T3 Or Not T3 – Exploring The Controversy

I don’t want that synthetic stuff; I want the natural thyroid hormone.

This is probably one of the most misguided requests I get in my practice.  To make sure we’re all on the same page here, I’m talking about levothyroxine vs dessicated (pig/cow) thyroid.  First, I must reject the premise of the patient’s italicized statement above. 

Levothyroxine is Natural; Pig Thyroid Isn’t

What?!  Every other blog I’ve read says the exact opposite!

That’s because none of what you’ve read has been written by an endocrinologist (or at least not an endocrinologist worth her salt).  Among endocrinologists, it’s an open secret that levothyroxine is one of the most natural forms of hormone replacement for the human body.  When your thyroid is underactive, and your doctor puts you on a levothyroxine pill, the body cannot tell the difference between levothyroxine and thyroxine (the native hormone).  In other words, your body is perfectly happy to use levothyroxine just as it was using thyroxine when your thyroid was healthy.

Pig thyroid pills, on the other hand, contain a mixture of T4 and T3, in a ratio of roughly 4:1, respectively.  That’s a wonderful cocktail – if you’re a hypothyroid pig.  Guess what the ratio of T4:T3 is in the human body – about 15:1!  So when you take pig thyroid, you’re getting way more T3 than what the human body is accustomed to seeing on a daily basis.  Not good.  I’ll explain why shortly.

So we’ve got levothyroxine – a “synthesized” hormone that is identical to the thyroxine that your thyroid would be making if it was functioning properly.  And then we have pig thyroid, which gives you both T4 and T3 (two for the price of one!), but in a ratio that is way out of proportion for the human body.  Which of these sounds more natural so far?

Well, I’d rather get too much T3 than not enough.  After all, if my thyroid isn’t working, doesn’t that mean that I’m not making enough T4 and T3?  I have to take at least some T3, right?

You’re still skeptical – I get it.  You’ve read that T3 is the “active” form of thyroid hormone that gets inside the cells and gets the job done.  The thing is, the body is efficient at taking levothyroxine (T4) and converting it into T3.  All the different tissues in the body (liver, kidneys, muscles, brain, etc) are going to make however much T3 they need.  Are there instances in which various tissues don’t make as much T3 as they need?  Yes, but this is nowhere near as common as some of the non-evidence-based information out there would have you believe.  And when it does occur, the magnitude of the impact is probably not as vast as one might think.  If you really want to geek out on the T3 conversion issue, read Guidelines for the Treatment of Hypothyroidism: Prepared by the American Thyroid Association Task Force on Thyroid Hormone Replacement, and jump to:

13a. Do genetic variants in thyroid hormone pathway genes (deiodinases or thyroid hormone transporters) affect the serum or tissue levels of thyroid hormones in healthy euthyroid individuals or hypothyroid patients taking replacement therapy?

 

■  Summary statement

Specific polymorphisms in the deiodinases are consistently associated with very small changes in serum thyroid hormone levels. Insufficient data exist to draw any conclusion about the clinically relevant effects of deiodinase or transporter polymorphisms on tissue thyroid hormone levels.

    

If you like, there’s a plethora of scientific text you can wade through after the summary statement, but I think the more relevant issue to dive into is, why do some people feel better with pig thyroid or when we add liothyronine (T3) to their levothyroxine therapy?  And the corollary: if people like pig thyroid, why is your doctor loathe to prescribe it for you?

Five Types of People Who May Need/Like T3

  1. If someone does have one of those (not clinically diagnosable) deiodinase polymorphisms, it is certainly possible that T3 therapy provides replacement for a physiologic need.  In this case, levothyroxine alone might not cut it.
  2. Patients who have had their thyroids removed have to rely entirely on T4 to T3 conversion for their T3 needs.  In other words, an absent thyroid can’t make any T3 at all, so patients with postsurgical hypothyroidism occasionally feel better with combination T4/T3 therapy.  Contrast this to the typical patient with an under-functioning thyroid (primary hypothyroidism), who probably makes enough T3 such that exogenous (supplemental) T3 won’t make a difference.
  3. Hypothyroid patients with depression may benefit from the addition of T3 to their levothyroxine.
  4. Anyone particularly susceptible to the placebo effect will like T3.  Frankly, this encompasses almost everyone – it is rare to be immune from the placebo effect.
  5. I saved the best for last, because I believe that this is the most common reason why people like T3.  T3 is a short-acting hormone that – especially when given in supra-physiologic doses (like pig thyroid!) – tends to act as a stimulant.  This is actually true of lots of hormones when taken in higher than physiologic doses.  Ever take a whopping dose of prednisone for a few days and feel like Superman?  Do you know any body builders who juice and feel fantastic for three days after an injection of 1000mg (venti-sized dose!) of testosterone?  So, just because someone feels good on T3 does not mean that she is deficient in that hormone.  Smoking crack probably feels pretty good, but you’d never assume the addict has a “crack deficiency.”

Your Doctor isn’t Mean – She Just Cares about Your Long-Term Health

When exposed to high levels of T3, the body may exhibit symptoms of thyrotoxicosis (too much thyroid hormone).  Symptoms like heart palpitations, tremors, sweating, anxiety, and insomnia may occur even if the TSH is within the normal range.  Remember, while the TSH is usually highly accurate, if you spend part of the day with high T3 levels and part of the day with low levels, that may average out to a normal TSH.  In this case, a normal TSH does not mean you are normal. 

After longer periods of time, the heart may go into a dangerous rhythm called atrial fibrillation, the bones may become more fragile and prone to fracture, and muscles may waste.  So, while your doctor would love to fix all your symptoms right away, a stimulant that masks whatever is really going on with you is probably not the best long-term solution.

OK, I’m hearing all this, but can’t we just check a T3 level in my blood and use that to gauge whether I need T3 therapy?

Oh, were it that simple…the T3 level in your blood does not correlate well with the T3 level in all your various tissues.  Remember, each organ is making its own T3 based on its needs at that moment.  We can’t measure that.  On top of that, when on levothyroxine therapy, the blood level of T3 is usually low-normal and sometimes even slightly low.  But there has been no evidence showing that these levels correlate with any symptoms.  Bottom line: it is not helpful to check T3 levels in hypothyroid patients on levothyroxine, in an attempt to determine whether T3 therapy is indicated.

How to Broach the Subject of T3 Therapy with Your Doctor

After all that, you’re going to advise me how to actually get my doctor to prescribe T3 for me?  Did I misread the first 2/3 of this post?

