Hypothyroidism

Q. What are the causes of hypothyroidism?

A. Hypothyroidism results from the failure of sufficient thyroid hormone reaching the tissues to control metabolism, which it does by governing the passage of nutrients across the cell membrane and controlling the activity of the mitochondrion, which produces energy within the cell. 

This happens:

1. When the pituitary and/or hypothalamus fail to work as they should to control thyroid output, which is therefore reduced.

2. The processing failure of conversion of T4 into T3.

3. Uptake failure, where tissue receptors fail to respond adequately to thyroid hormone.

4. Where adrenal insufficiency adversely affects thyroid hormone processing and receptor uptake.

5. Primary thyroid failure due to a number of causes which may be genetic; due to environmental deficiencies or pollutants; glandular fever; major illness, surgery, or accidents; damage to the thyroid itself from injury or surgery; multiple or traumatic pregnancy. Probably the most common is autoimmune attack (as in Hashimoto's disease), from antibodies the immune system itself makes, which overact and progressively damage and shut down the thyroid.


Q. Am I too young to have thyroid disease?

A. Undiagnosed hypothyroidism in a foetus can cause cretinism (unnatural shortness or dwarfism). A baby like this has an enlarged tongue, too large for the mouth; a protuberant abdomen; altered muscle tone; it fails to thrive and may develop fatal infections early on. This is more common in areas of the world where there is iodine deficiency. In the UK all babies are screened for thyroid disease soon after birth, using the TSH test only.

However, hypothyroidism may develop AT ANY TIME after birth, usually from an inherited genetic cause. Babies then fail to grow as they should and reach their proper milestones. The baby may be sleepy and generally lethargic, although it may sometimes be hyperactive.

In children it can cause interrupted growth. A child with frequent infections, doing poorly at school is by no means an uncommon presentation. Puberty is particularly a time when hypothyroidism may become apparent: weight gain, poor sexual development, learning difficulties, should raise suspicion. Adolescence, with all the hormonal strains and stresses at that time, may well be affected by loss of proper thyroid function. In summary, you can never be too young to suffer from hypothyroidism.


Q. Why do women get thyroid disease more than men and what are the percentages?

A. In general terms, women indeed suffer more from hypothyroidism than men; but it really is not possible to define percentages, since the diagnosis may so often be missed. Most authorities would agree, however, that it is 4-5 times more common in women than men, particularly in the over 40 age group. Hyperthyroidism has about the same sex frequency, but is certainly more common in younger women. Thyroid disease is most commonly caused by autoimmune attack, and women's physiology is such that the immune system is more likely to go out of balance sometime during their lifetime than men. Firstly, there is the constant monthly ebb and flow of sex hormones controlling the period. The massive hormone disturbance of pregnancy, together with the immune system having to cope with, and allow for, what is effectively a "foreign body"; together with the trauma of childbirth, most certainly impacts the thyroid. The temporary thyroid upset after pregnancy, often the root cause of postnatal depression, happens to ever so many mothers. The effect is increasingly likely to become permanent if the pregnancy is "traumatic" (ie caesarian section, retained placenta, massive haemorrhage and with multiple or frequent pregnancies).


Q. Is thyroid disease hereditary?

A. There is an undoubted genetic component to hypothyroidism and babies may be actually born with it. However, most people develop it as a result of injury or autoimmune disease, which may or may not be genetic.


Q. What tests can I have done to check for hypothyroidism?

A. There are a few blood serum tests: Free and Total T4; Free and Total T3; TSH; Antibodies; reverse T3. There is also now a 24 hour urine test, which seems to correlate better with symptoms. The most valuable self-help test is the Barnes Basal Temperature Test.

Q. I am borderline, but my doctor won’t give me a trial of thyroxine.
What can I do?

A. I’m afraid you are left with two alternatives – try and treat yourself using glandulars or visit one of the doctors on our list.


Q. I am not on thyroxine and my blood test results have come back “normal”.
I have all the symptoms of hypothyroidism. Can I still be hypothyroid?

A. Yes, you can! 
Because your doctor has said “normal” this probably means that you are still within the range. You need to find out where you are within the range, as you could be borderline and your doctor is not telling you. Your normal could be at the top of the T4 range or at the bottom of the TSH range. If you are at the other end of the range, you could be hypothyroid because this is not normal for you.

Your T4 and TSH levels may look normal but this may not mean that you are. 

