How Hashimoto's Disease Is Treated

Hashimoto's disease, also known as Hashimoto's thyroiditis, is an autoimmune condition that attacks the thyroid gland, often resulting in an underactive thyroid (hypothyroidism).

Treatment for this condition depends on whether it is causing subclinical (without symptoms) or overt (causing symptoms) hypothyroidism. The standard treatment is a daily thyroid hormone replacement medication, and there are lifestyle changes, supplements, and complementary alternative medicine options to consider as well.

Alternative medicine and lifestyle changes to help manage symptoms of Hashimoto's disease
 Verywell / Ellen Lindner

Considerations

Hashimoto's disease can cause overt or subclinical hypothyroidism. In general, the distinction is made based on whether there are symptoms, the level of thyroid hormone, and thyroid-stimulating hormone (TSH) levels.

Typically, when the thyroid gland is not making enough thyroid hormones, the thyroid hormone levels are low and the TSH is elevated,

Overt Hypothyroidism

Overt hypothyroidism is diagnosed when the TSH level is elevated (generally above 4.5 mIU/L) and the free thyroxine (T4) level is low (under 0.8 ng/dL).

Overt hypothyroidism is typically accompanied by symptoms such as sensitivity to cold, weight gain, enlarged thyroid, and dry skin.

  • When TSH levels are above 10 mIU/L, treatment with thyroid hormone replacement is required.
  • If TSH is between 4.5 and 10, thyroid hormone replacement might be recommended, but not always.

Subclinical Hypothyroidism

Subclinical hypothyroidism can cause mild symptoms, but many people have no symptoms at all. It's diagnosed when the TSH level is above normal, but the free T4 level is normal.

Subclinical thyroidisim
Verywell / Emily Roberts

Treatment for subclinical hypothyroidism is complex because TSH level doesn't always correlate well with symptoms or prognosis.

Hashimoto's Disease Without Hypothyroidism

Hashimoto's disease doesn't always cause hypothyroidism. The majority of people with this condition have thyroid peroxidase (TPO) antibodies present in their blood.

The presence of these antibodies indicates that you may have Hashimoto's disease, but it doesn't necessarily indicate that you have hypothyroidism. You may have TPO antibodies present with normal TSH and free T4 levels, which suggests that your thyroid is functioning as it should.

If thyroid tests are normal, treatment with thyroid hormone is unnecessary, but there are things that may potentially improve the underlying thyroid autoimmune condition.

These include:

  • Avoiding nicotine, including second-hand exposure
  • Consuming 100-200 mcg of selenium per day
  • Boosting omega-3 fatty acids intake
  • Keeping vitamin D level in the normal range

Prescriptions

The standard treatment for hypothyroidism is synthetic thyroxine (T4), and there are also other options for specific situations.

Levothyroxine (T4)

Synthetic thyroxine (T4), generically known as levothyroxine with brand names Synthroid, Tirosint, Levothroid, Levo-T, Levoxyl, and Unithroid, is typically the only treatment that's needed for hypothyroidism.

This medication is generally taken once a day, every day. It replaces thyroid hormones and reduces symptoms of hypothyroidism. It may take some trial and error to find the right dose, and the medication has to be continued throughout a person's life.

Subclinical Hypothyroidism

Treatment recommendations vary for subclinical hypothyroidism, depending on TSH level, age, and other factors. In subclinical hypothyroidism, the free T4 level is normal.

TSH of 10.0 mIU/L or Greater

If TSH levels are 10.0 mIU/L or above, treatment with levothyroxine is recommended by most experts, including the American Thyroid Association (ATA).

  • Studies have found that around 33 to 55% of people with subclinical hypothyroidism go on to develop overt hypothyroidism. The chances of overt hypothyroidism increase with a TSH level higher than 12.0 to 15.0 mIU/L and the presence of TPO antibodies.
  • Subclinical hypothyroidism may be associated with a higher risk of heart diseases, such as atherosclerosis (a condition in which plaque builds up in the arteries), heart attack, heart failure, coronary artery disease, and stroke. This risk is higher with a TSH level above 10.0 mIU/L.

Taking levothyroxine may slow down or halt progression into overt hypothyroidism, and decrease the risk of heart disease.

Research has found that treating subclinical hypothyroidism in patients whose TSH is under 10.0 mIU/L doesn't improve hypothyroid symptoms. However, for people under 65 years old, treatment may reduce the risk of heart disease.

