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Let’s Talk Thyroid Lab Interpretations: Driving the Body “Hypo” and the Brain “Hyper”

Another case study from a real client and my recommendations…

This client was experiencing both hyper- and hypothyroid symptoms. In this video, I want to show you their labs and talk about the importance of getting enough thyroid hormone and how it can change what’s going on in your physiology.

Video Transcript

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In this video, I’m walking you through a series of labs on one of my clients and want to show you the importance of getting the appropriate amount of thyroid hormone and how it can really change what’s going on in your physiology. 

So this is a patient who was struggling with chronic signs and symptoms of hypothyroidism. They actually had both hyper- and hypothyroid signs and symptoms, from resistance to weight loss to GI problems, you name it.

Here are their initial lab values:


So what were they taking? This person was taking 110 micrograms of T4 and they were taking 25 micrograms of T3. And the patient was still symptomatic.

TSH is 9.92. What’s going on here? Why is TSH so high? I think the general consensus was to keep going up with the amount of T3 in the system. 

But why is her TSH 9.92, even though she’s taking 110 micrograms of T4 and 25 micrograms of T3? Typically a day’s worth of thyroid hormone that the body would generate is about 88-100 micrograms of T4 and about 30 micrograms of T3…

So why wasn’t this person feeling better? Why was TSH at 9.92? 

Essentially what’s happening here is they’re not taking enough thyroid medication. 

Yes, their T3 looks normal, but that’s because they took the thyroid medication T4 and T3 right before the blood draw. So if you take T3 before the blood draw, of course it’s going to make the T3 look better, but outside that timeframe, there’s not enough T4 in the system. 

That’s why total T4 is 4.7. That’s why free T4 is 0.77 and that’s why reverse T3 is at 7.1. The person’s not taking enough T4.

At some point, somebody saw that they weren’t converting T4 to T3 and thought that the solution was to provide more and more T3, but essentially what they did was create a more hypothyroid state in this person.

So what about the T4:T3 ratio? I talk about that all the time, but it’s actually not valid because they’re taking T3, so we’re not really seeing what they’re converting.

Okay so in the second set of labs in this timeframe, I suggested to this person to go back to their prescribing doctor and start weaning off of the T3 dosage. Now, that medical physician said no, that they were on the right dose, so we can only do so much because I don’t prescribe. 


So we started working on their diet, working on their macros, working on their GI tract, the lifestyle factors. We get another set of labs done a few months later.


So what’s happened here, the reason TSH has come down a little bit, the dose of the medication’s exactly the same, but what’s probably happening is she’s actually absorbing more of the T4 medication that she’s taking, which is why T4, free T4 and reverse T3 are going up. 

So again, what do I say? I say, “Hey, you should really go back to your doc and ask to change the dosage.” And the doctor says, no, we’re not changing the dosage. And she wants to go on T4 only based on my recommendation. He says no.

She goes back to her doctor to try and get that conversation handled and the doctor runs her labs…


So we’re at a point where we’re not making headway anymore. We’re not making any more progress. We’re kind of plateaued with our improvement. She’s frustrated. I’m frustrated. 

I know a big part of what’s going on here is that she’s overmedicated or improper medication. So we have that conversation. “I don’t know how much more I can help you change because the inappropriate thyroid medication strategy is inhibiting your physiology.” 

So she tries to get ahold of her prescribing doc can’t get ahold of the doc. 

She winds up running out of thyroid hormone replacement therapy, and she actually starts feeling a bit better initially without the thyroid hormone. 


So after about 30 days of no medication, I’d say we better run another thyroid panel to see what’s going on and make sure that you’re not in more problem mode. 

When we do, what do we see? 


We see TSH did go up 9.5. That makes sense because there’s not enough thyroid hormone maybe in the system. Her total T4 is still 6.0. It didn’t really drop off. So what does that mean? That means she has a thyroid gland that can actually make T4.

So what’s going on here? 

Now she’s not taking any medication. The thyroid gland is able to make thyroid hormone and it’s maintaining that. But as quickly as she’s making that T4, she’s converting that T4 to T3. So now we’re actually getting conversion of T4 to T3!

So this is a person who was told that probably you’re a non-converter, we have to give you T3. But that was never the case that she couldn’t convert it. It was probably more of an adaptive change.

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So in the meantime, after these labs, she does start to feel more tired, more fatigued.

She goes back to the endocrinologist because she needs medication. It’s been about 3 months at this point. And her doctor says, well, you’re going to need some medication. And he says, well, I’ll just put you on the T4 and we’ll see what happens. 

So she gets put on 112 micrograms of T4. After 30 days on that dose, we take a look at her labs and her TSH is coming back down. 


Guess what? She’s losing weight and feeling and functioning better. 

This is a person who was on T3 medication and probably shouldn’t have been on it. 

Yes, I understand why people did it. “It doesn’t seem like it’s converting. Let’s give you T3 and we’ll help out the system and you feel a little bit better.” 

But then numbers start to look worse, so you start to feel worse, and so we’ll just give you more then. And then you keep stacking up that T3. As you add more and more T3 and sometimes T4, it creates more of a hypo/hyperthyroid condition in the body. 

You can drive the brain hyper-, the body hypo-, and at some point this treatment actually becomes the problem. 

So now we’ll wait and see. We’re going to give her another 60 days on that level and see how she does. If she hits the plateau or what I call “the stall,” then I told her to get the blood work done at that point, if she’s doing better, doing better, doing better, and she hits a stall or the plateau, that’s the time we want to retest the labs. 

And many times what we’re going to find is now that person is overmedicated because the thyroid gland is continuing to recover, to make more T4. 


So what happens in these scenarios is that the T4 the gland can make, and the T3 that they’re taking as a medication, together drive TSH too low. And when it drives TSH too low, then it shuts down T4 production in the gland and reduces the T4 to T3 conversion in the periphery. 

This is another case where somebody maybe had good intent to try and fix or optimize somebody’s T3, but in the process, they actually made the person have more symptoms, more problems, and probably that treatment was actually the biggest part of why they couldn’t get well.

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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.