There may be a problem converting T4 into T3. A T3 test should be done to check this; if low this will confirm it.

You could have receptor resistance, ie the T3 is unable to enter the cells properly. In this case, it might be a good idea to have a 24 hour urine test.

You could have low adrenal reserve. Again, all blood tests may look normal, even the T3 test, but low adrenal reserve may affect thyroid processing at all levels. You will need to have an adrenal saliva test done to check your cortisol and DHEA levels.

When you have the results of all the tests, you can try your GP again. Show them to him, talk to him about what you have learnt and try and persuade him to give you a trial of thyroxine. If this fails, I’m afraid you are left with two alternatives – try and treat yourself using glandulars or visit a private doctor. (See list of Private doctors)


Q. I am on thyroxine, but I still feel ill.
Why could this be?

A. Some people still have symptoms when they are on thyroxine. This can be due to many things. It can be that they are not on enough thyroxine for their needs. Before blood tests came into play, people were given more than 200mcg, although many doctors now don’t like to give more than 150mcg. Thyroxine should also be given according to weight, so the bigger you are, the more you should have. In reality, this does not happen. Each doctor seems to have his own ideas about the highest level he will allow his patient to be in the range. He then tells the patient that she cannot have any more thyroxine, even though the patient still has symptoms.

Another reason many people still feel ill on thyroxine is that they are not converting the thyroxine into T3 (tri-iodothyronine). This conversion takes place outside of the thyroid, mainly in the liver, so if the patient has some kind of problem with the liver or any of the other places where conversion takes place, then deficiency will occur. Certain vitamins, especially those of the B group and some minerals are also necessary to aid conversion, namely: iron, selenium, magnesium and zinc. If you are deficient in any of these then conversion will be less effective. If this is your problem, then you will need to supplement your T4 with T3, or take the natural form of thyroid hormone. Armour natural thyroid is an excellent alternative, which has not only T4, but T3, T2 and T1.

If you have adrenal insufficiency, this can also cause major problems for the receptor uptake of the T3. Some kind of adrenal support will be needed before the receptors can uptake properly. Many people have this problem in these stressful times; it can be caused by car accidents, major surgery, autoimmune disease attacking the adrenal glands and, of course, inadequately treated hypothyroidism.

Lastly, there seem to be a lot of people who just cannot tolerate the synthetic form of thyroxine and fare much better on the natural form which contains all four thyroid hormones. 

If you are not receiving enough thyroid hormone or not getting the correct form of hormone into your body, then you will still have symptoms. 


Q. How can I get a second opinion beyond my GP?

A. Probably, with difficulty. You are, however, entitled to seek a second opinion privately, whether your GP likes it or not.


Q. What medications can affect my thyroid blood test results?

A. Thyroid test results may be wrongly lowered by the following four mechanisms.

1. Suppression of TSH, due to: 
a. Excess glucocorticoids
b. Dopamine

2. Reduction of thyroglobulin transport protein (TBG) due to:
a. Androgens
b. Excess glucocorticoids

3. Impaired binding to TBG due to:
a. Salicylates
b. Diphenylhydantoin
c. Frusemide

4. Impaired hormone production:
a. Propylthiouracil
b. Neomercazole
c. Lithium
d. Excess iodine

Thyroid test results may be wrongly raised by the following two mechanisms.

1. Increased TBG due to:
a. Oestrogen
b. Tamoxifen

2. Reduce T4 - T3 conversion:
a. Amiodarone
b. Propanolol
c. Excess glucocorticoids


Q. What medications can be affected by my thyroid medication?

A. Medication for diabetes may need to be reduced.


Q. Are there any supplements that interfere with my medication?

A. Don’t take iron supplements or antacids within two hours of your medication as these affect absorption. Calcium can also interfere with the absorption of thyroid drugs. You should take calcium at least two to three hours apart from your thyroid medication. Don’t forget some fruit juices are calcium fortified.


Q. Can I improve my hypothyroidism without having to take thyroxine or other medication?

A. Paying careful attention to nutrition, in particular full vitamin A, B and C support may well prove beneficial and nutritional companies provide complexes of supplements specifically directed at providing thyroid support. Selenium for example is essential in the T4 to T3 conversion process. However, unless the level of hypothyroidism is mild, these may be insufficient.


Q. I had radioactive iodine treatment six months ago for hyperthyroidism and now all my hair is falling out.
Is this normal?

