Some people feel worse even when their TSH is normal on levothyroxine. If that sounds like you, there are real alternatives and steps you can try — but they need testing and doctor oversight.
If your body doesn't feel right on T4-only therapy, doctors sometimes try combination T4/T3 therapy. This mixes levothyroxine (T4) with liothyronine (T3) in a ratio that aims to raise active T3 levels. Some patients report better energy and clarity, while others see no change. Another option is natural desiccated thyroid (NDT), sold under brand names like Armour. NDT contains both T4 and T3 from pig thyroid and can help some people, but it has variable hormone amounts and may not suit everyone. Pure T3 therapy exists too but is used rarely because it can cause heart palpitations and unstable levels.
Diet and addressing nutrient gaps can make a difference. If you have iodine deficiency, replacing iodine helps — but too much iodine can harm people with autoimmune thyroid disease, so test first. Selenium supplements can lower thyroid antibody levels in some people with Hashimoto’s and may ease symptoms. Vitamin D often shows low levels in people with thyroid issues, so correcting that is a simple win. Fixing gut health and treating chronic inflammation can also improve how you feel.
Start with the right tests: TSH, free T4, free T3, reverse T3, and thyroid antibodies if autoimmune disease is suspected. Keep a symptom diary so you and your clinician can see trends. Any medication change needs follow-up labs about six to eight weeks after adjusting doses. Watch out for overtreatment — symptoms like palpitations, anxiety, or weight loss can mean your dose is too high and long-term overtreatment risks bones and heart.
Combination therapy or NDT is most often considered when symptoms persist despite normal labs on levothyroxine, especially when free T3 is low. Pregnant people stay on levothyroxine because it’s stable and safe during pregnancy. If you have heart disease, be extra cautious with T3 because it can raise heart rate and oxygen demand.
Ask about why your current treatment isn’t working, whether full thyroid testing has been done, risk vs benefit of T3 or NDT, and how follow-up will be handled. If your clinician is unsure, a referral to an endocrinologist makes sense.
Small changes can help you feel better, but do them with testing and monitoring.
Expect any change to take time: give a new plan at least two months before judging results, and keep notes on sleep, mood, weight, and energy. Dosing mistakes happen, so never switch doses without professional advice. If side effects like chest pain or severe tremor appear, stop and seek care. NDT can shift antibody tests and thyroid levels unpredictably, so labs are the way to know if you're under- or overtreated. Want help framing notes for your doctor or a checklist for labs? I can make one you can print now.