TSH of 7.0 to 9.9 mIU/L

Treatment with levothyroxine may be appropriate for people under the age of 65 with a TSH level in this range because of the potential link between subclinical hypothyroidism and heart disease.

For patients who are 65 and older, levothyroxine is usually only prescribed when they also have hypothyroid symptoms.

TSH of 4.5 to 6.9 mIU/L

The upper limit of the normal range of TSH is 4.5 mIU/L. In people under the age of 65 whose TSH falls in this range, treatment with levothyroxine may be helpful if they have symptoms of hypothyroidism, an enlarged thyroid (goiter), and/or high levels of TPO antibodies.

Treatment usually isn't necessary for those who are 65 years or older. And TSH levels tend to increase with age even for people who have normal thyroid function.

Untreated Patients

For people with subclinical hypothyroidism whose TSH falls in the 4.5 to 9.9 mIU/L range but who don't need levothyroxine, the ATA recommends close monitoring to check TSH and free T4 levels yearly.

Attempting Pregnancy

For women with subclinical hypothyroidism who are having problems with infertility and/or are trying to get pregnant, the ATA recommends treatment with levothyroxine if the TSH is above 2.5.

Liothyronine (T3)

Most people respond well to levothyroxine, so the ATA doesn't advise routinely adding triiodothyronine (T3), called Cytomel (liothyronine), to the daily dose of T4. However, adding T3 can be helpful for people who still have hypothyroid symptoms while taking T4.

This can include:

  • Those who've had part or all of their thyroid removed, known as a thyroidectomy
  • People who've had their thyroid treated with radioactive iodine therapy
  • Those whose T3 level is at or below the normal range

Desiccated Thyroid Extract

Made from pig thyroid, desiccated thyroid extract is a natural combination of T4 and T3, rather than synthetic like the other options. It goes by the brand names Armour Thyroid, Nature-Throid, NP Thyroid, and WP Thyroid, and it's available only by prescription. The ratio of T4 to T3 is 4:1.

Desiccated thyroid is an old treatment that was used for decades before levothyroxine became available. It isn't recommended by the ATA, but it's considered an alternative for people who aren't responding well to levothyroxine alone or to a combination of synthetic T4 and T3.

The Need for Close Monitoring

A major part of Hashimoto's treatment plan is regular follow-ups to ensure that symptoms are well controlled and testing of TSH and free T4 to make sure that the medication is at the right dose.

Supplements

Making sure you're getting adequate nutrient levels can help in managing your hypothyroid symptoms.

If you are taking supplements for you, it can affect your required doses of thyroid hormone replacement.

Be wary of supplements that claim to support thyroid function such as kelp, bovine thyroid extracts, and herbal preparations, as these can interact with your medication.

Selenium

Though selenium deficiency is rare in the United States due to our selenium-rich soil, it's a possibility, especially if you have digestive issues, human immunodeficiency virus (HIV), are undergoing kidney dialysis, or have had gastric bypass surgery.

Selenium deficiency can make some autoimmune thyroid diseases worse, so your healthcare provider may check your level if you are at risk.

1:33

What is Selenium and How Does It Work?

There's no official recommendation for selenium supplementation with autoimmune thyroid disease, but research has shown that it lowers TPO antibody levels.

Selenium supplements may be helpful when your selenium level is low. An excess could lead to toxicity.

Selenium toxicity has a whole host of unpleasant symptoms ranging from garlicky-smelling breath to hair and nail loss and skin lesions, which is why your healthcare provider would check your selenium level before recommending supplements.

Iodine

The majority of people living in the United States don't have an iodine deficiency. However, some may have low iodine levels due to dietary restrictions or medication use.

If your healthcare provider thinks you may be iodine-deficient, you'll likely have a urine test to check it out. Since this deficiency causes thyroid dysfunction, your healthcare provider may start you on iodine supplements for a short period of time if you're found to have an iodine deficiency.

Make sure you talk to your healthcare provider before you take iodine supplements. Too much iodine in a short amount of time when you're hypothyroid can actually lead to an overactive thyroid (hyperthyroidism) and/or make your condition worse, so it's important that you only take these with your healthcare provider's approval.

Iron

Scientific studies have found that lower iron levels are linked to an increased prevalence of subclinical hypothyroidism and lower levels of T4 and T3.