A. The level of radioactivity from the iodine may have been considerably too high, which in itself might have induced excessive thyroid damage and caused hypothyroidism, which will in itself cause hair loss.


Q. How long does it take to get better once on medication?

A. From our experience, it can take anything up to two years to become completely well again, depending on how long you have been ill. Complete wellness will only come if you are on the right treatment and the correct amount of replacement therapy.


Q. Will my libido return?

A. Again, it should return once you are properly balanced, with the correct supplementation at the appropriate level. 


Q. I feel very depressed and suicidal – is this part of thyroid disease?

A. It certainly can be for some people. Inappropriate levels of thyroid hormone can affect people in very different ways. So for some, the main symptom might be joint and muscle pain, but for others it might be deep depression and suicidal thoughts.

More information about how thyroid disease can be mis-diagnosed as mental illness can be found on the Thyromind website at http://www.thyromind.info/


Q. Can you recommend an expert on thyroid disease?

A. Unfortunately we are unable to recommend doctors or specialists but a list is available of practitioners who are sympathetic to our point of view.

 

Q. When is it best to take my thyroid medication?

A. It is best to take your medication first thing in the morning with a drink of water on an empty stomach. Don’t eat for at least ½ an hour to an hour if you can. A high fibre diet can affect absorption. If you have always had a high fibre diet, carry on as usual. If you are on thyroid replacement and you decide to try a high fibre diet, then your absorption may be affected and you need to have another test done about 6-8 weeks into your new regime, to check to see if your levels change. You need to be consistent. Don’t do high fibre for a couple of weeks and then change back, as your levels may change with it!

Q. Is it OK to eat before having a thyroid blood test?

A. It's not important so long as you do the same thing as you usually do i.e. always have breakfast before a test, or always have breakfast after the test. That way blood levels are about the same.

 

Q. Should I take my thyroxine before my blood test?

A. It's best not to take your thyroxine on the morning of the test otherwise you may show a peak level spike on the test, and be under-treated by your doctor because of this.

Q. Should I take my natural thyroid hormone before having my blood test?

A. Any T3 containing hormone replacement should not be taken before the test. Generally, you should not take your medication between 6 and 24 hours before the test.

Q. I've read or heard somewhere that the thyroid is more efficient during the summer months.
Should I reduce my dosage during the summer months?

A. With a higher ambient temperature less thyroid hormone is needed to maintain our internal temperature, since we lose heat less. In winter, by contrast, we need MORE thyroid hormone to stimulate our metabolism to produce more heat to maintain our internal body temperature within narrow limits. It is not that the thyroid is more efficient in the summer months, it is just that a failing thyroid will produce enough thyroid hormone until the winter comes. If you feel that you are over-stimulated during the summer, cutting back slightly might be a good idea.

Q. Are there any foods that interfere with my medication?

A. Goitrogenic foods ( brussel sprouts, rutabaga, turnips, cauliflower, cabbage, almonds, peanuts, walnuts, sweet corn, sorghum and millet can act like an antithyroid drug in disabling the thyroid function. They contain chemicals, which prevent the thyroid from taking in enough iodine. Eat these in moderation if you are taking thyroid hormone replacement. It is thought that the enzymes involved in the formation of goitrogenic materials in plants can be destroyed by cooking, so cook these foods thoroughly if you want to eat them. 

Soya causes real problems for the thyroid because it is an oestrogen like compound which increases the level of oestrogen in the body, thus having the effect of removing some thyroid hormone by increasing the level of binding globulin.


Q. What is Hashimoto’s Disease?

A. Hashimoto’s is an autoimmune disease. The antibodies kill off the thyroid cells and eventually you will become hypothyroid.


Q. I have thyroid antibodies, but my doctor says there are not enough yet?
Do I have Hashimoto’s Disease?

A. People do not have thyroid antibodies unless they have autoimmune thyroiditis. Symptoms may not yet be present, but are almost certain to develop in due course, so start to check for symptoms and your basal temperature.


Q. My doctor tells me that he doesn’t want to give me a trial of thyroxine because there is strong evidence that, once I start taking it, my own thyroxine production will decrease and I will become dependent on taking replacement medication.
Is this true?

A. There is no evidence at all. He's just made the whole thing up. If thyroid levels are already low, no amount of waiting about will cause them to come back to normal. The purpose of thyroid replacement should be to reduce or eliminate a patient's hypothyroid symptoms, although doctors usually prefer to regulate thyroid replacement therapy based on TSH test results.

