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9 Step Guide to Stop Thyroid Fatigue in its Tracks

Fatigue is one of the most common (and frequently reported) symptom of hypothyroidism. 

​Fatigue is the result of various changes in your body including nutrient imbalances, poor mitochondrial function and even tissue level hypothyroidism. 

What's more interesting is that in order to treat and reverse thyroid fatigue you actually need more than just thyroid medication.

Why?

Because the subjective symptom of fatigue can come from multiple different places in the body. ​

More...

Thyroid Patients and Energy Levels

Why do thyroid patients get fatigue?

Despite it being

Fatigue is a subjective symptom and is synonymous with "energy levels". 

​Thyroid patients are very prone to developing fatigue and low energy for several reasons: 

​What's even more interesting is that simply replacing thyroid hormone in the body may not be enough (and frequently it isn't) to increase your energy levels. 

Why?

Well if you are Vitamin B12 deficient as a result of low thyroid hormone, then simply taking thyroid hormone isn't necessarily going to magically increase your B12 levels.

This same logic holds true for a number of conditions that we will talk about.

​But first, some further questions: 

If fatigue is a symptom of hypothyroidism shouldn't it go away when you take thyroid hormone?

Does having fatigue even after taking thyroid medication with a "normal" TSH mean that your thyroid is "fine"?

​These are interesting questions and worth exploring further. 

If you look at patients who have had their thyroid removed studies show that these patients have persistent fatigue for YEARS after their surgery when compared to age matched controls.

What does this mean?

​Well, it can mean a couple of different things...

#1 - Taking your thyroid out causes fatigue in some way that is unrelated to your thyroid hormone. 

Or. 

#2. Maybe we don't quite understand thyroid function and physiology or we are under-treating our thyroid patients. 

​In reality it's probably a combination of the both and I will expand on that theory below. 

With these factors in mind let's talk about the many different ways that your thyroid can cause fatigue, but more importantly what to do about it: ​

#1. Support your Adrenals and Cortisol Level

No matter how you look at it your thyroid hormone is involved with the production of cortisol (in more ways than one). 

Studies have shown that TSH tends to track with cortisol levels.

Meaning:

As your TSH increases your cortisol tends to increase as well.

In this setting a high TSH is used as a marker for diagnosing hypothyroidism, so when you don't have enough thyroid hormone in your body you may develop HIGH cortisol levels. 

​What you may not realize is that small changes to your cortisol levels can result in big changes in terms of symptoms. 

Anything that causes an increase or change to your normal cortisol regulatory pathways may result in fatigue and even a decrease in cognitive ability.

​Even if you didn't have these studies you probably intuitively know that your thyroid may be influencing your HPA axis. 

Why?

Because you probably have other classic symptoms of HPA dysregulation: ​

  • Fatigue especially upon wakening in the morning
  • Increase in energy or "second wind" at night right before sleep
  • Difficulty with sleep or insomnia
  • Inability to tolerate stressful situations
  • Weight gain or inability to lose weight
  • Increased cravings for certain foods including carbohydrates and refined sugars
  • Reliance upon caffeine and other stimulants for "pick me ups"

Most thyroid patients have experienced some degree of these symptoms listed above. 

And the problem may be related to cortisol and your HPA axis.

But what can you do about it?

We will talk more about other factors that influence your cortisol but for starters you should learn about cortisol and what supplements you can take to manage these cortisol levels. ​

How to Supplement with Adrenal Support
Why I like it

May boost energy and well being

Almost ALL hypothyroid patients have adrenal problems

May help boost immune function

Most patients experience improvement in 1-2 months

How to tell if you Need it

I don't always recommend testing for cortisol levels prior to treatment in every patient but if you do I recommend checking the following:

  • Serum Cortisol - AM cortisol should be between 14-16, anything less may be a problem (note: normal serum level doesn't rule out adrenal fatigue)
  • Urinary cortisol and cortisone x4 - I recommend using DUTCH testing (you can see an example of the report below)
Increased cortisol causes weight gain
How to Use

  • 1-2 Tablets per day if using Glandulars (preferably taken in the am and at noon)
  • If using supplements designed to lower cortisol like phosphatidylserine then use at night
My Recommended Brand and Product:

Adrenal Glandulars (for more severe cases of Adrenal Fatigue)

Adrenal Adaptogens​ (for less severe cases of Adrenal fatigue)

Phophatidylserine - Soy Free (for cases of ELEVATED cortisol)

​#2. Make sure your Iron & Ferritin are in the "Sweet Spot"

​Another very important nutrient that is absolutely required for proper energy production is iron. 