No, you didn’t misread me.  After years of offering small doses of liothyronine to a subset of patients on levothyroxine – in a physiologic ratio of T4:T3 – I am disappointed with T3 therapy and skeptical that it has much benefit.  However, I do have a minority of patients who have tried T3 and have had a durable response to it.  I say “durable” because patients will often have an immediate benefit from the stimulant effect, which then wanes over the course of weeks to months.  If someone still feels better six months after starting T3, I consider that a durable response.  So, if a patient meets all of the following criteria, I may offer a trial of T3 therapy:

  • The TSH is already in the lower half of the normal range.  Sometimes (not all the time), hypothyroid symptoms will improve just by bumping the levothyroxine dose a bit to push the TSH down below 2 – 2.5.
  • There is no competing diagnosis to explain the “hypothyroid” symptoms.  For example, if a patient has sleep apnea and isn’t treating it because she doesn’t like the CPAP mask, T3 is not yet on the table.
  • The patient does not have active heart problems (angina, atrial fibrillation, etc.).
  • The patient does not have moderate-severe anxiety.  In my experience, T3 makes this worse.

If you feel you meet the above criteria, then consider broaching the subject with your doctor.  But you must understand and embrace the following bullet points before you ask:

  • If you do try T3, keep your expectations low.  Remember, you may feel better when you start it, but that feeling may disappear if the benefit was solely due to the stimulant effect.
  • If your doctor went through medical school and residency/fellowship in the 1990’s or after, chances are she has been taught that T3 is unhelpful at best, evil at worst.
  • T3 therapy is often associated with naturopathy; the naturopathic approach to hormone treatments is way out in left field and mostly antithetical to the allopathic (mainstream medicine) approach.  The number of people I’ve taken care of who have been misdiagnosed and mistreated by naturopaths should be horrifying to the lay public.  More on this in future posts.
  • Before prescribing T3, your doctor may want to probe aspects of your health and lifestyle that you feel are irrelevant to your symptoms.  I recommend you listen to your doctor, as it is impossible to be objective when it comes to your own health.  You may “know your body,” but your doctor knows hundreds – if not thousands – of bodies just like yours.  I know it’s disheartening to read that you’re not that special, but trust me, you’re not.

If you’re still reading by this point, I assume that you remain interested in discussing T3 therapy with your doctor.  Here’s how I would initiate the conversation:

Doc, I’ve been on levothyroxine for quite some time now, and I still have several symptoms that just won’t resolve, like [symptoms].  I realize that my TSH is optimized, which should mean that the treatment of my hypothyroidism is optimized.  So I’ve been thinking about what else could be causing my symptoms, and I just can’t come up with anything.  I’m getting at least 7-8 hours of sleep every night, I’m eating clean, and I exercise several times per week [this better be true].  Based on what you know about me, can you suggest any other avenues to explore that might help me figure out these symptoms?

Now you pause.  Let your doctor earn her $20 copay ($40 if she’s an endocrinologist).  Give her time to ask you questions, look at your lab work from the past couple of years, and see if perhaps there is something else to explore.  If she has some suggestions, great.  If she agrees that you are otherwise healthy, it is possible that she may actually broach the idea of a trial of T3 (this is much more likely if you have a mid-late career Endocrinologist).  If she comes up empty and basically shrugs her shoulders, then you can carefully and respectfully bring up the possibility of a trial of T3:

Doc, don’t worry about being out of ideas.  I’ve been wracking my brain for [weeks/months/years] and I haven’t come up with any competing diagnoses either.  So I wanted to get your opinion about something I read.  It was written by an endocrinologist, so I hope it’s more trustworthy than the majority of the nonsense out there on the internet.  It seems like there is a small subset of hypothyroid patients who will benefit from adding in a small dose of liothyronine to their levothyroxine.  I understand that, when used, the levothyroxine dose should remain somewhere around 10-20 times as much as the liothyronine dose, to keep the ratio close to normal for human physiology.  I also understand that it may not work, and I’m ok with that.  If it doesn’t work, then I’m happy to stop it.  What do you think?

You’ve done several things by couching your request as above.  You’ve communicated that you and your doctor are on the same team, and you’ve acknowledged that you don’t expect miracles.  You have implied that you understand how doctors feel about internet research and that you understand the limitations of such research.  You have asked your doctor to give her opinion of what you’ve read, thereby demonstrating that you respect her education and experience, and you value the doctor/patient relationship.  Now the ball is in her court.  She can agree to a trial or not.  If not, you can try to gauge if there is any wiggle room in that “no.”  But if there isn’t, you need to accept that and either forget the trial of T3, or go get a second opinion.

What do you think?  Have you tried liothyronine or talked to your doctor about it?  What has your experience been with your trial or with your doctor?  Are you a doctor who has used T3 for your patients?  Do you think it has value?  Comment below!

By interacting with me in the Comments, you agree that you have read and will abide by my Disclaimer.

January 28, 2020 Update: The Comments section of this post is now closed. Any further discussion about the issues raised in this article should take place after the appropriate post in my ongoing T3 Controversies Series. For a complete explanation of the rationale for closing this post to new comments, please read Comments and Controversies on Hormones Demystified. Here’s the TLDR version: reader comments on this post have veered off into realms that this blog was created to refute/debunk. Each post in my new T3 Controversies Series will address one specific unsupported claim or falsehood found in the comments on this post. This narrower focus of each post should help keep comments on topic, helping you find the information you need. As always, thanks for reading and staying engaged. -HD

380 Replies to “T3 Or Not T3 – Exploring The Controversy”

  1. Excellent, informative and entertaining summary of thyroid hormone replacement and the intricacies of T3T4. I especially like the sample script at the end. It is so important to be prepared when you meet with your doctor. This article has you more than prepared.

    1. Thanks, Dr. Scher. If people are going to ask for T3, I hope that they will do so from a position of knowledge and have realistic expectations.

      1. Hello.
        I’m speaking as someone who suffered from undiagnosed, hence untreated, hypothyroidism for 10 years. Having had some clinical training, I recognised the signs & had the authority of lived experience for the symptoms.

        When I went to my GP (doctor who’s a general practitioner in primary care in the UK) he didn’t examine me, didn’t even look at me properly, & dismissed my reported symptoms as menopausal. A year later, when everything was worse, he asked me if I was depressed. Two years after that, he finally gave me a blood test which proved to him I was “normal”.

        For 6 years I just soldiered on, feeling like the walking dead. By then my TSH was up to 33. He conceded I was ill – and asked why I hadn’t come in sooner! I requested & was given Armour DTE.

