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Is Your Thyroid Medication Working? (Part 2)

The labs and markers I look at to tell if a patient is on the right dose and type of thyroid hormone replacement…

It’s not just about TSH! These are the thyroid lab values and comprehensive metabolic markers you need to pay attention to if you want to know how well your thyroid replacement strategy is working (dose and medication type).

Video Transcript

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We’re back for Part 2 of analyzing your thyroid hormone replacement strategy. In Part 1, I talked about the free T3 to free T4 ratio.

If you’re taking T4 only, or if you’re not taking thyroid medication, you can use that ratio and get a bird’s eye view of whether your strategy is appropriate. 

If you’re taking T4 and your free T3 to free T4 ratio is high, you probably need a little bit more.

If you’re taking T4 and your free T3 to free T4 ratio is still low, even if you have a high T4 or a high free T4, it’s probably too much thyroid hormone replacement therapy. The cells are just resisting it, so more is not going to make the situation better regardless of what your TSH is.


I know some people try and pound TSH down to a certain range, but you have to keep in mind that there’s more than T4 that influences it. T3 also influences TSH levels, and inflammation influences TSH levels. 

So we don’t necessarily want to be trying to drive so much T4 into the system and hope that at some point you’re going to get Deiodinase 1 to kick in and make more T3. 


What you’ll typically see is as you start ratcheting up your T4 dose, maybe because you’re still symptomatic, this ratio many times actually gets worse.

Even though your doctor may say, “Hey, that TSH is better, it’s coming down, it’s at two, it’s at one.” And so they think that by ratcheting up the T4 and dropping the TSH, that’s going to make you feel and function better. 

In reality, what we often see is that the more T4 medication you take, the lower you drop TSH, the worse the free T3 to free T4 ratio gets. 


So a lot of times if somebody’s on thyroid hormone replacement therapy and we’ve worked with them and their physician to start reducing the dose and they’ve been doing good signs and symptoms are approving, but then they hit “the stall” where they haven’t lost any weight, or their symptoms are static or increasing, we’ll do another thyroid panel…

If their ratio went from 0.31 to 0.34, and now all of a sudden they hit “the stall” and this number goes down below 0.31, that’s a really good indication that it’s time to reduce the dose of thyroid medication because the cells don’t need it. 


Now we can go to the rest of the panel…

If free T3 is dropping and free T4 is going up, we can also look at something like reverse T3. If reverse T3 is going up as well, it’s probably a really good indicator that it’s time to drop their thyroid hormone replacement. 

If we’ve made a suggestion to a physician to reduce the T4 dose, and we look at a thyroid panel maybe 30 or 60 days later to see if it was the right strategy, and this free T3 to free T4 ratio is lab high, then we know that maybe that strategy was a little too aggressive or that the thyroid gland just hasn’t caught up yet. 

And when I say that, some people would say, “what do you mean? The thyroid gland hasn’t caught up yet? I thought once I have hypothyroidism or Hashimoto’s thyroiditis or thyroiditis that my thyroid gland will never recover.” That’s not true!

We see people all the time that as we actually start to address the root causes of what’s driving the cell stress, improve their diet, their lifestyle, their habits, and their behaviors, then their need for thyroid medication goes down.

First of all, they start absorbing more of the medication, then it starts converting better. 

Then we realize that, oh, now the person’s more in a hyperthyroid state because they don’t need it. And as we drop that thyroid hormone medication, we can see their T4 levels, their T3 levels actually get better with less medication. 

And for a lot of clients, they need to take a lot less medication than they were ever taking before, and a lot of ’em in time don’t need it at all, which tells you that the thyroid gland can actually recover. 

Why does this usually not happen? Because physicians aren’t often addressing the true root cause. So in an allopathic model, nobody’s really addressing the root cause. 

But I want to give you some caution. Even in functional medicine, there are practitioners who think that if they just play whack-a-mole with T4 and T3, just keep increasing doses and driving up T4 or driving up T3 to optimize the blood levels then they can optimize the cellular levels.