It's not a matter of becoming dependent on the medication it's simply replacing what the body has ceased to produce in order to function properly.

Think about what happens when you take the pill, which suppresses oestrogen and progesterone in the ovaries. Stop the pill, and the ovaries are back in business in a month, usually. If the thyroxine doesn’t help, then you stop taking it and your levels will return to the same place as they were before the trial.


Q. I read that tea has fluoride in it.
Can you tell me if herbal teas and redbush tea are safe to drink?
Do they have any properties that may be damaging to my condition?

A. Most herbal teas are, as far as we know, better than ordinary tea with the exception of Green Tea and some camomile teas. In addition, herbal teas are caffeine free. This is an important consideration when attempting to balance adrenal function in long standing thyroid problems. Like anything else, the fluoride content of any tea will depend to a large extent upon where that tea was grown and what pesticides were involved in its cultivation. (See our Fluoride page) 

Basal Temperature Test

Q. How do I do the Basal Temperature Test?

A. In the morning, before getting out of bed and with as little movement as possible, place the thermometer under your armpit. Leave it in position for 10 minutes. If you do not have the time, 3 minutes in the mouth. Do not drink alcohol the night before you take your basal temperature. Do this for five consecutive days. Make a note of all the readings and then average them out. Use a mercury thermometer (digital thermometers are to be used orally only). Menstruating women must take their temperatures on the 2nd, 3rd and 4th days of their periods only. Non-menstruating women, women who have had total hysterectomies and men may take their temperatures any day. 97.6F - 98.4F (36.6 -37C) = Euthyroid (normal). If temperature falls below 97.6F (36.6C) consider hypothyroidism as a possible cause.


Q. Why can’t I use a digital thermometer to take my basal temperature?

A. You can use a digital thermometer orally, but it is not recommended under the armpit since it may give an abnormally low reading. Heat transfer from the skin to the thermometer is slower in the armpit than under the tongue; the digital thermometer may read before the heat transfer is complete.


Q. If I take my oral temperature instead of the underarm temperature, should the range for the Basal Temperature be raised?

A. Yes – by about half a degree.


Q. Why doesn’t my GP know about the Basal Temperature Test?

A. Although first described by Dr Broda Barnes in the Lancet in 1942 (Barnes B. Basal temperature versus basal metabolism. J Am Med Assoc 1942 Aug 1;119 (4):1072-4), it is not taught in medical schools and is therefore unfamiliar to most doctors and so not generally accepted by them as a diagnostic tool.  


Q. Are there other causes of low temperature?

A. Other causes of low temperature are malnutrition, liver disease, hypothermia and alcoholism.

Adrenals

Q. I am already on thyroid treatment and I want to try some adrenal support.
How do I go about this?

A. If there is every indication that you have low adrenal function, adrenal support should make all the difference. However, adding adrenal support without stopping the thyroxine for several days, preferably a week, could well cause a thyroid crisis, since the unused thyroxine may quite suddenly be taken up by the body. If, however, the dose of thyroxine has been quite small and not of long standing, adrenal support, so long as it is started from a low dose is unlikely to create this problem. To be safe, however, it would be best to discontinue the Armour/thyroxine for approximately 7-10 days. This is particularly true of hydrocortisone or deltacortril, but the adrenal glandulars are less likely to have an abrupt effect.


Q. I’d like to try prednisolone/cortisol.
How do I do this?

A. You will have to ask your doctor, as prednisolone and cortisol replacement are prescription only medication. For details about prednisolone and hydrocortisone see The Role of the Adrenal Glands. Alternatively you could try adrenal glandulars eg Adreno-Lyph, which are natural supplements not requiring a prescription. 


Q. How long will I have to be on prednisolone/cortisol?

A. Several weeks or months depending on response. As adrenal status improves a programmed withdrawal may be made.


Q. How do I come off prednisolone/cortisol?

A. There should be a programmed withdrawal after a trial period of at least of 4 – 6 weeks before an attempt is made to come off the prednisolone or other adrenal support. If a downturn is experienced , you merely restart the adrenal support. If there is no downturn, the adrenals are better able to cope and adrenal support should not therefore be needed any more. Your doctor will suggest a dosage reduction plan. In general for hydrocortisone the dose may be reduced by 5 mg every 10 days, until satisfactory response is established. Prednisolone may be reduced by 2.5 mg every 14 days, until response is established.