When I'm talking about iron I am referring to iron deficiency and NOT anemia.

Most physicians consider iron to a problem when you develop a condition known as anemia, which is to say your number of red blood cells in the blood stream have dropped to a point where they are causing symptoms in your body.

But to suggest that iron deficiency is only a problem when it causes anemia is not a good idea.

Why?

Symptoms of low ferritin

Because studies have shown that low iron by itself (even if you have normal red blood cells) has been shown to have anemia.

What's more interesting is that iron supplementation in non anemic menstruating women has been shown to INCREASE energy levels and reduce fatigue.

​How many women run around with low iron levels but normal hemoglobin levels but who are never treated with iron?

I've seen a fair amount of these patients.

Another important aspect to consider is the fact that iron is required for proper thyroid hormone production.

Thyroid hormone is also involved in iron absorption, so hypothyroidism increases your risk of developing iron deficiency. 

So now we have a scenario where thyroid patients are at increased risk for developing low iron, they are increased risk for not absorbing it, the iron itself lowers thyroid function AND most providers only treat anemia. ​

It's easy to see why hypothyroid patients should have their iron levels checked AND treated if it is determined to be low (regardless of what your hemoglobin is). 

You can read more about iron deficiency and thyroid function here

What if your iron level is low? 

You can of course supplement in a way that won't cause constipation and may increase your energy levels: 

How to Supplement with Liquid Iron

Why I like it

May Boost Energy Levels

Up to 50% of Hypothyroid patients are deficient in iron

Helps promote thyroid conversion & function

Generally works within 1-2 months

How to tell if you Need it

Check your iron studies and only supplement if your levels are sub optimal or low: 

  • Ferritin - Optimal Levels = 40-50
  • Serum Iron - Middle of the reference range
  • TIBC (Total Iron Binding Capacity) - Middle of the Reference range
  • Percent Saturation - 35-38%
Low iron studies patient case study
How to Use

  • Liquid iron: Start with 10 ml each day, do not exceed 20 ml per day (if you take more than 1 dose per day make sure to split it apart from one another and take at least 4 hours away from your thyroid medication)
  • Iron capsules: Start with 1 capsule of iron and increase up to 3 per day as tolerated and based on your serum iron/ferritin levels (take at least 4 hours away from your thyroid medication)
My Recommended Brand and Product:

Use liquid iron if you have intestinal issues such as gas, bloating, diarrhea, constipation or if you have previously failed capsule forms of iron: 

Use this capsule form if you don't tolerate the liquid iron version above (some patients have various symptoms on liquid iron such as teeth pain or simply can't tolerate the taste or texture of the liquid): 

#3. Consider B12 Shots over Oral & Sublingual B12 Supplements

Up to 40% of hypothyroid patients also have sub optimal levels of B12 or are considered vitamin B12 deficient.

​This is a huge deal because vitamin B12 is involved in the production of energy due to its effects in your mitochondria. 

Low levels of vitamin B12 result in a reduction in mitochondrial energy production (due to reduced efficiency) which manifests as fatigue.

B12 is also well known to provide "boosts" of energy in those that consume it.

One of the main products of energy drinks and other energy supplements is B12.

Why?

Because so many patients have sub optimal B12 levels.

Which brings us to our next point: ​

​So why B12 shots versus oral or sublingual B12?

In my experience I've found a huge difference in terms of how vitamin B12 shots improve fatigue in thyroid patients. 