And for some people, this can create change in symptoms, but if the cells are in a cell danger response, forcing more thyroid hormone into the system that doesn’t want it… 

I see the after-effects of these people getting blasted with high doses of T3, only T2, or T4. They feel good for a period of time, and then their doctors are ratcheting up their T4 and their T3 and taking T2 and thyroid booster supplements and all kinds of stuff, but they’re not symptomatically better. 

The physician may be happy because their TSH is driven into the ground and their T4 is high and their T3 in the bloodstream is high, and maybe they’ve been trying to drive reverse T3 low for whatever they think that does, but the patient’s still symptomatic.

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So if we’ve tried to optimize their blood levels with different types of thyroid hormone replacement, but they still have the signs and symptoms of hypothyroidism, and their labs still indicate that they have both signs and symptoms of hypothyroidism, did we really optimize them? 

The analogy we could use is if I want to optimize the function of my car, I could fill the gas tank up, but if the engine’s not running, it doesn’t matter how much gas I put in the car. It doesn’t matter if it’s the best gas that they have, the car’s not going to run. We have to address the engine. 

And I think too many clinicians, both in allopathic and functional medicine think that it’s all about how much hormone we dump into the system. 

If your gland can’t make hormones, it is important how much hormone goes into the system, but more hormone into a system that’s in that cell stress response, yes it’s going to create potentially some short-term improvement of symptoms…

But the problem is there are detrimental effects that can be caused by taking excessive, super-physiologic doses of thyroid hormone replacement long-term.


So what else can we do? What story do the rest of your labs tell? 

I rarely ever run a thyroid panel by itself, especially when somebody is taking thyroid hormone replacement and their doctors are trying to manipulate blood values.

I just had a client come in and her previous physician thinks they’ve optimized this woman. They’ve put her on T4, T3, and T2 to optimize the blood levels of T4 and T3. They have her on hormone replacement therapy for estrogen and progesterone and testosterone. 

And they say, okay, now we’ve optimized you and now we’re going to go try and, I don’t know, fix other issues. I don’t know what they’re trying to do, but they’re not optimized because they’re still symptomatic. They still have problems.

And so what we want to do is look at a comprehensive metabolic panel, and we can look at lipids.

I almost always run a lipid panel because it’s one of the easiest markers to determine if we have appropriate thyroid hormone T3 inside the cells and tissues. 

If your cholesterol is elevated, and LDL is elevated, you probably have not optimized your thyroid physiology at the adrenal gland or at the liver.

If you have elevated triglycerides or elevated VLDL, you definitely haven’t optimized your thyroid physiology in all the cells and tissues. 

If your GFR is down, you probably haven’t optimized your renal function. 

If you look at blood sugar markers, if you’re still showing signs and symptoms of glucose and insulin resistance, you haven’t optimized your thyroid physiology. I don’t care how much T4 and T3 you put in your system.

Here are the other Thyroid Thursday videos I’ve recorded about lipids, cholesterol, and blood sugar:

Can Hypothyroidism Cause High Cholesterol or High Triglycerides?

How to Know If You’re Insulin Resistant (Beyond Fasting Glucose)

The Thyroid Paradigm Shift

If you’re a clinician, watch these videos and also go look at the Clinician Course that Dr. Kelly and I teach. 

But if you’re just the client, the patient who’s struggling with hypothyroid signs and symptoms, this is why I think it’s so important to find a functional medicine practitioner who understands thyroid physiology. 

Big picture, your thyroid is not typically the problem. Thyroid physiology adapts to the stress response going on in the body. 

So if somebody says they’re a thyroid expert and they’re not looking at your blood sugar markers and your lipid markers as indicators as to whether their thyroid hormone strategy is working, then you’ve got a problem. 

Because their assumption is, like the car analogy, if I just fill the tank, it’s got to run. And that’s not the case. In this situation, you could wind up doing more harm than good. 

More from Dr. Balcavage:

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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.