Q. I’d like to try adrenal glandulars.
How do I do this?

A. You can obtain these from an alternative practitioner or a company making nutritional products. The manufacturers recommended dose should be followed. (See Treatment Of Thyroid And Adrenal Deficiency Using Natural Glandulars).


Q. How long will I have to take adrenal glandulars?

A. It depends on the severity of your adrenal weakness and the length of time you have been ill. Several weeks or months is normal, depending on your response to the glandulars. As adrenal status improves a programmed withdrawal may be made. 


Q. How do I try to come off adrenal glandulars?

A. As with prednisolone, there should be a programmed withdrawal after a period of trial of at least 4 – 6 weeks before an attempt is made to come off the adrenal support. If a downturn is experienced, you merely restart the adrenal support. If there is no downturn, the adrenals are better able to cope and adrenal support should not therefore be needed any more. Your practitioner will advise you, but if you are self-treating a reasonable regime would be reduction of ½ tablet every 10-14 days.


Q. How safe are glandulars?
I am worried about BSE.

A. The glandulars from Nutri Ltd., for example, are bovine sourced, grass fed Argentinean range cattle or from USA/Canadian pasture fed or corn fed cattle. Nutri guarantee that this is free of any risk of BSE.


Q. Which is better to use, adrenal glandular or cortisone/prednisolone?

A. Adrenal glandulars by themselves are suitable if the low adrenal reserve is not too severe; it really does depend on the severity of the problem. If the low adrenal reserve is long standing and/or severe, cortisone/prednisolone will probably be necessary. Or a combination of both treatments may be desirable.


Q. I have high cortisol and DHEA levels.
Why is this and what can I do about it?

A. High cortisol and DHEA levels suggest a degree of over-activity of the adrenals which may be due to high stress levels. If these levels are very high, thought has to be given to overproduction from growths of the pituitary or adrenals. An extreme form of this is Cushing’s disease and full investigation is then required.


Q. I have high cholesterol – does this mean that this will change into extra pregnenolone?

A. As we know, long-term hypothyroidism causes high cholesterol. The excess does not mean, however, it is going to turn into extra pregnenolone, or indeed anything else.

Vitamin B12

Q. I notice in the Information Pack that "Some doctors believe that the "normal range" of B12 is too low and that the normal range should be at least 500 - 1300 pg/ml."
Do you know if any of the Private Doctors on your list subscribe to the above view and would therefore be prepared to treat a patient who has a B12 level in the 300 - 400 pg/ml range?

A. Several of the doctors on our list will treat low B12 levels and many people have benefited from B12 therapy.

Armour Thyroid

Q. Is Armour thyroid better than thyroxine?

A. Armour thyroid has all the components that a human thyroid produces ie T4, T3, T2 and T1. Thyroxine is only T4. Many people need T3 especially and therefore may not have much benefit from thyroxine. Also, we find that some people are intolerant of thyroxine simply because it is synthetic. 

Q. Can I obtain Armour from my GP and will I have to pay for it?

A. According to the Medicines Control Agency, your doctor is allowed to prescribe medicines not licensed in the UK on a “named patient basis”. He can write a prescription for you on a normal green form. Whether he will actually do this for you on the NHS is something you will have to ask him. One grain of Armour or any natural thyroid contains 38mcg T4 and 9mcg T3, although it has the efficacy of approximately 100mcg of thyroxine. Your doctor will work out how many grains a day you will need. They also come in half grains, two grains and three grains. He can also give this to you on a private prescription, which means that you will have to pay for the Armour.


Q. I have a prescription for natural thyroid hormone. Which chemist do I go to?

A. So, you have persuaded your GP or Endocrinologist to let you have a prescription for natural thyroid hormone. Now you must take the next step (sometimes a hurdle) to get your prescription filled. Thankfully, it is much easier now than it used to be!

You can take your prescription to any chemist, whether it is a big High Street pharmacy such as Boots or your local pharmacy.

When you hand them your prescription, explain to them that it is being prescribed on a named-patient basis and give them the name of a wholesaler (see “What is Named-Patient Basis”).

Please ensure that your doctor has written the name of the medication along with the number of grains required and the wording, “Required for hypothyroidism” on the prescription.

You should have no problems but if you do, please ask your pharmacy to contact either the MHRA or the wholesaler.

