSH test is consistently normal in the range where the doctor wants it. Labs that fluctuate up and down are a whole other topic. However, the same kind of fixes I'm gonna talk about today can help there as well. When I dig deeper with these kind of people, I almost always find something important that was missed. And today I wanna walk you through what some of those things could be. So let's paint a picture. You started your thyroid medicine, usually, it was levothyroxin with high hopes because your TSH was off, or maybe you had thyroid surgery, or you've already been on thyroid meds for years. But even with your treatment, your energy is still poor. You're gaining weight, you're cold all the time. You have brain fogs, gut problems. Your hair is thin and limp. Maybe you're even depressed or anxious, and nobody seems to have more answers because your labs are normal. Or maybe you have Graves' disease and they're giving you something that suppresses your thyroid and it causes you most of those symptoms. But if you stop the medicine and the anxiety, the jitters and the inability to sleep come right back. And the answer you usually get is,"oh, your labs look fine!" Or maybe your doctors changed your medication and your dose several times chasing your TSH up and down. But no matter whether it's high or low, you don't feel normal. Some of us can't even remember what it normal feels like. We feel weak and sickly, like it's just part of who we are, but it's not. I'm not saying nobody feels well when they get on thyroid medication, but up to 30% of people don't. And there are three common patterns that I see in people who come in taking thyroid medicine. Some of'em feel better somewhat, but not truly well. Some feel enough better that they're somewhat satisfied and they never seek additional answers. But compared to their friends, they wear out quicker, they get sick more often. They gain more weight eating the same meals. The second one is they start the meds and they feel nothing at all. The symptoms persist. This is common. In patients who've had surgery to remove part of their thyroid gland. The final one is they feel worse, more fatigue, more brain fog, more anxiety, even weight gain. And that third pattern is especially common in people whose TSH was kind of borderline to begin with, not terribly abnormal, just a little abnormal. And maybe slightly low T4. But once they start treatment, they feel worse. And this is because they end up with less T3 than they had before. This patient is sometimes referred to as subclinical hypothyroidism, and a lot of them have Hashimoto's disease. So why does this happen? So let's break it down. So thyroid medicine, especially the T4, only containing medication like levothyroxine works for some people. It raises your blood levels of T4, which is supposed to convert in your body tissues into the active hormone T3. So T4 and levothyroxine are basically the same thing, T3 being the active hormone. For a percentage of patients who take levothyroxine, the conversion just doesn't happen as vigorously as it does in somebody with no thyroid problems, and we see when we pay attention is that it's not enough to flood the bloodstream with T4 precursor hormone. We have to make sure your tissues will actually use it. That's where reverse T3 is coming in. So when T4 gets broken down by your body, your body's either activating it into T3. The active hormone or it's inactivating it into reverse T3. Reverse T3 does not go into your nucleus, does not activate the hormone receptors, and doesn't have the good actions that we expect from thyroid medicine. So very frequently there are condition where your body starts making less T3 and more reverse T3 and too much reverse T3 is a signal that the effects of T3 in the cells, in the body tissues are too low, not enough blocked. So even though your levels look fine on paper, you still feel like you're running on empty. There's a couple reasons why this happens. The first one is if you give somebody T4 in a pill, particularly because they give it all at once in the morning, your blood levels, once you swallow that pill will spike high for a few hours, like two to three hours, and then start dropping and that large peak in T4 actually shuts down your body's own production of thyroid hormone, if you still had some functioning thyroid tissue and it suppresses your TSH which is what naturally stimulates the release of that T3 from the thyroid gland. So you're not making anymore and you're not releasing anymore. So you end up with lower T3 levels than before you started the meds. Normally, thyroid hormone fluctuates throughout the day. A bit higher in the morning, a bit lower in the evening. So it sounds okay to take thyroid hormone once a day. We think that we doctors, for years were told that T4 containing medicines have a 14 day half-life in the body, so it must be stable. Turns out that's not true. The half-life is seven days. But it isn't okay to take it all in the morning. And this is very different than the way thyroid hormone was dosed before the synthetic T4 Synthroid levothyroxine existed. And back when the only way we had to decide how it was working was when your symptoms got better. This medicine was given three times a day, so the half life that I mentioned means how many hours or days does it take for half of the medicine you just took to disappear out of your blood system. But in reality, once daily dosing creates a massive swing in your blood hormone levels, right after you take your pill, your T4 level spikes high for two to three hours and stays about 25% above normal for as long as nine hours, and then falls down sharply for the rest of the day. And this is way more than the natural fluctuation of thyroid hormone release. So if you're only testing your blood labs first thing in the morning before you took your meds that temporarily way too high level is completely missed because it's gone after that first few hours and most docs don't realize that high T4 equals a drop in your