Hashimoto's disease is associated with a higher risk of developing other autoimmune conditions, including celiac disease and autoimmune gastritis, which can impair iron absorption.

Low iron levels are associated with persistent symptoms in people who are being treated for hypothyroidism, and several studies have shown that adding iron supplementation to levothyroxine treatment can more effectively help relieve symptoms. Iron supplements should be taken at least 4 hours away from thyroid medication to avoid interactions. Talk to your healthcare provider about testing your iron level if it hasn't been checked already.

Vitamin D

Research has shown that vitamin D deficiency is more common in people who have autoimmune thyroid disease—Hashimoto's disease or Graves' disease—and may even contribute to the development of these diseases. Studies have also found that vitamin D supplements may significantly reduce TPO antibodies and thyroglobulin (Tg) antibodies.

The research regarding vitamin D's effect on the thyroid isn't definitive, and an excess can lead to toxicity.

Vitamin B12

There may be a link between vitamin B12 deficiency and autoimmune thyroid disease.

A note about taking multivitamins or B-complex supplements: Taking biotin supplements within three days before your thyroid tests test can interfere with the results.

Probiotics

Probiotics are found in food and supplements and contain a good type of bacteria or yeast that may help balance the digestive system and boost the immune system. Hypothyroidism slows down the digestive system, which can lead to constipation, diarrhea, gas, and bloating. Probiotics may help reduce these symptoms.

Probiotics don't affect thyroid hormone levels. Talk to your healthcare provider before you start using them to be on the safe side.

Complementary Alternative Medicine

Complementary alternative medicine (CAM) should never be used as the only means to treat an underactive thyroid, but it can be used in conjunction with your medication to help relieve symptoms.

Acupuncture

Considered to be a safe procedure as long as you go to a trained professional, acupuncture may help with some symptoms of thyroid disease, like constipation, insomnia, and depression.

However, acupuncture is not associated with restoring thyroid levels to normal when you have hypothyroidism or hyperthyroidism.

Yoga

A small 2016 study looked at 22 women taking levothyroxine for hypothyroidism who did yoga for an hour, four times a week, for six months. The researchers found that at the end of the trial period, the women's cholesterol levels were significantly lower, their TSH levels were slightly lower, and the practice may have reduced how much levothyroxine the women needed.

Though more research needs to be done on the effectiveness of yoga for hypothyroidism, it may boost your mood, improve your sleep, and help you relax.

Involve Your Healthcare Provider

It's important that you talk to your healthcare provider if you're using or considering using CAM or supplements.

Some of these methods interfere with the effectiveness of treatment, and many of them aren't regulated by the government like standard treatments are. Your healthcare provider can help you navigate the waters and answer questions you may have about CAM and supplements.

Home Remedies and Lifestyle

Along with taking your medication, you can implement some lifestyle changes that may help you prevent other medical conditions, reduce stress, lose or maintain weight, and feel your best.

Healthy Diet

Eating plenty of fruits, vegetables, and whole grains is recommended for just about everyone, and people with hypothyroidism are no exception.

However, you do need to be careful when it comes to foods that contain goitrogens, most of which are cruciferous vegetables like broccoli, cauliflower, cabbage, and kale. Ingesting large amounts of uncooked goitrogens regularly can slow down your thyroid and/or create swelling in your thyroid called a goiter.

Exercise

Regular exercise improves general health, and it can also help relieve hypothyroid symptoms like fatigue, lack of energy, sleep problems, low mood, sluggish metabolism, and bone loss. It can also lower your risk of developing heart disease.

Stress Management

Stress can exacerbate your hypothyroid symptoms, so it's important to find healthy ways to cope and to minimize your stress. Make time for doing activities that you enjoy. Ask for help if you need it. When you're feeling stressed, try meditation, journaling, painting, listening to music, deep breathing, taking a bubble bath, calling a friend, or going for a walk.

A Word From Verywell

Treatment of Hashimoto's hypothyroidism and the accompanying symptoms include medication and lifestyle measures. Be sure to talk to your healthcare provider about any supplementary treatments you're considering to make sure it's safe for you before you start.

Frequently Asked Questions

  • Are there foods you shouldn’t eat if you have Hashimoto disease?

    Avoiding raw cruciferous vegetables and soybean-derived foods is often suggested because they contain goitrogens that interfere with the thyroid.

  • Do I need to take hormones for Hashimoto disease?

