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Is Your Thyroid Medication Working? (Part 1)

The three questions to ask to know if your thyroid hormone replacement therapy is right for you…

In this video, I cover the three questions to ask to know if you’re on the right thyroid medication and dose, including the most important thyroid lab value to look at.

Video Transcript

Today we’re talking about thyroid replacement therapy. How do you know if your thyroid hormone replacement strategy is working? 

This is a really good question. It’s one that I don’t think a lot of physicians and my clients really get or understand completely.

Are you going to a clinician who just prescribes T4? Are you going to a clinician who prescribes a glandular? Are you going to a clinician who prescribes T4 and  T3? Are you going to a practitioner that’s prescribing T3 only? Are you going to a practitioner who’s also prescribing T2? 

Depending on who you’re seeing and what their drive, goals, and motivations are, you may get a whole bunch of different opinions as to whether your thyroid replacement therapy is working.

At the end of the day, there are three key things you need to answer that question for yourself. 

Is my thyroid hormone replacement strategy working and what does that mean to me? If it’s working, you take it and you feel and function like you’re back to normal. 

You hear clinicians or people in this space talk about optimizing your physiology, but what does that really mean? 

If we’re truly optimizing physiology, then technically we shouldn’t really need thyroid hormone replacement therapy or any other hormone replacement therapy.

I would make the argument that if we need to take a drug or supplement on a regular basis, then we’re not optimized.

Because in an optimal body, we don’t need that stuff. All we’ve got to do is eat well, digest well, live well, sleep well, breathe well, and we should be optimized. 


So here are the three key things to keep in mind. How do you know if your replacement therapy strategy is working? 

If you’re still symptomatic, it’s not working optimally.

Could it make you feel better? If you have limited amount of thyroid hormone in your body and you get some  T4, are you going to potentially feel better, at least in the short run? Absolutely. Absolutely. 

If your body is not doing a great job converting  T4 to  T3 and your  T3 numbers and free  T3 numbers are really low and you take  T3, are you going to potentially feel better in the short? Absolutely. You might feel better. 

Does that mean you’ve optimized your physiology? No. You’ve just put in a medication to replace a hormone and your doctors have done this under the assumption that your body forgot how to do it versus that your cells and your tissues probably didn’t want to do it. 

So it doesn’t really matter if you take some thyroid hormone replacement. Many times we find that it works initially, but then it starts to plateau because you haven’t actually addressed the real issue. Then you take more, sometimes that makes you feel better, but there’s a certain point where you’re taking so much that you have both hypothyroid symptoms and hyperthyroid symptoms and you just feel awful. 

So if you’re still symptomatic – I don’t care what type of medication you’re on, T4, T3, glandular, T2 – it may be changing symptoms a little bit, but your strategy is not working appropriately in my opinion. 


The other thing we have to ask is what story does your thyroid panel tell? 

And that’s a complicated one too because depending on who you go to, you’re going to see what they consider the most important parts of a thyroid panel. They’re not. Very few practitioners, especially an allopathic model, run a full thyroid panel. They typically just run what they need to assess whether their strategy works. 

And even in the functional medicine space, you’re going to see people who, based on their strategy, are going to run numbers and they’re going to interpret them based on their philosophy. And they may tell you that you’re optimized, we’ve optimized you, but you don’t feel optimized. 

So we have to ask the question, what story does our thyroid panel tell? 

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And then the last question is, what story does your comprehensive metabolic panel tell? 

Are your blood sugar numbers better? Are your cholesterol levels better? Are your adrenal markers better? Are your inflammatory markers better? Are your gut markers better? 

We should see if somebody truly optimized you, then we should see the optimization of the restoration of normal homeostatic metabolism in your body if they’ve optimized you, right? 

Just putting more thyroid hormone into the bloodstream doesn’t necessarily mean it’s going to optimize your cells and tissues. It doesn’t mean that it’s going to restore normal physiology. 

I say this all the time: cells operate in one of two modes. They’re either in homeostatic regulation, low stress, homeostatic regulation, they have all the resources to do what they need to do; or in they’re in allostatic regulation, meaning there’s some type of excessive stress response, and there’s an intentional downregulation of the metabolism and an upregulation of the immune inflammatory response. And the thermostat to determine and help shift the cell chemistry from manufacturing mode to cell defense mode is the amount of  T3 inside the cell.

So let’s talk about the thyroid panel on today’s video. We’ll talk about the rest in PART 2.

I don’t care what markers your doctors use, there is one test that’s going to give you the best indication of if the thyroid hormone replacement strategy is working. 

When we look at the thyroid panel – and the problem is, it’s really only useful if you’re taking a T4-only medication. If you’re taking T3, you’re getting a distorted picture because the T3 that we’re looking at in the bloodstream isn’t really what the cells converted. A lot of it is what you’re taking. 


So this is really the most important marker when I’m looking at labs to see if somebody’s strategy’s working: what’s the free T3 to free T4 ratio?

All of the  T4 is made by the thyroid gland, most of the T3 is made in the peripheral cells. 

And so what we want to know is, are the cells and tissues in a cell danger hypothyroid state? Or is there a true hypothyroid state going on where there’s just not enough thyroid hormone in the system? That’s what we want to determine, so we can look at this ratio. 


So if the free T3 to free T4 ratio is between 0.31 and 0.34, and you’re not taking thyroid replacement therapy or you’re taking T4 only, then the strategy is probably appropriate. 

If somebody’s in that range, then they’re probably on the right dose for now.

If you’re on T4 therapy and your free  T3 to free T4 ratio is less than 0.31, this means that ultimately, the cells are not doing a great job converting  T4 to  T3. It’s typically an adaptive response. 

And then I’ll look at somebody’s T4, free T4. Are they high because they’re on  T4 therapy? If reverse T3 is high as well, then this is a person I typically will tell to back to their prescribing doctor and reduce the dose, because more is not going to help this. 


If they’re above 0.34 and they’re not taking hormone replacement on they’re on T4 only, then this is a person who’s probably not getting enough T4 into the body. The cells are rapidly converting T4 to T3 because they need more T3.

Now, if you’re taking T3 medication, you can’t really use this ratio, which is a huge problem, because that free T3 number could be mostly your thyroid medication.

Now, if you’re taking the same dose of T3 from blood chemistry panel to blood chemistry panel, thyroid panel to thyroid panel, you might be able to say, okay, I’m doing a better job converting it… but you can’t really use this ratio. 

So to sum it up, if you are symptomatic and your free T3 to free T4 ratio is either below 0.31 or above 0.34, your thyroid replacement strategy is probably not working.

We finish the rest of this conversation in Part 2…

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Hi, I’m Dr. Eric Balcavage, owner and founder of Rejuvagen. If you’re struggling with health issues or have questions, let’s chat. You can schedule a 15-minute call with me to get started.