        My hair hasn’t grown back, my adrenals are probably depleted and my heart weakened, but my energy for life came back and the clarity of mind I value, and had been losing, returned. I have been stable on Armour, 15 mag twice a day, for 8 years. I have been able to stop sleeping excessively, start walking again, and participate in social activities including voluntary work. I worked as a tutor until I was 70. My blood test results for TSH, T3 and T4 satisfy the GP.

        Now, Armour is being removed for reasons of cost.

        You airily dismiss the genetic polymorphism affecting deiodinase 2, but I’ve read clinical papers suggesting 10-15% of the population has the variant gene which inhibits T4-T3 conversion. Shovelling buckets of Levothyroxine at someone with that defect will certainly give you blood test results you find acceptable, but as you acknowledge, such results won’t indicate what’s happening in the organs and tissues being starved of an essential hormone. You will be condemning us to a procrastinated, wretched death. We will die of exhaustion and co-morbidities culminating in heart failure, but you won’t classify that as iatrogenic in origin because our blood test results will look normal.

        Just because patients can’t always articulate in clinical language what’s happening to them, it doesn’t follow that you shouldn’t listen to them.

        DTE was the only hypothyroid treatment in the US for decades. That’s why it was grandfathered into the modern system. If there are no studies proving efficacy and safety, do them. But RTEs aren’t the only form of credible evidence. They relate to groups. You are supposed to take care of individuals, in a mutual contract of patient-centres care. In the interim, if patients get their lives back when they take Armour, let them have it. We have decades of empirical evidence that it can safely be prescribed.

        1. As always, I’m happy to hear when someone feels like they’ve gotten their life back. Just a couple of points:

          – Desiccated thyroid isn’t a physiologic form of thyroid replacement for humans. There’s really no way to argue otherwise, whether you feel well on it or not. Adding T3 into T4 in a physiologic ratio for humans would more closely replicate normal human physiology – another fact. Not opinion.

          – I don’t believe I “airily dismiss” the polymorphism. I wrote about it here: Is TSH the Best Test?

          – Practicing evidence-based medicine and listening to patients are not mutually exclusive; I can do both.

          1. Thank you for your note.
            I don’t dispute that porcine thyroid has an arrangement of hormones that don’t precisely mirror the proportions produced in a human gland. There is an understandable concern that excess T3 may be damaging.

            However, in just the same way that most humans can eat animal flesh, and transform it so that it becomes part of our physiological processes, Armour users seem to take what their bodies need from pig thyroids and excrete the rest. My T3 levels have never gone outside the acceptable range in 8 years of use. Nor have I ever had symptoms such as erratic or quickening heartbeat, or other responses which might indicate a movement towards thyrotoxicosis.

            I once gave a lecture on EBM, & researched its origins. It seems the germ of the idea was a Canadian paper which showed you could accurately judge what year a doctor graduated, because s/he was still prescribing whatever was the norm when s/he was training.

            EBM was supposed to give busy doctors computer-based updates, without requiring a lot of reading. In practice, it’s meant heavy reliance on RCTs & meta-analyses, which are not a safe guide to individual patient care, so I’m glad you listen to your patients as well.

            Clinical signs, a patient’s credible report of symptoms, blood tests, & a doctor’s training and experience, all contribute to the information base. A good differential diagnosis is one which makes sense of all of them.

          2. Armour users seem to take what their bodies need from pig thyroids and excrete the rest. My T3 levels have never gone outside the acceptable range in 8 years of use.

            It is not surprising that your T3 levels have been in the normal range, as you are on a tiny dose of Armour compared to what many people take. In the folks who are taking higher doses, they may very well experience thyrotoxicosis at the tissue-specific level. There is no evidence that their bodies can take what they need and excrete the rest, but there is substantial evidence that taking too much thyroid hormone (T3 or T4) can lead to bad things.

            It seems the germ of the idea was a Canadian paper which showed you could accurately judge what year a doctor graduated, because s/he was still prescribing whatever was the norm when s/he was training.

            I’ve seen so many variations on this theme plastered across the internet. I even wrote about it here: Alternative Medicine is Kicking Our Ass. I do not see this happening in real life. The doctors I know do CME and adjust their practice of medicine accordingly.

            I agree with you that we can’t necessarily regard aggregated RCT data as gospel when treating the individual patient in front of us. Your point about taking all data (including the patient’s reported symptoms) into account is well-made.

          3. This is a question I have Where is the evidence that taking too much T3 can cause problems? I ask this as this is where I get really confused. My GP and Endo seem happy enough to let my FT4 be well over range as long as my TSH is still within the bottom end of range (but not suppressed). Yet they don’t like the idea of adding T3, even though my FT3 is sometimes below range, as excess T3 is bad. All the papers I have seen seem to suggest that taking too much T4 creates too much T3 and that is the problem. But I can’t find any evidence that categorically says excess FT4 on its own is a problem, or excess FT3 is a problem. I am genuinely confused. Yet there are papers saying too little T3 can also cause problems. Likewise papers saying that a suppressed TSH causes problems, but again with the assumption that both T4 and T3 are high. My body feels tight all the time. Specifically my tendons and what feels like the fascia around my muscles. Like I have no give, no amount of stretching, yoga, massage helps. My osteopath has joked I am all grisly. I cannot help but think that this is a side effect of low T3. I ask again, is there any significance in a large discrepancy between FT4 and FT3 levels?

          4. Too much T4 or too much T3 are both bad. Yes, too much T4 can be converted to too much T3 as well, but the point isn’t to differentiate between too much T4 or T3. The point is, taking too much of any kind of thyroid hormone is bad. In the office, the obvious signs of this are tachycardia, high blood pressure, hyperreflexia, tremors, obvious nervousness/irritability…the list goes on. In the labs, the TSH will be low. That’s it.

          5. Thanks for the explanation. So what is seen as high? Out of range? So on that basis, my high FT4 is dangerous?

            My TSH has been bottom of range, 0.30 (range 0.30-3.94) my FT4 has been very high 36 (range 12.3-20.2), yet my FT3 was lowish 4.10 (range 3.70-6.80) yet I felt the best I had since getting Hashimotos. The endo and I had worked slowly and carefully to get it to here. On examination my heart beat was a steady 66bpm. No sign of tremors. I felt the best I had in a long time (6 years). Previous to this I was practically bed bound, hair and nail less!

            He conceded that I showed no signs of tachycardia or hyperreflexia, but he worried the FT4 was a bit too high, so reduced my levo, again slowly over the year and now my FT4 is in range again 18.90, my TSH is 1.92 but my FT3 is out of range at 3.30.
            I have had hairloss again and am knackered again.

