What Happens If You Don’t Take Thyroid Medication?

Written by Dr. Michael Ruscio, DC on May 31, 2024

To Understand Your Risk, First Understand If Your Levels Require Meds At All

Do You Need Thyroid Meds?|
What if You Don’t Take Them?|
Taper and Wean|
Don’t Wing It!|

It’s becoming increasingly clear to me that thyroid medication is often overprescribed, especially for some cases of hypothyroidism.

Medication is necessary if you have overt (or true) hypothyroidism or hyperthyroidism, but many people (especially women and folks over age 60) are prescribed medication when they have subclinical versions of these thyroid abnormalities [1, 2, 3]. In this context, taking thyroid medication is like using a sledgehammer on a finishing nail—it’s too much and not helpful for solving the problem at hand. It can even be damaging in some instances.

That said, if you do need medication, it’s really important that you take it, so finding out if you truly need it should be step one. A blood test from your healthcare provider should get you the results you need to determine whether you have a thyroid condition that would actually benefit from medication.

In the United States, hypothyroidism is diagnosed eight times more often than hyperthyroidism, and the vast majority of my clients with thyroid issues have hypothyroidism. So, I’ll briefly touch on hyperthyroidism, but I’ll mostly focus on hypothyroidism and its treatments to help answer questions about what happens if you need but don’t take thyroid medication [4]. Let’s first understand how to determine if you really need thyroid medication. If you do need it but aren’t taking it, I’ll explain the risks. And then, for people on thyroid replacement hormones who discover they need a lower dose or don’t need them at all, I’ll go over safe ways to taper or wean off thyroid medication with a doctor’s supervision.

Do You Need Thyroid Medication?

There are four main categories of thyroid disease. Overt and subclinical hypothyroidism (or underactive thyroid) and overt and subclinical hyperthyroidism (or overactive thyroid). The overt (or true) versions of each category require medication, but the subclinical versions are usually temporary and go away with time and possibly some diet and lifestyle adjustments.

I’ll break down each category into its lab values, symptoms, potential causes, and appropriate treatment.

Overt (True) Hypothyroidism

Diagnosed when: TSH is above 4.5 and free T4 is below 0.8.

Going by lab values, when thyroid-stimulating hormone (TSH) is above 4.5 and free thyroxine (T4) is below 0.8, an overt hypothyroidism [5, 6].

If TSH is above 4.5 and free T4 is below 0.8, and thyroid peroxidase (TPO) antibodies are above 500, that’s overt hypothyroidism with Hashimoto’s thyroiditis [5, 7, 8]. Hashimoto’s is an autoimmune attack on the thyroid gland that sometimes, but not always, leads to hypothyroidism [5, 7, 8, 9].

The most common symptoms of overt hypothyroidism, listed below, may overlap with other conditions. It’s possible to have a combination of these symptoms, so getting blood work is important.

Symptoms of hypothyroidism may include:

Tiredness [5, 10, 11, 12, 13, 14]
Constipation [5, 10, 11, 12, 13, 14]
Dry skin [5, 10, 11, 12, 14]
Cold intolerance [5, 10, 12, 14]
weight gain [5, 10, 12, 14]
Hoarseness [5, 10, 12, 14]
Mood changes [5, 11, 13]
Muscle pain [5, 11, 13]

The top two causes of overt hypothyroidism are a lack of dietary iodine (which is now rare in the U.S.) and Hashimoto’s thyroiditis [5]. While a deficit in dietary iodine can be addressed without medication, autoimmunity takes a bit more effort to resolve. But it is possible to manage it with diet and supportive supplements.

Even though Hashimoto’s is the most common cause of overt hypothyroidism [5], not all hypothyroid patients have or will develop Hashimoto’s thyroiditis, and not all Hashimoto’s patients develop hypothyroidism [9].

For example, roughly 5–19% of the U.S. population has Hashimoto’s, but only 0.3% of people in the U.S. have hypothyroidism [8, 9, 15, 16, 17]. In fact, only 9–19% of people with TPO antibodies (which attack the thyroid gland) go on to develop true hypothyroidism [9]. Those people typically have TPO antibodies that are higher than 500 [9], but a Hashimoto’s diagnosis occurs when that number is just above 35.

Great ways to bring TPO numbers down are by eating an anti-inflammatory diet [18, 19, 20, 21, 22]—reducing sugar, processed foods, trans fats, gluten, and alcohol—and adding in selenium [23, 24] and vitamin D supplements [25, 26].