I have many patients who have been on oral and even sublingual forms of B12 who don't respond, only to respond with increased energy once they switch to shots.

Shots are superior to oral forms because they get directly into the tissues and bypass gastrointestinal absorption.

Many thyroid patients have issues with constipation, SIBO and other GI related issues that can impair absorption of nutrients (and even other hormones).

So whenever possible it's best to bypass the GI tract to ensure as much absorption of nutrients as possible. ​

Vitamin B12 shots can be a quick and effective way to consistently manage energy levels in hypothyroid patients. ​

How to Supplement with Vitamin B12 Shots

Why I like it

May Boost Energy levels and reduce fatigue

May help increase metabolism and fat loss

Helps improve mood and increase concentration

Generally works very quickly (within 1-2 weeks)

How to tell if you Need it

Patients with the following symptoms should consider using B12 shots: 

  • Obesity or weight gain 
  • Fatigue or low energy levels
  • Lack of sleep or insomnia (including difficulty falling asleep)
  • Depression or other mood issues like anxiety
  • Hair loss or a lack of hair growth
  • Low serum B12 levels (less than 1,000)
  • High homocysteine levels (greater than 9.0)
  • MCV (mean corpuscular volume) that is higher than 92
  • High levels of inflammation
Low serum B12 levels
How to Use

  • Take 5,000 mcg of Methylcobalamin every 7 days for at least 10 weeks
  • You will need 10 weeks worth of injections to saturate tissues and increase cellular B12 levels
My Recommended Brand and Product:

Make sure you get methylcobalamin shots in a high enough dosage for best results. You can purchase high quality, pharmaceutical grade methylcobalamin which comes pre-filled with needles and syringes in the box below: 

#4. Get on the Right Type and Dose of Thyroid Medication

The truth is that being on the right type and dose of thyroid hormone is also necessary for proper energy levels. 

While it is not necessarily the ONLY or even the most important factor for increasing your energy levels it is still worth discussing.

Currently the thyroid treatment paradigm is focused on treating your thyroid based on your TSH.

Most providers and physicians feel that this allows a steady stream of thyroid hormone into your cells and technically makes you euthyroid.

This is interesting because most patients still have symptoms of hypothyroidism despite having "normal" lab work.

In addition several studies have shown that patients who are treated to "normal" TSH levels still show around 20% less circulating T3 and T4 thyroid hormones in their blood compared to age matched controls.

When you read this it's important to consider that your T3 and T4 levels are far more important than your TSH in determining cellular function of thyroid. 

​This would suggest that TSH is not the best marker for evaluating your thyroid levels in the body and indeed I have written about several conditions where the TSH isn't very accurate

​When it comes to thyroid hormone in the body most patients do require more thyroid hormone than they are currently being treated with. 

It turns out that a more sensitive marker for assessing cellular levels of thyroid hormone is your reverse T3:free T3 ratio.

This ratio gives you an idea of how much thyroid hormone (specifically T3 thyroid hormone) is entering your cells and turning on genetic function.

​In order to feel optimal most patients will need some combination of T4 plus T3 thyroid hormone. 

This can be taken in various forms including synthroid plus cytomel or medications such as natural desiccated thyroid hormone like WP thyroid or armour thyroid.

List of thyroid hormone medications

​Not all patients will need T3 thyroid hormone, in fact sometimes simply switching from levothyroxine to Tirosint is enough to boost thyroid hormone sufficiently. 

In addition, taking your thyroid hormone at night may actually increase your thyroid hormone levels in the serum due to changes in hormones and absorption. 

#5. Avoid Stimulants & Caffeine

This one may sound counter intuitive so let me explain:

​Stimulants and caffeine work by increasing the demand of existing hormonal systems in your body. 

Caffeine helps produce energy by putting pressure on your adrenal glands to produce more cortisol and increase adrenaline production.

But what if you are putting pressure on a system that is already weak to begin with?

This is exactly what happens when thyroid patients take stimulants.

And by the way, stimulants can include medications like adderall and other ADD/ADHD medications.