Q. I am on Armour thyroid. There was initial improvement, but now my hypothyroid symptoms have returned.
Is there anything more that can be done?

A. If you have been taking Armour thyroid or thyroxine for some time with a disappointing response, you need to investigate the possibility of low adrenal reserve, by for example, doing an adrenal saliva test. 

T3

Q. I'd like to test for T3 without any medication in my system.
How long would I have to refrain from taking the tertroxin before it's out of my system?

A. Tertroxin (liothyronine (T3)) has a half life of about 8 hours. This means that for any given dose, 8 hours later half of it has been used up. 8 hours later, half of the remainder would have been used; and so on. After 24 hours there is 1/2 x 1/2 x 1/2 = 1/8 of the original dose left; so by then it is hardly worth talking about. (In two days there is only 1/64 left which is nothing really.) Certainly, for either urine or blood test, the dose should be stopped the previous day.

DHEA

Q. I have been taking DHEA as my levels were low, but I am growing more hair on my body. What can I do about it?

A. Try changing to 7-Keto DHEA, which does not have the usual side-effects of ordinary DHEA because it is not metabolized into testosterone. 

Q. Does DHEA interfere with T3 and T4?

A. No, it doesn't interfere with T4 and T3 - it aids the process. 

 

Weight

Q. I am getting better, but I just cannot lose the weight I put on. 

A. You will probably not lose weight until you are properly balanced. For some people this can happen with thyroxine, but they need to be on the right dosage for their metabolism to pick up. Some people find that when they start on T3 or Armour thyroid, then their weight will start to drop, when previously no matter how hard they try to lose weight, it would not happen. A low carbohydrate diet is better for losing weight.

The Parathyroids

Q. I have been diagnosed with hypoparathyroidism - What is it?

A. The correct level of calcium in the blood is maintained by the parathyroid hormone, which controls the amount of calcium released from bones, and the amount absorbed by the gut. It is made by four very small glands, two above and two below, the thyroid gland itself. Production of parathyroid hormone may decline with age and illness and if they are accidentally damaged by thyroid surgery. Hypoparathyroidism will cause loss of calcium in the blood stream, which will cause calcium tetany and eventually paralysis. It is not thought to be genetic. 


Q. I have Pseudo-hypoparathyroidism - What is it and can I pass it onto my daughter?

A. In this condition, the parathyroid glands work normally, but the tissue receptors are unable to respond properly. This is a genetic condition, though rare; subjects are short, overweight, have shortened bones in their hands and have scattered nodules of calcium over their body. Symptoms are likely to be the same as with hypoparathyroidism noted above.

Miscellaneous

Q. What is Sheehan’s Syndrome?

A. Sheehan's syndrome is a condition where major trauma, or major surgery, which has resulted in severe blood loss, causes a loss of blood flow to the pituitary gland, which then becomes damaged and fails to produce a sufficiency of the thyroid stimulating hormone to enable the thyroid to function properly. This is called secondary or central hypothyroidism.

Q. I want to stop taking HRT and seek natural alternatives.
Could you tell me it if it is advisable to take wild yam root in conjunction with thyroxine?

A. There will be no problem at all with the thyroid dosage while taking wild yam. We must point out, though, that there seems to be no reliable evidence that the active principle of wild yam, diosgenin, will undergo any useful change to progesterone. We would recommend that progesterone made from wild yam into a trans dermal cream (by a simple process), is every bit as natural, and likely to be very much more effective. We have found a great number of ladies respond well to one called Serenity (Wellsprings Trading, Guernsey).


Q. Am I entitled to free prescriptions now that I am hypothyroid?

A. Yes, you are.
NHS Booklet HC11 (Are you entitled to help with health costs) will explain. These can usually be obtained from your doctor and some pharmacies. Or you can download the PDF version here:
http://www.dh.gov.uk/assetRoot/04/13/89/53/04138953.pdf

You need a Medical Exemption Certificate. To obtain the certificate you must complete form FP92A (EC92A in Scotland) which is available from your doctor, hospital or pharmacist. The form (which will need to be signed by your doctor) tells you what to do. These certificates only last for a specific period of time and they will need to be renewed, often without reminders.
While you are waiting for your Exemption Certificate, make sure that you obtain NHS receipts when you pay for your prescriptions (form FP57). This form tells you how to get your money back.

More specific information on the Medical Exemption Certificate can be found here:
http://www.ppa.org.uk/ppa/medex.htm