            I would love to not be on any medication, but sadly I cannot function without as I soldiered on for 4 years without and I was practically bed bound and very unwell.

            I am not trying to dispute, I am desperately trying to understand so that I can feel well, yet work within the parameters of medical care. I do not want to damage my body by taking too much yet, there is no point in living if you are so unwell on less. ( A big statement, but when you feel that ill, that is how you feel). And when you have had a taste of feeling almost normal on a dose, you want to remain there. I guess you must be fed up with Lay people like me trying to understand, bit like everyone thinks they can design from a professional designers point of view! LOL

            Are you suggesting that there is no need for Liothyronine medication in treatment of Hashimotos? I am confused. The world of Thyroid disorders is like the world of diets, eat this, don’t eat this, this is good for you, this isn’t! LOL.

            I understand that low FT3 can also be dangerous also. Have I got that wrong?

          6. Hi Kit,

            Your T3 previously was in mid-range which is where studies have found is a good and safe number to be, mid-range is where pain levels in pain patients will drop. T3 is the active form so it was in the correct level.

            You TSH was still in range do there was no reason to drop your medication to the point that you are suffering hair loss.

            Yes, your T4 was too high, but….
            You were still producing TSH in the normal range. And medication is made with two mirror-image molecules, one your body can use, but the other is unusable. Of course, physicians do not take this into consideration. They still fear it will cause body damage, however your heart was good, no tremors and no hyperreflexes Also, if you were over- medicated your temperature would be higher than normal, up above 99.7°F. There were no symptoms of over-medication.

            Now, you are definitely under medicated, and you need yo convince your physician to increase your medication.

            Why did your physician reduce your needs by do much? Likely they gotbthe usually Endocrine Society notice threatening physicians if they do not treat based MAINLY on the TSH.

            You need to be firm but kind, and insist on higher medication. Point out your hair loss, total lack of overdose symptoms,etc.

            What is your temp running now? If it too is below normal, that is an obvious sign of undertreatment.

            Good luck, and be insistent.

      2. Hello there,
        Very interesting article! So I was diagnosed by my endo with subclinical hypothyroidism in early 2019. I’m a 28 year old female, very active, and eat a balanced clean diet. My initial labs indicated my TSH was 4.66 (considered high to my endo), T3 was 3.4, and T4 was 1.3. I was prescribed 60mg of Armour Thyroid.
        Took 60mg of Armour for 3 months then she increased my dosage to 90mg.
        4 weeks later, I experienced my first ever anxiety attack and heart palpitations. It scared me enough to stop the medications. 4 months later I was encouraged to try the medication again so I did, starting at 40mg of Armour this time around. The same incident happened, 4 weeks later I started up again with heart palpitations, nervousness, heart fluttering. It got so bad that I couldn’t exercise for 2 weeks or drink coffee because my heart rate would drastically increase during my workouts and I was excessively sweating. I told me endo about the same incident when taking Armour. She suggested I try levothyroxine 50mcg now.
        I’m not sure what to do at this point and time because I don’t want to have anxiety attacks again and the heart palpitations.
        A friend recommended I try T3 itself (L-thyronine). Im very interested to hear your thoughts / feedback with my situation. Much appreciated!

        1. Hi Theresa,

          Your T3 is good, so it looks like your body has no problem turning T4 into the active form T3.

          But your T4 is way low, so this means your thyroid gland appears to be not be making enough T4.

          You say you are eating healthy, so are you using iodized salt? If you have decreased or eliminated salt, that could be the cause of the low T4. The salt in prepared foods has no iodine in it, so you need to get iodine daily.

          Your body needs about 150mcg of iodine daily, in order to make T4 . Do not take more than this because too much iodine will be a problem. There are sites on-line that will recommend high doses of iodine, and then after awhile people get toxic body levels of iodine, wwhich makes them very ill.

          Do check yourviodine intake, that make help fix the low T4.

          1. Aelxa, Remember that thyroid hormone contains iodine, so if you are taking a substantial dose of thyroid you are already getting a dose of iodine.

          2. Hi Jim,

            I am only taking 150mcg of iodine, which is the daily value(DV) the US government says each person needs to get each day. Since I can not use iodized salt, due to the maltodextrin in it now jacks my blood sugar up into the diabetic range, that 150mcg of iodine is all I get. I hate seafood, do not eat any seaweed, or other iodine containing foods.

            Back in my 20s I stopped using salt because of a family history of high blood pressure, and by my thirties I had developed hypothyroidism. I got terrible cravings for tunafish once I stopped using iodized salt, now I know it is because my body never got any iodine. I really hate and despise fish, so if I ate tuna twice a month, that was alot. I am sure my body tried real hard to hold on to iodine, but there is no real very active system of recycling it in the body.

            It was last year that I realized that I was not getting any iodine, and started taking the 150mcg of iodine daily. My tuna cravings stopped. But the biggest change was the continual slow increase of my body making it’s own T4, so after only a couple months I did not need to take any Synthroid at all.

            I still need to take T3, but only because of my conversion problem caused by the double copies of MTHFR gene C667T, about 2.5mcg of T3 every two hours during the day, raised my body temp from 96.5°F with no body hair, up to 98.7°F and all my body hair coming back. Also my chronic severe depression that no medication worked on went away. That T3 is needed by the brain as the basic building block to make neurotransmitters, such as the serotonin. No serotonin being made from the lack of T3, then the SSRI antidepressant has no serotonin to work with.

            Low serotonin and other neurotransmitters cause the perception of pain levels to go up in the brain. Get the T4 and most importantly the T3 into mid-range, and pain levels drop. This information is taught in medical school, I read it in a basic endocrinology textbook shortly after my pain levels dropped, and I was curious why that happened, so I researched T4 and T3.

            The biggest huge benefit is my chronic pain levels that were at a constant 9 for decades and requiring three different opioids to be at a 9, dropped down to a 2 to 3 level after only three days of having my T3 blood level in mid-range, and I was able to cut my pain medication doseages in half. After only three days, that was a miracle for me. Right now I am down to a minimal dose of one pain med every 8 hours, and I hope to be totally off all pain medication in a year, if the positive changes continue, andbit appears that they will.

            My pain levels keep dropping which is so wonderful, after being bed bound or barely able to walk 100 feet for decades from Chronic fatigue and Fibromyalgia. You could lightly brush the skin on my arm and it would feel like I was hit with a baseball bat, my brain was over-reacting to any pressure stimulus on the nerves. Now I can get a full body massage and experience no pain at all, it just feels good.

