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Hypothyroidism: The Hidden Chronic Fatigue Syndrome Symptom

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Hypothyroidism and Chronic Fatigue Syndrome

A significant percentage of people with ME/CFS (myalgic encephalomyelitis / chronic fatigue syndrome) also have an underactive thyroid, better known as hypothyroidism. Unfortunately, hypothyroidism often goes undiagnosed due to insufficient testing and wide variations in what different laboratories classify as “normal” thyroid levels. Could some of the symptoms you’ve been attributing to ME/CFS actually be caused by an underactive thyroid?

ME/CFS and Hypothyroidism: My Story

In the fall of 2014, I developed a new batch of weird symptoms. I had terrible insomnia, I had no energy, my emotions were all over the place, I had gained twenty or thirty pounds, and I had insane levels of brain fog. This was on top of my already-present fatigue, muscle pain, and general chronic fatigue syndrome symptoms. Eventually, I started seeing a new functional medicine doctor, who ran a number of labs, including a full thyroid panel. I didn’t have a sky-high TSH (thyroid stimulating hormone), but it was elevated, and I had all the symptoms of hypothyroidism. My doctor prescribed a combination of the thyroid medications Armour Thyroid and Cytomel, and I soon started to feel better. Since then, my thyroid dose has fluctuated based on my symptoms, and getting regular labs has helped keep everything in check. I recently got my labs back, which showed my TSH had increased since the spring, and suddenly all of the symptoms I’d been experiencing lately made sense: here was some hard evidence to show the insomnia, lethargy, dry hair and skin, and mood issues weren’t just in my head. Taking thyroid medication and supplements has not cured my ME/CFS, but addressing my thyroid issues has improved my quality of life dramatically.

What Is Hypothyroidism?

Hypothyroidism occurs when your thyroid gland produces insufficient levels of thyroid hormones. The pituitary gland produces thyroid stimulating hormone in response to your body’s levels of thyroid hormones. If your own thyroid hormone levels are low, then your pituitary sends out more thyroid stimulating hormone, so you’ll produce more thyroid hormones. This is why hypothyroidism is often diagnosed via an elevated TSH. For some patients, hypothyroidism is caused by Hashimoto’s thyroiditis, an autoimmune condition where the immune system attacks the thyroid gland.

The Hypothyroidism and ME/CFS Connection

A 2018 study found a higher prevalence of “low T3 syndrome” in patients with ME/CFS than in healthy controls. The ME/CFS patients had similar TSH levels, but lower Free T3, Total T4, Total T3, and urinary iodine, but higher % reverse T3. Further research and confirmation of these findings might spur treatment of ME/CFS patients using T3 or iodine. (For more information about this study, read “The Atypical Thyroid Issues in Chronic Fatigue Syndrome (ME/CFS), Plus a New Thyroid Subset?

Hypothyroidism Symptoms:

Not surprisingly, many symptoms of hypothyroidism overlap with ME/CFS symptoms. They include (among others):

  • Fatigue
  • Weight gain
  • Depression
  • Brain fog and difficulty concentrating
  • Feeling cold (especially hands and feet)
  • Dry hair and skin
  • Thinning of the outer third of your eyebrows
  • Insomnia
  • Constipation

Lab Testing for Hypothyroidism:

A standard thyroid panel usually just includes TSH and T4. Ideally, your doctor will order a full thyroid panel, which includes the following tests (if you can’t get a lab order from your doctor, many of these tests can be ordered online):