​While caffeine may provide you with a "quick" boost to help you get through the day, it may be causing more harm than good in the long term. 

​If you find yourself reliant upon caffeine (one of the systems of adrenal related issues and adrenal fatigue), then it's a good sign that you should NOT be consuming it. 

As you wean yourself off of stimulants you will find your energy naturally increases and your sleep schedule naturally improves. ​

#6. Get 8 Hours of HIGH Quality Sleep each night

Another obvious, but often ignored, cause of low energy in thyroid patients is a lack of sleep.

Why?

Well it could have something to do with the fact that thyroid hormone is involved in both REM and non REM sleep.

Meaning that low (or high) thyroid hormone may directly reduce the QUALITY of your sleep.

This may explain why some patients can still have fatigue despite sleeping 10+ hours per night.

It doesn't matter how long you sleep if the quality of that sleep is poor.

So make sure that you focus on quantity but also quality.

If hypothyroidism is causing a reduction in your quality then you will need thyroid hormone replacement to fix this problem.

If you simply aren't sleep well as a result of high stress, anxiety or reliance upon caffeine then you really need to step it up and focus on getting more sleep.

Another important factor is to consider WHEN you are getting your sleep.

People tend to have better functioning circadian rhythm's when they sleep through the EVENING, and not through the daytime.

​This is outlined perfectly in studies that show people who work nights (in this cases nurses) have an increased risk of DEATH from all causes and an increase risk of heart attacks

Moral of the story?

Time to get 8 hours of sleep per night.

If you need help with supplementation then see the list below: ​

How to Supplement to Boost and Improve Sleeping patterns 

Why I like it

May help to improve energy levels

May helps to reduce levels of inflammation

Helps reduce brain fog and mental fogginess

Required lifestyle change for optimal results

How to tell if you Need these supplements
  • You should be getting 8 hours of high quality sleep each and every night
  • If you find yourself waking up exhausted then you should consider checking for sleep apnea or a trial of the following supplements to improve sleep
How to Use

  • Take each supplement as indicated on the bottle or as recommended below
  • Start with supplements that don't contain melatonin, if these supplements don't work then add more supplements until you are getting 8 hours of quality sleep each night
  • In addition to these supplements make sure you practice adequate sleep hygiene, that means: black out curtains for your bedroom, noise cancelling ear plugs, glasses that remove blue light and avoiding electronics 3 hours prior to your scheduled bed time
My Recommended Brand and Products:

For minor sleep issues start with supplements containing 5-HTP which may promote proper melatonin production and induce sleep naturally (take 100mg 30 minutes before your scheduled bed time): 

For more difficult cases consider the addition of melatonin + 5-HTP, start with 1-3mg of melatonin and don't be afraid to use melatonin if you need it. I've found through urinary testing that MANY patients with sleep issues have low night time levels of melatonin. 

For more the most difficult cases consider using serotonin and GABA potentiators. These supplements help enhance GABA and sertonin neurotransmitters in the brain and help induce deep sleep. 

#7. Eat more Healthy Fat (minimize and eliminate sugar + refined carbohydrates)

Changing your diet is another important aspect of increasing your energy and reducing your fatigue.

One common theme you will find among thyroid patients is that they run to sugar or carbs as a source of energy.

Why?

​Sugar, much like caffeine, may provide a quick "boost" to your energy due to its rapid absorption and metabolism but, much like caffeine, it will do more harm than good in the long run. 

If you think of energy drinks, what do they consist of?

Loads of sugar and loads of caffeine.

Constant and frequent snacking and eating of sugar/carbs will result in higher levels of insulin resulting in long term weight gain and/or difficulty losing weight. 

Instead of focusing on sugar as a source of energy it's better to focus on healthy fats.

Healthy fats (listed below) provide long term and sustained energy throughout the day and will not give you the highs/lows that sugar does. 

healthy fats and oils for more energy

Make sure to incorporate healthy fats into your diet, but do realize that it may take up to 3-4 weeks before your body is fully able to metabolize and oxidize fats for energy. 