    If your blood tests show that your thyroid hormones are deficient, your healthcare provider will recommend thyroid hormone replacement, usually levothyroxine taken daily. However, you may have Hashimoto and have normal hormone levels, which means you might not need medication.

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  1. Mincer DL, Jialal I. Hashimoto Thyroiditis. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459262/

  2. Khandelwal D, Tandon N. Overt and subclinical hypothyroidism: who to treat and how. Drugs. 2012;72(1):17-33.

  3. Chakera AJ, Pearce SH, Vaidya B. Treatment for primary hypothyroidism: current approaches and future possibilitiesDrug Des Devel Ther. 2012;6:1–11. doi:10.2147/DDDT.S12894

  4. Garber JR, Cobin RH, Gharib H, et al. Clinical practice guidelines for hypothyroidism in adults: cosponsored by the American Association of Clinical Endocrinologists and the American Thyroid Association [published correction appears in Endocr Pract. 2013 Jan-Feb;19(1):175]. Endocr Pract. 2012;18(6):988-1028. doi:10.4158/EP12280.GL

  5. Gosi SKY, Garla VV. Subclinical Hypothyroidism. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. Available from: https://www.ncbi.nlm.nih.gov/books/NBK536970/

  6. Promberger R, Hermann M, Ott J. Hashimoto's thyroiditis in patients with normal thyroid-stimulating hormone levels. Expert Rev Endocrinol Metab. 2012;7(2):175-179.

  7. Tipu HN, Ahmed D, Bashir MM, Asif N. Significance of Testing Anti-Thyroid Autoantibodies in Patients with Deranged Thyroid ProfileJ Thyroid Res. 2018;2018:9610497. doi:10.1155/2018/9610497

  8. Jonklaas J, Bianco AC, Bauer AJ, et al. Guidelines for the treatment of hypothyroidism: prepared by the american thyroid association task force on thyroid hormone replacementThyroid. 2014;24(12):1670–1751. doi:10.1089/thy.2014.0028

  9. Fu A, Zhou R, Xu X. The synthetic thyroid hormone, levothyroxine, protects cholinergic neurons in the hippocampus of naturally aged miceNeural Regen Res. 2014;9(8):864–871. doi:10.4103/1673-5374.131602

  10. Tng EL. The debate on treating subclinical hypothyroidismSingapore Med J. 2016;57(10):539–545. doi:10.11622/smedj.2016165

  11. Ross, MD Douglas. Subclinical hypothyroidism in nonpregnant adults.

  12. Suh S, Kim DK. Subclinical Hypothyroidism and Cardiovascular DiseaseEndocrinol Metab (Seoul). 2015;30(3):246–251. doi:10.3803/EnM.2015.30.3.246

  13. Kim MI. Hypothyroidism in the Elderly. In: Feingold KR, Anawalt B, Boyce A, et al., editors. Endotext [Internet]. South Dartmouth (MA): MDText.com, Inc. Available from: https://www.ncbi.nlm.nih.gov/books/NBK279005/

  14. Knobel M. Which Is the Ideal Treatment for Benign Diffuse and Multinodular Non-Toxic Goiters?Front Endocrinol (Lausanne). 2016;7:48. doi:10.3389/fendo.2016.00048

  15. Baumgartner C, da Costa BR, Collet TH, et al. Thyroid Function Within the Normal Range, Subclinical Hypothyroidism, and the Risk of Atrial FibrillationCirculation. 2017;136(22):2100–2116. doi:10.1161/CIRCULATIONAHA.117.028753

  16. Maraka S, Singh Ospina NM, Mastorakos G, O'Keeffe DT. Subclinical Hypothyroidism in Women Planning Conception and During Pregnancy: Who Should Be Treated and How?J Endocr Soc. 2018;2(6):533–546. doi:10.1210/js.2018-00090

  17. Celi FS, Zemskova M, Linderman JD, et al. Metabolic effects of liothyronine therapy in hypothyroidism: a randomized, double-blind, crossover trial of liothyronine versus levothyroxineJ Clin Endocrinol Metab. 2011;96(11):3466–3474. doi:10.1210/jc.2011-1329

  18. Padur AA, Kumar N, Guru A, et al. Safety and Effectiveness of Total Thyroidectomy and Its Comparison with Subtotal Thyroidectomy and Other Thyroid Surgeries: A Systematic ReviewJ Thyroid Res. 2016;2016:7594615. doi:10.1155/2016/7594615

  19. Hoang TD, Olsen CH, Mai VQ, Clyde PW, Shakir MK. Desiccated thyroid extract compared with levothyroxine in the treatment of hypothyroidism: a randomized, double-blind, crossover study. J Clin Endocrinol Metab. 2013;98(5):1982-90.