            My TSH is normal, so taking the T3 every two hours is not suppressing it.

            While the iodine molecule is released from the T4 to make it into T3, there does not seem to be too much recycling of it going on (unlike the CoQ10 molecule in the body, which gets recycled over 30 times via selenium before it degrades too badly and is discarded by the body), and the kidneys excreting iodine in the urine appears to take care of releasing iodine daily and keeping it to where you do need to take daily iodine.

        2. Hi Theresa,

          The Armour made you anxious, and all the other symptoms showed you were getting too much T3 , Armour has huge amounts if T3, the active thyroid hormone, in it. And as I noted in my previous post, your T3 level looked basicly good, so there is no problem at this time converting from T4 to T3.

          It is that low T4 which is the problem, your pituitary gland is pushing out enough TSH that your T4 level should be much higher.

          Try the iodine first, see if the problem is a lack,of iodine in your body to make the T4.

          Then if after a few weeks of supplementing with iodine, if the T4 is still low, then it would look like your thyroid gland is just not able to make enough T4, even with the raw materials to do so. That means something has damaged the thyroid gland itself, most likely some chemical you absorbed.

          Or you are very deficit in Vitamin A, the retinoic acid form and not the precursor called beta-carotene. Retinoic acid is required in order for your body to absorb and utilize iodine.

          Iron is needed to convert beta-carotene into retinal form of Vitamin A. So if you have low iron, that will cause low vitamin A, which will cause low iodine levels, which will cause low T4 production by the thyroid gland.

          Zinc is needed to transport vitamin A, so if your zinc is low that will affect iodine levels, but zinc also affects wound healing, so suspect low zinc if you healing scratches, etc slowly.

          At that point where nothing like iodine increases your T4, then the only solution would be to take Synthroid, in order to supply the T4 your body needs. My endocrinologist recommends taking the brand name Synthroid, as the generics vary widely in the amounts of T4 in each manufacterer tablet and even each batch made by the same manufacterer. Synthroid is the most consistent T4 on the market.

          But do the iodine first, I really suspect that is your problem, and there us no reason to pay for a medication, if your body could make it with the correct raw materials.

          1. Hello! Thanks for the prompt reply!
            I never tested my iodine or rentenoic acid levels, would that be ordered in a lab panel? I’m going to definitely give try the iodized salt a try first as you suggested. Any particular brand you recommend? Also, why not Levo vs synthroid? Will T4 cause any palpitations or anxiety?
            Thank you so much for thoroughly educating me. My goal is to try and fix my thyroid naturally and avoid taking any medications if possible.

          2. Hi Theresa,

            I have no idea if there are tests for iodine, I am unable to recommend any brand of iodized salt, they contain maltodextrin which I have problems with. I use the Life Extension brand Sea-Iodine supplement instead. The capsules contain1,000mcg of iodine, so I open a capsule by twisting off the cap, shake about 1/6 of the capsules contents into the cap, then pour the caps content into my mouth and swallow with water. You could pour the small amount on food instead if you wanted. One capsule lasts six days, and gives me about 150 mcg of iodine.

            Some people do not like the taste of iodized salt, but try the iodized salt first as it is inexpensive and found everywhere. Check the salt container to see how much salt you need each day to get the daily iodine, use a measuring spoon to make sure you are getting the correct amount, then sprinkle a little of that measured daily amount on each meals food.

            I use the Synthroid brand of T4 because my doctor found the generic brands of Levo are too variable in the amount of T4 they will supply. His patients would get too much or too little, so he insists on the Synthroid brand, and the few times I tried the generic they were very variable. I am sensitive to the amount as even a tiny change will affect me greatly, too much and my body temp jumps over 98.7°F and right up to 100°F fast. If I did that weekly thing some endocrinologists do, I would get very sick. My pituitary gland would react badly. (But that is me, brain problems from 6 TBIs.)

            If you just need the iodine to make T4 in your thyroid gland, your body should make the correct amount. The TSH tells the thyroid how much T4 to make.

            If you have to take Synthroid (T4), then the physician should prescribe a daily amount, and adjust it according to your blood results. I forget how long after starting the T4 they order tests. But if you get shaky, anxiety, fast heartbeat, these are all symptoms of too much. Remember, it looks like your body can turn T4 into T3, too much T4 and your body could turn that T4 into T3 too fast, making the shaky, etc symptoms.

            In that case you should call the physician, ask to have thyroid blood testing done that same day, to catch what the thyroid levels of T4 and T3 are, and then take less Synthroid. At one point I was taking 1/2 tablet of Synthroid each morning. Right now I take no Synthroid at all, just Cytomel (T3)

            My problem is not that I can not make T4, it can with enough iodine. My problem is my body can not turn T4 into T3 very well, I have a gene problem. I have two copies of MTHFR gene C667T, and so my body methylation conversion rate is only 20% of normal. So I have enough T4, but it hardly gets turned into T3 and I am always cold, no hair on body, little hair on my head. So I have to take Cytomel (T3) 5mcg 1/2 tablet every two hours from 8am to 8PM. This keeps my body temp at 98.7°F while awake, and about 10PM my body temp drops to 97.6°F, and I am able to go to sleep. If I took a whole 5mcg tablet at once my temp jumps to 100°F, then drops so by 2 hours later it is 97.6°F, but I had 6 TBI and things are very different for my body.

            Hopefully, the iodine will fix the problem for you, if it is merely that you weren’t getting the iodine needed for the thyroid gland the make the T4. The Thyroid gland also makes some T3 each morning, but it only does it once a day. The T4 is there to be available throughout the day for being turned into T3, which is the active form your body uses every where to do different processes. Your blood test showed ok T3, but that very low T4, so see if the T4 will increase with the iodine, and make sure you get the iodine every day. Hopefully, the iodine will do the trick. Too many people do not use iodized salt, and are not getting any iodine for the thyroid to use. If it works, come back and tell us, it would be good to hear your results.

  2. Thank you for the article, but you haven’t addressed why I take T3, which is as an anti-depressant adjutant. My understanding is that the level of evidence is for T3 as an anti-depressant is not great, that the mechanism of action is not understood, but that it is routinely tried in cases of recalcitrant depression, and that the evidence is clear that T4 is not helpful in these cases.

    I’m also concerned about long term T3 use in these circumstances. I’ve yet to find anything relevant on this. And periodically my doctor orders a full thyroid panel which always comes back abnormal, but is apparently “normally abnormal.”

    Also my hair fell out once, but that has not been repeated, and the dermatologist did a thyroid and told me that if it had been my thyroid, that the problem had gone away.