T3. So if you still have residual thyroid function, we already said that, that your T3 production is lower than it probably was before you started taking your thyroid medicine. But that high level of T4 also blocks the level of T4 conversion to T3 that's happening in your tissues. So if you don't have functioning thyroid tissue in your body, for example, you've had radioactive iodine or you've had surgery to remove all your thyroid tissue, the only way you can get active T3 is by conversion and the higher your T4 is going right after you take the pill the lower your T3 conversion is all day long, so it's like putting in too much fuel, but then stuffing a rag in the air intake to your car engine. The engine won't run properly because it's flooded. So this is a natural body defense mechanism against the potentially deadly problem of way too much thyroid hormone, similar to what happens in Graves' disease. So, that's also why I ask my patients to divide their dose of T4 levothyroxine or similar brands into a two time a day dose. This means you take less at one time, take the same overall amount, but less at one time so that we get a more realistic picture of how high your levels are when you go to the lab. And because you checked less at one time, the T4 level never spikes up as high, and it's a little more stable. It smooths out those highs and lows in your blood levels and increases your ability to convert T4 to T3 instead of reverse T3. It will also, in many cases, improve your symptoms and make them much easier to track and treat. Here's another thing. Because of these highs and lows, when you take your medicine, the time you take your meds needs to be consistent. If you take it at 6:30 in the morning, one day and 10 o'clock the next, it dramatically affects how much hormone you appear to have when you go get your lab test. It can also get you into situation where sometimes you're eating a meal a little too close to the time you swallowed your pills. And this changes how much medicine you'll absorb into your blood on any given day and throws off your labs too. So there are very few medications where minute to minute timing really matters, but thyroid hormone is kind of one of them. So it's also really important to get your labs done at the same time of day every time. You can get it in the morning right before you take your pill or you're half a pill as long as you went ahead and took your pill the night before, you won't see as low of a low, but you won't see the high either. My preference is for you to go to the lab six hours after you took your morning thyroid medicine. So, for example if I have somebody who's taking their meds. At 10:00 AM and 10:00 PM and going right to bed at 10:00 PM then I'll have them go to the lab six hours after that. So 10, 11, 12, 1, 2, 3, 4. So they'll go to the lab at 4:00 PM and that's what I have them do every single time. Unfortunately, most people who get their labs drawn at their primary care, it's like, well, the appointment was at 2, the appointment was at 8:30, the appointment was at 4 o'clock. So they're getting their labs done at a different time every time. And when you think about the fact that those hormone levels are fluctuating, you can see sometimes it's gonna look too high, sometimes it's gonna look too low, and you'll be chasing that dose up and down. Overdosed some of the time, underdosed some of the time. Anyway, once that pattern is set, it's really easy to figure out if you're converting enough T3 from your T4, because we look at the free T3 level and also compare total T3 to reverse T3. So that number dividing total T3 by reverse T3 will ideally be around 12 if somebody's in really good shape. Then if you still don't have enough circulating T3, we can just add it to your med regimen until it's in the upper third of the range, which is where I ideally like to see that. All right, though there are several coexisting conditions in addition to Hashimoto's disease that can lower your ability to produce adequate T3 from the T4 that you take in. So even if your T4 is right, a lot of people are just not making enough T3 and there are lots of chronic diseases that can do this, like low iron, diabetes, kidney or liver disease or even certain medications. But two problems I wanna mention here in particular, because most doctors have no idea that this exists. The first one is a set of genetic defects called SNP, single nucleotide polymorphisms that impair the enzyme that makes T4 into T3 in your body tissues. There is no easy way to test this SNP this genetic defect are these enzyme. So the only way to know this is by looking at the T3 to RT3 ratio. The other one is stress and oh my gosh, if you have stress that's chronic and high level all the time, and your cortisol is high, there are two ways that that damages your ability to have enough T3, so that that first of all, suppresses your TSH, your stimulation of thyroid hormone. The second way is it increases the amount of reverse T3 that you make and decreases the amount of T3 that you make. So that's what stress does. If it raises your cortisol level really high, but there are some other reasons you can still feel bad, even if your thyroid is dialed in and your timing is perfect. You might still feel awful when you're taking thyroid medicine and particularly T3 that's very activating to your metabolism. The first one is adrenal dysfunction, so if your cortisol is too low. And your body cannot keep up with the increased metabolic demand that comes with ideal amounts of thyroid hormone. You might feel weak, anxious, even more fatigued or even jittery. This can frequently be seen in somebody who has been very, very stressed for a long time, had very low thyroid, very low T3 for a long time. That's really, really common, and adrenal support is necessary for those folks. The next one. And this is even more common, so most people who have hypothyroid symptoms their biggest symptom is low energy. So they are relying on lots and lots of caffeine to get