During this process you may notice increased irritability and/or a reduction in energy (this is normal). ​

Healthy fats to help increase your energy: ​

  • Coconut butter/oil
  • Cold pressed/organic oils such as olive oil
  • MCT oil
  • Organic flax seed
  • Avocado oil

Avoid industrial seed oils which can promote inflammation and lead to weight gain: 

  • Safflower oil
  • Soybean oil
  • Sunflower oil
  • Corn oil
  • Cottonseed oil
  • Hydrogenated or partially hydrogenated oils

#8. Reduce & Manage your Stress with these Techniques

Hopefully I don't need to convince you that stress will lead to fatigue and a host of other problems like weight gain and autoimmunity.

Instead let me give you some tips to help manage your stress. 

One of the easiest ways is to help relax your mind by listening to audio clips.

Listening to these clips can help promote delta wave activity in your brain which may help improve your sleep and help you manage your stress. ​

You can start with these 2 clips below: ​

Find this site on your iphone/smart phone, throw in some earphones, and let these audio clips run while you lay in bed. 

Do this every night and you will find benefit over a few weeks.

These were the techniques that I used to help during residency. ​

#9. ​Consider a B Complex Vitamin

While vitamin B12 is important for mitochondrial energy production, it's certainly not the only B vitamin involved in this process.

Vitamins B2, B3, B5 and ​B12 are all required: 

Vitamin B12 and energy production

In addition Vitamin B6 supplementation has been shown to improve energy and mood. 

Vitamin B deficiencies are also very common, especially among hypothyroid patients. 

Supplementing with a B complex in addition to vitamin B12 shots can dramatically improve energy levels.

Make sure to find a B complex with high levels of B6 like this one.

Wrapping it up + What to do next

Fatigue is a very common symptom of hypothyroidism and may indicate a deeper problem ranging from hormone imbalances to nutrient deficiencies. 

Simply replacing thyroid hormone may not be enough to completely energize your body and reduce your fatigue. 

Instead make sure to take a comprehensive approach which includes evaluation for nutrient deficiencies and treatment of other aspects of your life such as diet, stress and sleeping patterns. 

The combination of these therapies above has proven to be very effective in my patients and I think you will also find these techniques helpful.

Make sure to employ ALL of the therapies that are relevant to you. ​

Now it's your turn:

Are you suffering from thyroid fatigue?

What have you tried?

What's worked and what hasn't?

Leave your comments below! ​

Dr. Westin Childs
 

I'm Dr. Childs and I write these posts. I'm a physician that specializes helping patients lose weight, have more energy and FEEL better. My practice focuses on hormone imbalances, thyroid issues and weight loss resistance. My goal is to provide the BEST information out there on the internet that is both actionable and trustworthy. Get my free ebook: Hashimoto's Diet Guide here. You can also find more about my personal journey back to health here.

Click Here to Leave a Comment Below 17 comments
Monica - March 28, 2017

Was on compounded T3/T4 35 mcg/50 mcg 1 capsule in the a.m. Labs 3/2017: TSH:2.040, RT3 8.7, low iodine, Free T3:2.3. No antibodies/Hashimoto’s according to labs. I’m on LDN. Still very tired (waves), scalloped tongue, outer third eyebrows sparse, splitting/peeling nails, weight gain/difficulty losing even on keto/low carb. Now on 30 mcg of Cytomel divided into 3 doses every 4 hours. It’s less than I was on although spread out more. Feels like “I’m back!” for the first hour and then it’s downhill from there until the next dose. Thinking I might be one of the higher T3 dosed folks out there. Tweaking isn’t fun but it’s progress. More thanks than I can ever express Dr. Childs for your generosity of effort and time to help me/all of us. Thank you.

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    jj - April 7, 2017

    my tongue was scalloped when I was low in b12 and had low serum iron

    Reply
Jodie Sipes - March 28, 2017

I have tried to download your diet book several times… Nothing happens??