  20. Hu S, Rayman MP. Multiple Nutritional Factors and the Risk of Hashimoto's Thyroiditis. Thyroid. 2017;27(5):597-610.

  21. Santos LR, Neves C, Melo M, Soares P. Selenium and Selenoproteins in Immune Mediated Thyroid DisordersDiagnostics (Basel). 2018;8(4):70. doi:10.3390/diagnostics8040070

  22. MacFarquhar JK, Broussard DL, Melstrom P, et al. Acute selenium toxicity associated with a dietary supplementArch Intern Med. 2010;170(3):256–261. doi:10.1001/archinternmed.2009.495

  23. Yoon SJ, Choi SR, Kim DM, et al. The effect of iodine restriction on thyroid function in patients with hypothyroidism due to Hashimoto's thyroiditis. Yonsei Med J. 2003;44(2):227-35.

  24. Soliman AT, De Sanctis V, Yassin M, Wagdy M, Soliman N. Chronic anemia and thyroid functionActa Biomed. 2017;88(1):119–127. doi:10.23750/abm.v88i1.6048

  25. Ravanbod M, Asadipooya K, Kalantarhormozi M, Nabipour I, Omrani GR. Treatment of iron-deficiency anemia in patients with subclinical hypothyroidism. Am J Med. 2013;126(5):420-4.

  26. Chahardoli R, Saboor-yaraghi AA, Amouzegar A, Khalili D, Vakili AZ, Azizi F. Can Supplementation with Vitamin D Modify Thyroid Autoantibodies (Anti-TPO Ab, Anti-Tg Ab) and Thyroid Profile (T3, T4, TSH) in Hashimoto's Thyroiditis? A Double Blind, Randomized Clinical Trial. Horm Metab Res. 2019;51(5):296-301.

  27. Ness-abramof R, Nabriski DA, Braverman LE, et al. Prevalence and evaluation of B12 deficiency in patients with autoimmune thyroid disease. Am J Med Sci. 2006;332(3):119-22.

  28. Liu Y, Alookaran JJ, Rhoads JM. Probiotics in Autoimmune and Inflammatory DisordersNutrients. 2018;10(10):1537. doi:10.3390/nu10101537

  29. Brake MK, Bartlett C, Hart RD, Trites JR, Taylor SM. Complementary and alternative medicine use in the thyroid patients of a head and neck practice. Otolaryngol Head Neck Surg. 2011;145(2):208-12.

  30. Cheng FK. An overview of the contribution of acupuncture to thyroid disorders. J Integr Med. 2018;16(6):375-383.

  31. Nilakanthan S, Metri K, Raghuram N, Hongasandra N. Effect of 6 months intense Yoga practice on lipid profile, thyroxine medication and serum TSH level in women suffering from hypothyroidism: A pilot study. J Complement Integr Med. 2016;13(2):189-93.

  32. Abbott RD, Sadowski A, Alt AG. Efficacy of the Autoimmune Protocol Diet as Part of a Multi-disciplinary, Supported Lifestyle Intervention for Hashimoto's Thyroiditis. Cureus. 2019;11(4):e4556.

  33. Chandra, Amar K. Iodine, thiocyanate and the thyroidBiochem Pharmacol (Los Angel) 4:171. 2015. doi:10.4172/2167-0501.1000171

  34. Masaki M, Koide K, Goda A, Miyazaki A, Masuyama T, Koshiba M. Effect of acute aerobic exercise on arterial stiffness and thyroid-stimulating hormone in subclinical hypothyroidism. Heart Vessels. 2019;34(8):1309-1316.

  35. Markomanolaki ZS, Tigani X, Siamatras T, et al. Stress Management in Women with Hashimoto's thyroiditis: A Randomized Controlled TrialJ Mol Biochem. 2019;8(1):3–12.

  36. Wojtas N, Wadolowska L, Bandurska-Stankiewicz E. Evaluation of qualitative dietary protocol (Diet4hashi) application in dietary counseling in Hashimoto thyroiditis: Study protocol of a randomized controlled trial. IJERPH. 2019;16(23):4841. doi:10.3390/2Fijerph16234841

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