    1. Thanks for the comment, Christine. In my post, I do mention (in the section about who might benefit from T3) that patients with hypothyroidism and depression sometimes benefit from the addition of T3 to their T4 therapy. You don’t say whether you take T3 for hypothyroidism/depression, or just for depression. In the absence of hypothyroidism, T3 is not considered a standard pharmacologic therapy for depression. Of course, I don’t know your medical history and would not presume to make any recommendations in this venue, so I’d defer to your treating clinician.

      As for long-term use of T3, high doses over long periods of time can be irritating to the heart, muscles, and bones, among other organ systems. Low doses of T3 are much less likely to cause any long-term problems.

      1. although t3 is not a standard treatment for depression, there are a number of classic [old] papers on using it as an adjunct to antidepressants in refractory cases. these days, with so many more agents available and well-proven to be effective [both antidepressants and proven adjuncts] it is more rare that such an approach would be taken. and sometimes it does work. there is no evidence to my knowledge, btw, that t3 is better in this use than t4. i was discussing bipolar disorder with an NIMH researcher who mentioned t3 and i asked him if he had any basis to prefer it to t4, and he did not.

        HOWEVER, this brings up the possibility of patients who are mildly hypothyroid but who have “normal” thyroid studies. 4.4% of NORMAL people will have studies outside of 2 sigmas, and presumably there must be individuals whose numbers look normal but aren’t optimal for those individuals. in some individuals who have refractory depression, and who have tsh in the upper half of the range, i’ve tried adding t4 [not t3] to drive their tsh down toward 1 or so. sometimes they feel much better.

        1. I think it’s reasonable to try levothyroxine for someone with uncontrolled depression and a high-normal TSH, especially if they have positive thyroid (TPO) antibodies. As long as we’re not suppressing the TSH, there is little harm in a 6-month trial.

    2. Hi Christine Rose,

      Your brain needs T3 to make the neurotransmitters like dopamine and serotonin, which are made in the brain. In certain cases people have problems turning T4 into T3, so giving T4 is, as you said, useless in these cases. You have to give T3.

      Another problem is the body can swiftly turn T3 into a form that is unusable. I have that problem, so I have to take 1/2 tablet of 5mcg Cytomel every two hours, and my depression disappeared. If I take the Cytomel twice a day, as usually prescribed, it is not effective.

      So playing around to find what works can take time. The idea of giving a big dose of T3 and the body will use it evenly and smoothly throughout the day doleing it out somehow, does not always work.

      You say your thyroid tests are normally “abnormal” but what does that mean? Actually numbers could help to figure out the problem, giving a clearer picture of your body’s process.

  3. I’m so glad to find this blog, being an endo patient myself. Before I got acquainted with skepticism, Quackwatch, etc., I fell for the T4/T3 idea, when after a thyroidectomy it took ages to feel OK again and all the “pro” patients in the forums were suggesting T3 supplementation or even dessicated thyroid. I couldn’t go to a naturopath, as there were none available in my country, so my only loss was an expensive reverse T3 lab test. Now that my skeptic muscle is trained better, I’m glad I didn’t go further with it, I’d probably get diagnosed with adrenal fatigue or Lyme, or some other imaginary disease.

    I do have a question – I was prescribed a selenium supplement to help with T4/T3 peripheral conversion (by a regular endo). Back then I must have a difficult patient with preconceived ideas about my problems, tired, depressed and anxious on top of it, so I can imagine the endo giving a placebo, but it seems it’s not entirely without scientific base. So what exactly is the evidence level for selenium supplementation in patients after thyroid removal?

    1. Great question, BL, and thanks for the kind words. The evidence for selenium improving T4 to T3 peripheral conversion in a clinically meaningful way (i.e. you will actually feel a difference) is poor.

      In my practice, I occasionally prescribe selenium for two reasons:

      – To reduce the risk of postpartum thyroiditis in a woman with a history of autoimmune thyroiditis (a woman with positive thyroperoxidase antibodies).

      – To improve symptoms in mild to moderate thyroid eye disease in a patient with Graves’-associated orbitopathy.

      Other than those situations, there isn’t much of a role for selenium, at least according to currrent evidence. Selenium does, interestingly, lower TPO antibody levels in patients with high titers; however, it has not been shown to decrease the need for thyroid hormone therapy in these patients. So it doesn’t seem to make much sense to use it just to lower the antibody level if it isn’t going to do anything tangible.

      In a thyroidectomized person, I’m not aware of any evidence that selenium is helpful.

      1. Thanks!
        One more thing about the dessicated thyroid – I always wondered about thyroid cancer patients using it so happily – shouldn’t they be worried about causing fluctuating thyroglobulin marker values? Wouldn’t you miss a recurence with this “natural” approach? Back when I read these suggestions in patient forums, this seemed to be quite a scary consequence.

        1. Another great point, BL. In theory, dessicated thyroid is even less ideal for a patient with a history of thyroid cancer (thyroid surgically removed) than it is for a patient with garden variety, primary hypothyroidism (thyroid that is underactive).

          Because most patients take dessicated thyroid once daily, and because there is so much short-acting T3 in there, they spend the first part of the day with high levels of T3, and the second part of the day with low levels. Because there is less long-acting T4 in that preparation of thyroid hormone, then there is less consistent suppression of TSH, which could (in theory), lead to more stimulation of residual thyroid cancer growth by TSH (Thyroid Stimulating Hormone). This would show up as a rising thyroglobulin level, as you suggested.

          This is all theory, as I am unaware of any data that proves patients on dessicated thyroid hormone have higher rates of thyroid cancer recurrence. But if I had thyroid cancer and a medium-high risk of recurrence based on the ATA risk stratification system, I would not take the risk of using dessicated thyroid hormone for my long-term thyroid replacement.

          1. I don’t know anyone and have never seen anyone advised, to take ndt once a day. Every person I know on it takes it twice a day. Issues arise when poorly advised and on too low a dose. Many thousands have transitioned from T4 only to ndt with great success and greatly improved physical responses, which are maintained. I have always had renauds and been susceptible to cold but with one range’ thyroid hormone testing. Adding some T3 to the mix has seen that reversed. Never once had renauds, plantar fasciitis and other hypo symptoms since using T3.

          2. Just about every person I’ve seen on NDT from their alt med provider has been taking it once daily. I agree that – if one were to take that preparation – it would best be dosed twice daily. The T3 component will not last through the entire day taking it just in the morning.

        2. As a thyroid cancer patient my thyroglobulin markers never fluctuated while taking t4, t4/t3 or Armour Thyroid actually they really never registered at all.

