Here’s How to Know If Your Thyroid Medication Is Too Low.
Today we’re talking about how to determine if you need to increase your thyroid medication. I get a lot of questions on discovery calls and from my patients: how do we know when we should increase thyroid medication? Now, it’s really important to know I don’t prescribe medication. I’m not your doctor, so I’m not telling you what to do. I’m just gonna give you some thoughts and concepts. When I review labs these are the things that I consider and then I tell my patients, Hey, this is what you need to go back and consider talking to your prescribing doctor about.
So the scenario typically goes like this. Somebody gets diagnosed with hypothyroidism, they’re playing with the dose. They get a dose, they don’t feel great. They go to their prescribing doctor, and the doctor says, well, if you still have symptoms, I’ll just give you more. And there, that’s a problem. If it’s inappropriate to give more thyroid medication, why?
If you give more thyroid medication, especially T4 medication, than the body needs, that can result in reduced conversion of T4 to T3 inside the peripheral tissues.
So even though somebody could drive TSH really low with thyroid hormone, making you look hyperthyroid, you could have mixed symptoms of hyperthyroidism, especially at the brain, and hypothyroid symptoms in the rest of the body. And this happens quite frequently.
So let’s go through this scenario. Somebody’s still symptomatic. Maybe you’re still tired, you’re still fatigued, you’re not losing weight, you’re on thyroid medication and your current thyroid dose of T4 (we’re gonna talk T4 medication only) has pushed your TSH into that 2 to 4.5 range.
Now, some prescribing doctors like to see the TSH below 1, given the person’s condition. Some people think that lower is better. I don’t believe that philosophy. Some people think that the sweet spot’s between 1 and 2, you’ll hear that functional medicine all the time. I don’t believe that’s the case either. And some physicians, as long as they’ve got TSH below the lab high reference range of 4.5, they consider the patient has been supported appropriately, especially if free T4 is within the lab reference range, and especially if T4 is at the high end of the reference range. But that’s not true either.
So if you’re still symptomatic and your TSH is, let’s say in that 2 to 4.5 range and your doctor says, Hey, I want to give more thyroid medication — or even if it’s really under 2 — and your doctor’s saying, I’ll just give you more medication ’cause you’re still symptomatic…
If your total T4 is functionally low or lab low, if your free T4 is functionally low or lab low, that might be an indication that you just don’t have enough thyroid hormone replacement.
If your total T3 is low and your free T3 is low, whether you’re using the lab reference range or the functional range, this might be another scenario.
And if reverse T3 is low, these things would all lead me to believe that somebody still needs more thyroid replacement therapy. There’s just not enough in the bloodstream yet.
But here’s the marker I really spend more time paying attention to: the free T3 to free T4 ratio. If this ratio is greater than 0.34, that means the cells are rapidly converting T4 to T3. Even if total and free T3 is low, the cells are trying to rapidly convert what T4 is available to T3. And this would be a good indication that somebody needs more thyroid replacement therapy. In this situation, I would say yes, it’s appropriate for now maybe to have somebody take a higher dose of T4 medication.
But if somebody was still symptomatic, their TSH is within that lab reference range, 0.45 to 4.5, and especially if it’s hanging in that 2 to 4.5 range, should you get more T4 medication?
Well, if your total T4 is normal or elevated, if free T4 is normal or elevated, if total T3 is low normal or low, free T3 is low normal or low, and reverse T3 is high normal or elevated, then we need to hit the pause button. There’s a good chance that this is not a case of not having enough T4 in the system. This is a good chance here that there’s that cell stress inflammatory process going on that’s causing tissue hypothyroidism, and more thyroid hormone wouldn’t be beneficial in this situation. It’d probably be more problematic. If the free T3 to free T4 ratio is less than 0.2 with plenty of T4 in the system, this is a good indication that more T4 medication in this scenario is not going to be beneficial.
Yes, you might have that initial phase where you feel a little bit better, but probably what’s gonna happen as you’re on that dose for a period of time is that TSH is gonna go lower and you’re gonna have maybe more hyper-type symptoms: maybe brain fog, insomnia, irritability. And then peripherally, you may see a plateau of your weight, you may see some weight gain. You may still be tired and fatigued. You may have more constipation, you may have more hypothyroid symptoms in the periphery.
Okay, so why might you not want to increase your medication? In this situation there is plenty of T4 available to get into the cells and be converted to T3 if the cells wanted it, but the cells don’t want it, or they would be increasing that conversion of free T3 to free T4, and this number would be normal or elevated. There’s potentially more deactivation of thyroid hormone going on to the reverse T3. So this would be a situation where I would be opposed to somebody increasing their T4 medication. I’d also be opposed to somebody taking T3 medication in this situation as well.
And I’m not your doc, I’m not telling you what to do, just explaining how I look at thyroid panels.
And I never look at a thyroid panel all by itself. I look at the signs and symptoms, I look at the rest of the blood work, look at lipids, look at blood sugar regulation for indicators that there’s this excessive cell stress, cell danger physiology going on that’s driving the cells to not convert T4 to T3 — not because they can’t do it, but because it’s an adaptive response. They’re trying to slow down their metabolism.
So in this situation, what would we do? We would try and identify what’s causing somebody’s excessive cell stress and address that. And then as we monitor their labs, what we’re likely going to see is their conversion go up and their symptoms improve.
If these values, the total T4 and free T4, were actually lab high — even though TSH is kind of the higher end of the range — we have to then ask the question, why would TSH still potentially be elevated even though there’s plenty of T4 and free T4 in the bloodstream, right? There’s plenty there. Why is TSH still high? And part of that is the cells still having insufficient T3 sending signals to the brain to keep TSH elevated because there’s low T3, free T3, and circulation low T3 and free T3 at the tissue level. So the brain is still getting some signals that there’s insufficient T3 in circulation.
And by sustaining TSH, I can still try and stimulate the thyroid gland to make more T3 because the peripheral tissues aren’t doing a great job converting it. Some people might say, well, that’s a great reason to give more T3, but in most situations, I don’t think it is. And I’ll explain why in another video.