through their days when their T3 is low and relationship to their reverse T3. But once your metabolism starts to wake up, that same caffeine that you've always been using can now cause you symptoms that it never did before. Anxiety, palpitations, blood sugar crashes and keep you awake, oh my gosh, keep you awake all night long. So it can be really important when you start on a T3 containing thyroid hormone combination. When you get that right, you have to lower your caffeine and lower your caffeine and lower your caffeine in order to tolerate the T3, and you won't need the caffeine anymore. The T3 basically is taking the place of the inferior stimulant of T3. All right. The third one, and this is also very strongly related to people who don't make enough T3, and that's insulin resistance. So high levels of insulin or high levels of blood sugar, swinging, block thyroid function. But if you're eating lots of carbs or sugar, your thyroid medicines aren't gonna work as well. So it's a chicken or the egg kind of thing. But if you're on thyroid medicine and you're on the ideal balance of thyroid medicine eating a lot of carbs and sugar can swing you into hypoglycemia, which feels really bad. And what are the symptoms? Heart palpitations, feeling weak, feeling jittery, feeling anxious. And so the fix for this is also pretty simple, and that is to stop eating sweetss and those quick release simple carbs, potatoes, flour, pasta, rice. Those things that spike your blood sugar up ordinarily really fast because they'll go up and then they'll go down and it feels terrible. There's other reasons why people can still feel bad with ideal thyroid. And you know, I've been talking for a long time already, so I'm just gonna mention them really quickly. Some of them are mineral imbalances, like too little iodine, too much iodine, low selenium, low magnesium low iron anemia, low protein intake. These are all things that kind of mimic hypothyroidism or make it worse. And there's something called MCAS, Mast Cell Activation Syndrome that is very, very devastating and difficult to deal with out of the topic and we can maybe come on back to that another time. Mold toxicity and sIBO or small intestinal bacterial overgrowth. All of these conditions can make you feel exhausted, bloated, tired sleepy, have trouble sleeping, brain fog, all the symptoms. And these conditions are really not screened for that often, but they absolutely interfere with how your body feels, even if your thyroid labs are fine. So if you want real answers about is my thyroid properly balanced on the thyroid medicine I'm on? Or if you're just thinking,"Hey, maybe I need thyroid medicine. I don't even know." I am starting a program very, very soon called the Thyroid Clarity Checkup. That check program was gonna start very quickly towards the end of August or early September. If you are interested in this, it's gonna be a very small set of folks that I'm gonna invite. You need to get on the priority list, which you can find at danagibbsmd.com/checkup. We are going to go over exactly what labs you need to get. I'm gonna help you get those. Even if your doctor doesn't wanna help you order them, I'm gonna help you figure out what they mean. I'm gonna help you figure out what of your symptoms mean, thyroid, and what could mean other things going on that need to be checked. And I'm gonna help you figure out what to do next. So this is gonna be a great, fun program. This will be the first time I'm running it. So it is gonna be priced quite low. If you are interested go right now to danagibbsmd.com/checkup and get on that priority list so we can get started in less than a month. And so in summary, if your thyroid labs are normal and you still feel terrible, please don't let your doctor tell you that this is just how it is. The system that I use to diagnose and treat thyroid dysfunction is way more sophisticated than the standard guidelines based care that you get in an insurance driven medical practice. Today we're looking at incomplete labs at the wrong time. We're ignoring the impact of the other hormones, the lifestyle factors, and the deeper imbalances. You deserve a treatment plan that actually works, not one that just looks good on paper, so come and. Find me on danagibbsmd.com and the link will be again in the show notes. If this episode helped you, please subscribe to Beyond the Thyroid and share it with somebody who's struggling with similar problems. Next week I'm gonna walk through a case study of a woman who had exactly this. She was on levothyroxin. She was terribly symptomatic. Labs when she came in, looked normal according to her previous doctors. We uncovered what was really going on, and within a few weeks she was doing quite well and resolving all those symptoms. So thank you for listening. You deserve to feel better. Until next time.

23:10

Thank you for listening to this episode of Beyond the Thyroid. If you found this information valuable, it would mean so much to me to take a few seconds and give the podcast a five star review. It helps other people who need this information find the show and it's really easy. Just search and click on the name of the show, Beyond the Thyroid, and scroll to the bottom to ratings and reviews. I truly do read and appreciate. Remember, when it comes to hormones, there will always be more to discover, so follow the show so you get the next episode as soon as it's released. And if you or someone you care about needs a caring doctor to help figure out how to heal hormone problems that other doctors have dismissed, check out my website at www. danagibbsmd. com. And if you're not a physician, please keep in mind, while I'm a doctor, I'm not your doctor. The content of this podcast is my opinion and it's for educational and entertainment purposes only. This is not meant to be individual medical advice and you should consult your own physician for any medical issues or diagnoses that you may have. I look forward to continuing this journey with you beyond the thyroid.