Other, less common, factors can also increase the chances of developing true hypothyroidism. They include [5]:

Certain prescription medications, including some cancer medications
Thyroid radioactive iodine therapy (for Graves’ disease, or hyperthyroidism)
Thyroid surgery
Radiotherapy to neck or head
Central hypothyroidism from disorders of the pituitary gland or hypothalamus
Giving birth
Subacute granulomatous thyroiditis (de Quervain disease, which is usually self-limiting)

Overt Hypothyroidism Treatment

People with overt thyroiditis do need conventional medical intervention to get their thyroid levels where they need to be. Thyroid hormone replacement medication—aka levothyroxine or LT4, brand name Synthroid—helps bring thyroxine (T4) numbers to healthy levels.

Adding certain functional medicine treatments to the conventional approach can help support thyroid function as well as the systems—primarily the digestive one—that affect it. In addition to prescription medication, functional medicine treatments might include the following:

Improving gut health with a thyroid-supporting diet [20, 22, 27, 28, 29, 30, 31, 32, 33] and probiotics [34]
Taking thyroid-supportive supplements like vitamin D [25, 26, 35, 36] and selenium [23, 24, 37, 38, 39]
Trying red light therapy [40, 41]

Subclinical Hypothyroidism

Diagnosed when: TSH is mildly high (4.5–10 mIU/L) but T4 is in normal range (0.8–1.8 ng/dL).

Thyroid labs showing a mildly high TSH (4.5–10 mIU/L) with a normal free T4 (0.8–1.8 ng/dL) indicate subclinical hypothyroidism or a mildly underactive thyroid [5, 7, 8]. However, these numbers tend to vary a bit for people who are 60 or older because their TSH levels rise naturally [1, 6, 42, 43]. The following chart shows how to identify subclinical hypothyroidism in older adults and avoid misdiagnosis when their TSH matches that of younger patients who qualify for subclinical hypothyroidism.

Another thing to look out for is a “sluggish thyroid.” That’s a term some functional and integrative practitioners sometimes use to refer to lab findings that are in the “suboptimal half” of the normal range for TSH, free T4, and even T3. For example, a TSH of 4.1 and a free T4 of 1.0 (which are very common) might get called sluggish thyroid. However, sluggish thyroid is not an actual diagnosis, and variations within normal thyroid hormone ranges are nothing to worry about.

Although subclinical hypothyroidism doesn’t typically cause symptoms, it can. The most common symptoms of subclinical hypothyroidism may include [44]:

Dry skin
Hair loss
Constipation
Loss of appetite
Weight gain
Brain fog
Anxiety
Fatigue
Irregular menstrual cycles

Subclinical Hypothyroidism Treatment

It’s not uncommon for well-meaning doctors to prescribe levothyroxine to patients with subclinical hypothyroidism [3]. However, in up to 74% of cases, a mildly underactive thyroid will resolve on its own over time or with dietary and lifestyle improvements [3].

Both research and my clinical experience tell me that many people take levothyroxine for no reason [45, 46] and get unpleasant symptoms that look like hyperthyroidism as a result [47, 48].

Appropriate treatments for most people with subclinical hypothyroidism overlap with the functional add-ons for true hypothyroidism, minus the hormones. Before they take any medication, I’ll have my subclinical hypothyroid clients consider dietary changes, probiotics, bedtime improvements, and stress reduction techniques that should reduce any inflammation that may be contributing to their symptoms. Then, we’ll retest their thyroid in 2–3 months.

If their numbers haven’t normalized, we’ll incorporate the nutrients selenium and inositol [49, 50, 51]. Again, after trying these nutrients for 2–3 months, we’ll retest. If abnormal TSH levels persist, I’ll ask my clients to speak with their doctor about thyroid hormone treatment. It is possible, after all, that they may have developed a true thyroid hormone deficiency. It’s also possible that they just need a temporary nudge from thyroid hormone medication.

Similarly, if my clients with subclinical hypothyroidism are pregnant or working through infertility, I recommend that they consult with their doctor about using thyroid medication, which can help when used temporarily [2, 52] .

Overt (True) Hyperthyroidism

Diagnosed when: Blood test results show low TSH (<0.4 mIU/L) and high free T4 and/or T3 [6, 53] .

To find out which type of hyperthyroidism is present, a doctor may run a 24-hour radioactive iodine uptake test and look for thyroid antibodies (against TSH-receptors, thyroid peroxidase, thyroid stimulating immunoglobulin, thyrotropin-binding inhibiting immunoglobulin, and thyroglobulin). Graves’ disease, a type of thyroid autoimmunity, is the most common type of hyperthyroidism.