          1. Trish, to my understanding that should be the case. My husband is a Thyroid cancer survivor and gets his thyroglobulin levels tested by his Endocrinologist regularly. They always come back “non-existant.” His Thyroid Cancer Surgeon had bragged to us what a great surgeon he was and that there would not be any thyroid left after surgery. (Not hubris at all – he really was that good and extremely likable). His post opt scan proved this to be true. No thyroid equals no thyroglobulin which is made in the thyroid gland. That is always good news to a thyroid cancer patient who does not want any thyroid gland remaining.

          2. For those of you that think having a very low or non-existent Thyroglobin level after thyroidectomy for Thyroid Cancer means you have a very low risk of recurrence…….YOUR WRONG ! I had a thyroidectomy in 2016 for pap cancer and was always told by my Endocrinologist that Im “low risk” for recurrence because my thyroglobin levels have always been super low on my labs and my Endocrinologist also told me your levels are perfect and you should never have any further issues…..fast forward to 11/2019 I just found out I not only have recurrence of thyroid cancer It has spread to my lymph nodes.

            How do you like that for Low Risk !

          3. Although I can’t comment on Grace’s situation, it is important for people to know that an undetectable or very low Tg post-thyroidectomy for papillary thyroid cancer usually means there is a low risk of recurrence. However, there are other factors that affect the risk of recurrence, which include but are not limited to:

            – The variant of papillary. Some are more aggressive/more likely to recur than others.
            – Were the surgical margins clear?
            – Was there cervical lymph node involvement at the time of surgery? How many, how large, any extension beyond the capsule?
            – Did the tumor invade the tissues/muscle outside the thyroid?
            – Was there any component of poorly differentiated carcinoma seen on the surgical path? This may not make Tg.
            – Was radioactive iodine given post-op?
            – Was the 1-year post-op ultrasound totally negative?

            While it is possible to have an undetectable Tg and have all the answers to the above questions be reassuring and still have a recurrence, it is a much rarer situation. Yes, I’ve seen it. But not often.

      2. I have been self-testing my T3 and my experimentation over the years has shown that selenium supplementation at 200 mcg per day consistently raises my T3 level from 3.0 to 3.2.
        Another metal that has a profound effect on my T3 conversion is lithium orotate, but unlike selenium, it comes with undesirable side effects on my neurotransmitters ( which might be desirable for others, however).

        1. That’s interesting, but I suppose the more important question is: all other variables being held constant, do you feel consistently better with a T3 of 3.2 as compared to 3.0?

      3. My understanding is that some of the evidence for selenium supplementation for thyroid eye disease is also based on European research where it was about correcting a selenium deficiency (common in Europe, far less common in North America where our soils tend to be rich in selenium). This is why the research done in the US into the use of selenium tended to be less conclusive there’s a benefit than the research done in Europe. There may be more current research that contradicts this but it seems to me that perhaps even the recommendation to supplement with selenium for TED may be misguided if the evidence really indicates that it’s only useful when someone has a deficiency (though I guess people eating a really terrible or highly restricted diet in North America may develop a deficiency).

    2. Tell my cousin who just spent 6 weeks in rehab as a result of Lyme disease it imaginary. Better yet tell my client his 17 year old son died from an imaginary disease after Lyme spirochetes attacked his heart and he literally dropped dead. Ps my dog recently died from anaplasmosis another imaginary tick disease. You are arrogant and ignorant.
      Yours Truley
      from NY Hudson Valley.

    3. Lyme is not a imaginary infection. See all of Dr Alan MacDonalds videos on YouTube showing Borrelia Burgdorferi bacteria in beta amyloid plaques of patients brain tissue that supposedly had alzhiemers. The question to be asked is Alzhiemers an imaginary word describing a brain infection. It’s not what you think you know it’s what is proven. Go to YouTube and type in Dr Ying zhang lime innovation. He is doing the research at John’s Hopkins on Lyme. Just listen to what the professor at John’s Hopkins says about Lyme disease or tick borne infection from Borrelia Burgdorferi bacteria. I think it shouldn’t be called Lyme disease personally and it should be called the infection that you have, like any other infection because their are many different types of bacteria and viral infections grouped into one disease with the name Lyme disease. And actually borellia Burgdorferi “bacteria” is a spirochetal parasite and not a bacteria and maybe that’s why so many people are not clearing the infection with normal antibacterial medicines because Lyme bacteria is far from a normal bacteria. Do the research and know the facts before you claim something is imaginary. If you want that imaginary stuff…. Well you imagine everyday your spinning on a ball at 1000mph. That’s imaginary!!

      1. OK, now this gets interesting!

        How are we able to kill spirochetes which are, after all, bacteria. If caught early, killing these parasites may prove to be the cure for many autoimmune conditions. Alzheimer’s, cancer, even.

        Opinions, please!

  4. Very interesting article. Love it. I went to a functional medicine doctor who was also a western medicine doctor prior to switching. She left me on my levothyroxine 75mcg but I also take liothyronine 5mcg daily for 5 months with no side affects. My hair loss is less on the combo. I’m 61 and I,m curious with any long term affects of this mixture. Can you comment? I would love to hear from you. Thanks

    1. Thanks for the kind words, Debbie. Functional medicine is an interesting field, as it is dominated by quacks in my area, but has the potential to be holistic in a good way if done right. As an aside, if you want to see what functional medicine can/should be, check out Dr. Bret Scher’s site. I will actually be posting my review of his book tonight (note that he and I have no financial relationship, but he is a friend).

      Regarding your thyroid question: for most people on 75mcg of levothyroxine, 5mcg of liothyronine would be considered a pretty reasonable dose. The only comment I have is that liothyronine peaks at 2-4 hours after ingestion and then wanes, such that it is best dosed twice daily if someone wants exposure to the medication throughout more of the day. Unfortunately, 5mcg is the smallest pill available, and when I ask people to split it to 2.5mcg twice a day, they usually report that it just crumbles to dust. I think some generic versions are better than others in that respect, though I don’t know which ones split nicer. Many people feel fine with just the morning hit of 5mcg, though, so if someone notices a clinical improvement on T3 that is durable, I am ok with once daily dosing.

      As for long-term ill effects, it would be unlikely to see higher rates of bone loss and heart arrhythmias with such a small dose of T3. Although there isn’t much data in this area, I wouldn’t worry much about people who take small, physiologic doses of T3. I would worry a lot more about people taking whopping doses of T3 who consistently have suppressed TSHs.