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Damaris - March 29, 2017

Wow I have like every symptom mentioned and I’ve been battling hypothyroid for over 15 years. I just found out I have hasimoto and now I’m in some vitamins/herbs. I hope to see results as I now want to incorporate good eating habits and loose weight! It’s a horrible feeling not to feel normal and others judging! So hard! I’m so desperate to try anything! Thank you for information! Very useful.

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Irina - March 29, 2017

Please, tell us what you consider optimal B12 level? Reference range is so broad! My last test showed B12 at 585. My doc said “it’s perfect”, but I have this chronic debilitating fatigue that I cannot fight no matter what I do. My ferritin was 20, for a month I was talking an iron pill with vit C. My ferretin went up to 21 in a month. I think I have a problem with absorption, but my doc is not concerned since all other numbers are ok. What would be the next step? Liquid iron? B12 shots? I am so lost and tired.
Irina

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Leslie - March 29, 2017

I can almost predict now when the Hashimoto’s Fatigue will hit: any stressful event will flatten me the following day. I’ve got my deficiencies back on track and discovered my B12 deficiency was actually pernicious anemia. Monthly injections help tremendously. Thank you for the music suggestions to de-stress. Will check those out.

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Lisa Vara - March 29, 2017

Hi Dr. Westin,
I keep trying to download your free book and can’t seem to get it?
I really would like to read it…
Thank you
Lisa Vara

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Barbara - March 29, 2017

Hi Dr. Childs,

What would you suggest as an alternative to Levothyroxine/Synthroid, if one has heart issues? Ever since I developed Graves disease, and subsequently had my thyroid removed, I’ve had heart palpitations. My doctor tried to put me on Cytomel (because of constant fatique and difficulty losing weight on Levothyroxine/Synthroid) and it was pretty frightening – gave me a lot of chest pain and a rapid heart beat. I took myself off of it after a week, because it was just scary.

I have a cardiologist, but he seems uninformed, when it comes to diet/thyroid options.

Any thoughts/ideas?

Thank you,
Barbara

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E. S. - March 30, 2017

Thanks for this excellent information.

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Jen - March 31, 2017

Dr. Childs,

Thank you so much for sharing your ‘wealth of knowledge’!

When I read your articles, I feel as if I am reading the bible for my healthy !!!

Sincerely,
Jen

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Irene - April 1, 2017

great info!!

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Annie - April 1, 2017

Hi … I am beyond at my ropes end!! It seems my doctors have no idea what to do when they see my blood tests are off. I had a thyroidectomy due to cancer. Synthroid was NOT for me … I was on Armour for years and then something changed … the last 3 to 4 years have been a nightmare of weight gain, fatigue, high inflammation, hair loss (on one side only!) my skin is now rough, change in mood to just blah! I watch you on youtube and asked the dr. to runs some tests like Leptin .. I have results but he didn’t say if it was high or low for me and when I asked he said you should be fine period. Maybe you’re getting a bit frustrated reading this, at the lack of interest on some doctors ability to explain to patients what their blood tests mean as a “whole” … I have several tests that came back either too high or too low and all I was told is “you’ll be fine” … ??? Can YOU help me Dr. Childs? I switched to WP Thyroid a week ago today. My doctor (endocrinologist) had no clue what it was! and asked ME how much she should give me??? So I’m on a “guessed” amount and it’s not helping me at all. Thanks for reading. Signed, ‘hoping for a miracle’

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jj - April 7, 2017

for those a little older especially women…I find maca GO- maca helps a lot with adrenals/cortisol, thyroid, and balancing other hormones hence very supportive…..

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si - April 19, 2017

After blood tests,I just learned that my pituitary gland is not “communicating effectively” with my thyroid. I was put on a pituitary support called pituitrophin pmg. Have you ever heard of or used this support before?
My tsh is low, t4 is low but t3 is optimal (upper 75% of range). I read your documentation all the time & even use supplements you recommend. Thank you for all your work, it has educated me & I share your site with everyone I meet who’ve just discovered they are hypothyroid. We wish more doctors were as knowledgeable as you!

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