The most common symptoms of overt hyperthyroidism are [48]:

Weight loss despite a higher appetite
Heart palpitations
Nervousness
Tremors
Difficulty breathing
Becoming easily fatigued
Diarrhea
Muscle weakness
Heat intolerance
Sweating more than usual
Irregular menstrual cycles

Factors that up the risk of overt hyperthyroidism commonly include:

Too much dietary iodine [48]
Iodine deficiency (which can lead to both hypo- and hyperthyroidism) [48]
A family history of hyperthyroidism [48]
Being female (it’s 10 times more likely to occur in women than men) [48]
Metabolic syndrome and insulin resistance are associated with increased Incidence of goiter and thyroid cancer [54]

Treatment for Overt Hyperthyroidism

Conventional treatment for overt hyperthyroidism includes taking radioactive iodine or antithyroid medication, or having part of the thyroid gland removed [48].

Functional approaches to improve the effectiveness of conventional therapies may include:

Dietary improvements [22, 29, 30]
Improving gut health [55, 56, 57, 58]
Taking one or more of the following supplements, as directed by a healthcare practitioner:
- Selenium [37, 59, 60, 61, 62, 63, 64]
- Vitamin D [35, 65]
- L-carnitine [66, 67]
- Bugleweed [68, 69, 70]
- Lemon balm [70]
Light therapy [40, 41]

Subclinical Hyperthyroidism

Diagnosed when: Thyroid labs show that TSH is low (<0.4 mIU/L), but free T4 and free T3 are normal [47, 53].

If symptoms occur at all, the most common ones are milder than those of the overt type. They may include [47]:

Irregular heartbeat
Heat intolerance
Insomnia
Increased appetite
Diarrhea
Weight loss
Hair loss
Sweating
Abnormal periods
Hand tremors

Factors that may lead to or increase a person’s risk of subclinical hyperthyroidism may include [47]:

Getting treated for thyroid cancer
Using thyroid hormones for weight loss
Taking too much thyroid hormone replacement therapy for hypothyroidism

Treatment for Subclinical Hyperthyroidism

Subclinical hyperthyroidism is typically resolvable and transient, meaning it usually clears up on its own without treatment or with general improvements in health. Even so, it may take up to 3–6 months for symptoms to resolve [47].

Treatment options include setting right any obvious and correctable contributors, such as a suboptimal cancer treatment approach, poor diet, or stressful lifestyle. Once those changes are in place, it’s important to recheck thyroid levels every 3 months. Very rarely, a doctor may suggest trying antithyroid medications, radioiodine therapy, or thyroid surgery, but these should be last-ditch options [47].

Key Takeaway: Typically, only the overt or true types of hypo- and hyperthyroidism require medication. Subclinical thyroid disease usually resolves on its own or with simple adjustments to diet and lifestyle.

What Happens if You Don’t Take Thyroid Medication?

If you need thyroid medication for any type of thyroid condition, it’s definitely not a good idea to go without it, especially for very long. A missed dose here and there is probably not harmful, but you may experience symptoms of your thyroid disorder if you’re not taking them as you should.

Long-term untreated thyroid issues can increase your risk of heart disease, bone problems, fertility issues, organ failure, and even premature death in some cases.

Hypothyroidism

Not taking medication for overt hypothyroidism highly increases the risk of illness, coma, heart failure, and death [5].

Though medication isn’t required, even unaddressed subclinical hypothyroidism could progress to overt hypothyroidism, which may then raise the risk of cardiovascular disease, congestive heart failure, and cognitive decline [71].

On the flip side, as you and your doctor manage your hypothyroidism medication, make sure you’re not taking too much thyroid hormone.

A Note on Gut Health and Medication

Sometimes poor gut health can limit the absorption of thyroid medication, requiring a higher dose to be effective. One way we help clients improve how well their hypothyroid medications work is to make sure they are taking steps to improve and maintain their gut health. Factors that can lower the effectiveness of thyroid medication for hypothyroidism include [72]:

Reduced stomach acid (from a Helicobacter pylori infection, PPI use, antacid use, autoimmune gastritis, or history of gastric bypass)
Leaky gut
Malabsorption (common in ulcerative colitis, Celiac disease, autoimmune gastritis, and other gut disturbances)
SIBO (small intestinal bacterial overgrowth)

When taking thyroid hormones for hypothyroidism, a gut-centered approach can help to improve the absorption and effectiveness of the medication and potentially reduce the necessary dose.

Hyperthyroidism

Not treating overt hyperthyroidism increases the risk of extreme hyperthyroidism, also called a thyroid storm. This involves rapid heart rate, diarrhea, excessive sweating, anxiety, fever, and multiple organs malfunctioning. A thyroid storm requires immediate treatment, or it can be life-threatening.

Over the long term, untreated or undertreated hyperthyroidism may raise the risk of acute cardiovascular events, atrial fibrillation (irregular heart rate), ischemic stroke (blood clot blocking blood flow to the brain), osteoporosis, infertility, abnormal menstrual cycles, and death [48].