  1. TSH (Thyroid stimulating hormone): Reference ranges vary for this critical test. According to Izabella Wentz, pharmacist and thyroid specialist, “despite some lab tests stating that a TSH of 8 or 5 μIU/mL is ‘normal,’ most people feel best with a TSH between 0.5-2 μIU/mL.” Further, The National Academy of Clinical Biochemists indicates that 95 percent of individuals without thyroid disease have TSH concentrations below 2.5 μIU/mL. (I personally notice a big difference when my TSH is around 1-2 versus 4-5).
  2. Free T4 (Thyroxine): T4 is the “storage” hormone, and your body converts T4 into T3. You can still feel exhausted with a “normal” T4 level, due to a conversion issue.
  3. Free T3: If your TSH, T4 and Free T4 are normal, but your T3 or free T3 is low, you may have hypothyroidism symptoms. According to Chris Kresser, functional medicine practitioner, this can be caused by inflammation and elevated cortisol levels.
  4. Thyroid antibodies: Thyroid peroxidase antibody (TPO) and Thyroglobulin antibody (TGAb) tests are both helpful in diagnosing autoimmune conditions like Hashimoto’s thyroiditis. Not all patients with Hashimoto’s symptoms will have positive antibodies, so pay attention to your symptoms.
  5. Reverse T3: Reverse T3 is an inactive form of T3 that is a result of a messed-up T4 to T3 conversion process. According to Mary Shomon, author and thyroid expert, elevated Reverse T3 can signal that your body is under stress, and can contribute to hypothyroid symptoms even if T3 or Free T3 levels are normal. Ideally, Reverse T3 should be in the lower half of the normal lab range.

Treating Hypothyroidism

If you’ve been diagnosed with hypothyroidism, there are a few ways to treat it.

Prescription Medications:

  1. Synthroid: Synthroid (levothyroxine), a synthetic form of T4, is the standard treatment for hypothyroidism. Some patients experience no improvement or even a worsening of symptoms from Synthroid, especially for those with high reverse T3.
  2. Cytomel: Cytomel (liothyronine) is a synthetic form of T3, which can be helpful for those with conversion issues or low T3 syndrome.
  3. Armour or NDT (Natural dessicated thyroid): these forms include both T4 and T3, as well as trace amounts of other thyroid hormones. Some patients find they do better on the combination of T4 and T3.
  4. Compounded thyroid: this is a custom dose, usually a blend of T4 and T3, which is determined by your doctor and formulated by a compounding pharmacy. Pharmacies can also make sustained-release T3 formulations.
  5. Low Dose Naltrexone (LDN): LDN is used for a variety of conditions, including ME/CFS and fibromyalgia. For patients with high levels of thyroid antibodies and/or Hashimoto’s thyroiditis, LDN can be a game-changer. LDN is available from compounding pharmacies at doses generally ranging from 1.5 mg to 4.5 mg.

If you decide to take prescription thyroid medication, then it’s important that you take the medication properly. This means on an empty stomach, first thing in the morning, and away from any medications or supplements that might interact with the thyroid hormones (this includes iron and calcium).

Supplements for Thyroid Support:

  1. Selenium: Selenium helps in the conversion of T4 to T3, and may help reduce thyroid antibody levels. Dietary sources of selenium exist, but the amount of selenium in foods like Brazil nuts varies greatly. For optimal thyroid health, Izabella Wentz has found selenium supplementation of 200-400 mcg per day to be safe, especially for patients with Hashimoto’s
  2. Zinc: A deficiency in zinc may result in hypothyroid symptoms, as zinc is critical in the conversion of thyroid hormones. Food sources include oysters, pumpkin seeds, beef, liver, and chicken; however, those with thyroid issues may find supplementation helpful. Take zinc supplements away from iron, as iron can affect zinc absorption. Forms like zinc picolinate are thought to be well-absorbed. Supplement with 30 mg or less per day.
  3. Vitamin D: A deficiency in Vitamin D can cause any number of issues, and can affect thyroid function. A 2013 study found serum Vitamin D levels were significantly lower in hypothyroid patients than in healthy controls. This can be checked with a serum 25(OH) vitamin D lab test.
  4. Iodine: Iodine supplementation is tricky for hypothyroidism, as low iodine levels can exacerbate hypothyroid symptoms, but excess iodine, especially in patients with autoimmune disease, can also make things worse. It’s best to work with your practitioner and and get necessary lab work done first.
  5. Ashwagandha: This adaptogenic herb may help alleviate hypothyroid symptoms, according to a 2018 study.

Other Potential Issues

It’s important to note that if your symptoms persist after starting hypothyroid treatment, you might have underlying issues that need to be addressed. A few of the possibilities include: pituitary dysfunction, under-conversion of T4 to T3, elevated or decreased thyroid binding globulin (TBG) and thyroid resistance. If your thyroid treatment doesn’t seem to be working, be sure to tell your doctor and discuss other possible issues.

My Current Hypothyroidism Regimen

I take a compounded thyroid medication, which includes a blend of T3 and T4. I also take one drop of liquid iodine daily (150 mcg), 3 mg of Naltrexone (LDN), as well as selenium, iron, and vitamin D to address deficiencies shown by my labs. I do not eat gluten or dairy, as I’ve found both to cause either stomach discomfort or skin issues. Because of fluctuations in my ME/CFS symptoms, I get labs done regularly to make sure I’m on the correct dose of thyroid medicine. Often I’ll be feeling sluggish and overcome with brain fog, only to realize that I need to adjust my medication.

How to Find a Doctor

If you’re struggling with hypothyroid symptoms, it might be worth looking for a doctor with an integrative focus. Good resources for this include The Institute for Functional Medicine’s Find a Practitioner and the Academy of Integrative Health & Medicine’s Find a Provider. Additionally, consider contacting your local compounding pharmacy, as they may know of endocrinologists and other physicians in the area.

Rachel Horton is a freelance writer and researcher based in Milwaukee, Wisconsin. She was diagnosed in 2008 with Chronic Fatigue Syndrome and Fibromyalgia, and now saves her energy for sailing and dinner parties. She graduated with a degree in Economics from Indiana University, and now applies her analytical skills to finding new treatments and experiments, which she chronicles at https://chronicfatiguesanity.wordpress.com/. Follow her on Twitter @cfsanity.


Hypothyroidism (underactive thyroid) – Symptoms and causes. Mayo Clinic. Retrieved 10/02/19.https://www.mayoclinic.org/diseases-conditions/hypothyroidism/symptoms-causes/syc-20350284

Kresser C. 5 Thyroid patterns that won’t show up on standard lab tests. ChrisKesser.com. 07/22/19. https://chriskresser.com/5-thyroid-patterns-that-wont-show-up-on-standard-lab-tests/

Mackawy AMH, Al-ayed BM, Al-rashidi BM. Vitamin D deficiency and its association with thyroid disease. Int J Health Sci (Qassim). 2013 Nov; 7(3): 267–275. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3921055/

Ruez-Nunez B, Tarasse R, Vogelaar EF, Dijck-Brouwer DAJ, Muskiet FAJ. Higher prevalence of “low T3 syndrome” in patients with chronic fatigue syndrome: A case-control study. Front Endocrinol (Lausanne). 2018; 9: 97. doi: 10.3389/fendo.2018.00097

Sharma AK, Basu I, Singh S. Efficacy and safety of ashwagandha root extract in subclinical hypothyroid patients: A double-blind, randomized placebo-controlled trial. J Altern Complement Med. 2018 Mar;24(3):243-248. doi: 10.1089/acm.2017.0183.

Wentz I. 11 Strategies to overcome Hashimoto’s Fatigue. 06/28/19. https://thyroidpharmacist.com/articles/strategies-overcome-hashimotos-fatigue/

Wentz I. Selenium: the nutriient that can reduce thyroid antibodies by 40%. 09/27/18. https://thyroidpharmacist.com/articles/selenium-deficiency-and-hashimotos/

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By ProHealth-Editor

Karen Lee Richards is ProHealth’s Editor-in-Chief. A fibromyalgia patient herself, she co-founded the nonprofit organization now known as the National Fibromyalgia Association (NFA) and served as its vice-president for eight years. She was also the executive editor of Fibromyalgia AWARE, the very first full-color, glossy magazine devoted to FM and other invisible illnesses. After leaving the NFA, Karen served as the Guide to Fibromyalgia and Chronic Fatigue Syndrome for the New York Times website About.com, and then for eight years as the Chronic Pain Health Guide for The HealthCentral Network.To learn more about Karen, see “Meet Karen Lee Richards.”

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