Similarly, not keeping an eye on subclinical hyperthyroidism can allow it to develop into overt hyperthyroidism over time and increase the risk of atrial fibrillation, osteoporosis, hip fractures, or death [48].

Key Takeaway: When a thyroid disorder requires medication, it’s very important to take it. Addressing subclinical thyroid conditions is also important to prevent them from becoming overt. Improvements in gut health may make it easier to absorb thyroid medication, which could make it more effective.

How to Taper or Wean Off Hypothyroid Medication Safely

I’ll start this section by saying that nothing in this article (nor anything on my site) is meant to replace your relationship with your doctor. I do not offer medical advice unless you are my client. Any time you change the dosing of a prescription medication, you should be under your provider’s close supervision.

In particular, people with hypothyroidism have the potential to take more thyroid hormone than they need for a number of reasons. For example, maybe their doctor has prescribed too high a dose, they accidentally (or intentionally) took more than their prescribed dose, or they’ve improved their gut health and can absorb their medication better.

Taking too much thyroid hormone may be especially common in people with subclinical hypothyroidism who probably don’t need thyroid hormone replacement [1, 2].

If you start to notice symptoms that suggest your thyroid meds are too much, you can talk with your provider about titrating down. If your lab results and symptoms support you reducing or going off medication, then you and your doctor can consider doing so together.

It’s important to know that stopping your medication suddenly may result in negative side effects [73]. Fortunately, as the following table shows, there’s a range of weaning options that research indicates are safe and effective [73]. They may be helpful to consider with your doctor if appropriate.

Note that stopping thyroid hormone medication may be easier if your original dose is 56 micrograms/day or less, and you’ve been on it for 4.6 years or less [73].

Option	Appropriate starting dose	Different science-backed strategies for safely quitting levothyroxine (LT4)
1	Lower (56 mcg or less)	Cut the original dose in half during week 1 and stop altogether at the start of week 2 [74].
2	Higher	Cut the original dose in half and take it for 4 weeks, then cut that dose in half and take for 4 weeks, etc., until you reach 12.5 micrograms (mcg)/day or less; then stop [74].
3	Lower	Cut the original dose in half, take that for 2 months, and then stop [74].
4	Higher	Cut the original dose by 25 mcg every 2 months, stopping no later than 6 months [74].
5	Higher	Slowly cut the original dose by 12.5–50 micrograms over 3 months until you’ve reached 12.5 mcg or less; then stop [73].
6	Any dose	Stop levothyroxine (LT4) and switch to liothyronine (LT3) for 2–4 weeks and then gradually taper off LT3 for 2 weeks [75].

As you move through this process, listen to your body and pay attention to your symptoms. If anything arises, report those changes to your medical provider [73]. For example, if you and your doctor decide to try the first option, but you don’t feel right at the start of week 2, they will be able to help you switch to a different schedule.

Note that each option may be better suited to particular dosages. For example, the first and third options may be fine if you’re on a lower dose, like 56 micrograms (mcg) per day or less, whereas the second, fourth, and fifth options may be better if you’re on a higher dose [73].

Although the science on the negative effects of stopping suddenly is generally observational and not exactly conclusive, some studies have found that some people can have severe reactions to a sudden discontinuation of levothyroxine [75, 76, 77, 78, 79]. Therefore, I do not recommend stopping suddenly.

When it Comes to Thyroid Meds, Don’t Wing It

Understanding your thyroid numbers is the most important step in the process of determining whether or not you need to be taking thyroid medication. With a doctor’s help, you can easily assess thyroid problems, even if the numbers change slightly over time. If your numbers reach a threshold indicating a need for prescription medication, take those results seriously, and work with your doctor to start medication for overt hypothyroidism or overt hyperthyroidism.

If your numbers suggest subclinical hypo- or hyperthyroidism, it’s a good idea to begin paying attention to your diet, gut health, and stress levels. As I’ve found with many clients, working on gut function is a reasonable place to start as we make a plan to retest their thyroid levels in a few months.

If you’d like more tailored guidance on your thyroid health journey, we’d love to help you get started. Reach out to our clinic to set up a consultation.

The Ruscio Institute has developed a range of high-quality formulations to help our clients and audience. If you’re interested in learning more about these products, please click here. Note that there are many other options available, and we encourage you to research which products may be right for you. The information on DrRuscio.com is for educational purposes only. It is not a substitute for professional medical advice, diagnosis, or treatment.

Dr. Michael Ruscio is a DC, Naturopathic Practitioner, researcher, and clinician. He serves as an Adjunct Professor at the University of Bridgeport and has published numerous papers in scientific journals as well as the book Healthy Gut, Healthy You. He also founded the Ruscio Institute of Functional Health, where he helps patients with a wide range of GI conditions and serves as the Head of Research.

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