      1. Wow that was great. I was on 5mcg of the livo in the morning and then in the afternoon but more hair loss so we discontinued the afternoon dose. I will try splitting to see what happens to my pill they are quite small. I’ll check out your friend info also. Thanks.

        I also asked about compounded hormone replacement vs Premarin any opinions or references on that. Estiodiol is what I am curious about and what about progesterone? I have no ovaries or uterus since 2001. Just curious.

        1. If you don’t have a uterus, you don’t need progesterone. As far as I know, estradiol is the closest estrogen to bioidentical.

      2. As T3 is only clinically available in 5 or 25μg, what might you consider a ‘whopping’ dose? The only solution for dosage variants are compounding pharmacies.

      3. Given that the bone loss and heart arrhythmias have only been linked to suppressed TSH (a pituitary hormone), not directly to a thyroid hormone, how do we know that it is the serum level of T3, rather than the T4, doing the damage?

          1. My TSH is 0.02, my FT4 is in the higher quarter of the range and FT3 in the lower quarter. How can I estimate my risk of osteoporosis and / or aritmia?

            Thanks.

  5. Way back in the mid 1960s I was diagnosed as hypothyroid and put on Levothyroxin. A few years later, while living in Europe, my prescription was changed to Cytomel (T3) at lowest available dose to treat chronically low BMR. I stayed on that treatment for almost 30 years. With age either my need for T3 declined or my conversion of T4 to T3 improved or reverse T3 (never measured) improved or? Anyway I started getting too high for T3 and after some delay discontinued the medication, but not until after I had developed AFib. Have now been off any thyroid med for 20 years with quite normal health, and the Afib controlled with meds. Seems like T3 can be beneficial for quite long periods, but needs to be discontinued immediately if things change.

    1. T3 should be considered an adjunct to levothyroxine replacement, at most. It is not a replacement for T4 therapy. I agree that it should be stopped in certain situations, especially if the dose of T3 is substantial.

  6. I’ve been taking WP Thyroid, natural T4/T3 combo, for at least 2 years now. Now I’m thinking I made a mistake asking for it. (At the least, I think it makes me anxious.) I’ve been taking only 1/4 grain equivalent per day, though. Hopefully I haven’t harmed myself? Ugh. (I have Hashimoto’s, with TPO between 300 & 380 for the last few years.) Thank you for this site!

  7. I was diagnosed with mild Hashimoto’s in 2009-10. I’ve had a couple of hyperthyroid episodes – eating twice my usual amount and still losing weight fast, not able to fall asleep until 7 AM, etc., etc..
    The weird thing is, both of these episodes happened when I started taking a small amount of liothyronine (T3) in addition to the levothyroxine. I didn’t change my dose of levothyroxine. But each time I started taking liothyronine, I had a hyperthyroid episode.
    I stopped both the T3 and T4 when I started having hyperthyroid symptoms.
    But, my hyperthyroid symptoms continued for maybe 4-5 days anyway. They gradually tapered off, and I resumed the levothyroxine but not the liothyronine.
    Since T3 is short-acting, it seems weird that it would trigger a prolonged hyperthyroid episode. Maybe it somehow triggered my thyroid into dumping a lot of thyroid hormone into my blood? Have you ever noticed this happening or know why it might happen?

    1. It’s not unusual to feel thyrotoxic after being on too much thyroid hormone, even for a few days after stopping the T3. T3 would not cause the thyroid to release more hormone, but it’s certainly possible to take too much exogenous thyroid hormone.

      1. It seems weird that a small dose of liothyronine added in (probably it was 5 mg/day), would put my body into a wildly abnormal state for days after stopping it.
        I got some thyroid values measured in one of those episodes – I had stopped taking T3 and T4 and I was calming down – my TSH was about zero, and my free T3 was > 11 pg/mL.

      2. ps Maybe adding liothyronine can set off a vicious circle because it makes the thyroid more active so it pumps out more thyroid hormone …

        1. I can’t comment on your specific situation, but I can say this:

          – liothyronine would not cause the thyroid to pump out additional hormone.

          – when I see someone with a very low TSH and very high T3/T4 levels, it usually means that they are massively over-replaced with exogenous thyroid hormone or they are actually hyperthyroid.

          – it is important to distinguish between hyperthyroidism, which is the overproduction of thyroid hormone by the thyroid; and thyrotoxicosis, which is the presence of too much thyroid hormone from any cause. Thyrotoxicosis can be due to taking too much exogenous thyroid hormone or due to the thyroid cranking out too much thyroid hormone.

          1. what does a very low TSH, a very high T4 and low T3 mean? I can’t find any literature that talks about that scenario…?

    2. Laura, I had the same thing happen to me after adding 5mcg of T3 to my 150mcg of T4 for only 1 week. I had labs drawn as well during these events (this happened twice, explained below). My TSH was very low, almost supressed. T4 was normal and T3 was low/normal. I stopped taking both T3 and T4. My face and fingers were swollen and I experienced an intense depression for 3 full days– darkest days of my life. I did not realize it was the T3 initially and took it again (blamed it on a change from generic levo to name brand Synthroid…which look exactly the same and were switched without my knowledge. That is a story for another day.). The second time was much, much worse. T3 should have a black box warning imho. I took a week to become somewhat back to baseline.

  8. My aging mother was doing poorly pn T4-only medication for her hypothyroidism. I advocated for her FreeT3 to be tested by her assisted living facility’s visiting physician and it was found to be low. She was given T3, and now she’s feeling better, has more energy, and is no longer sleeping 16 hours a day.

    I am on combination NDT treatment and Unithroid (T4). This combination is fantastic for me. I have been on it for now 8 years.
    Two of my three children, also (sadly) hypothyroid, are also on a combo of NDT plus Unithroid. All are doing well and my eldest sailed through college and grad school on NDT. At the age of 12, she was so depressed she could not carry out her obligations (homework, musical instrument practice). She was overweight, had no energy, her beautiful thick curly hair was falling out and breaking, she had plantar fasciitis, and had terrible well-being. NDT reversed all that. None of us but my mother began our treatment with T4-only, so apart from my mother, I can’t speak to having seen a first-hand difference. However, I’m a part of aj online forum of over 60,000 Hashimotos patients, and I can tell you with no hint of indecision that the vast majority of those in the forum have had their lives turned around by the addition of T3. Infertile women and those with no children due to multiple miscarriages have been able to bear children, even. Perhaps the fact that you haven’t seen much longterm benefit in your practice from the use of T3 is that you may not have been trained properly in its use. Surely such training is not widely available in medical schools, and is kept out of physician conferences because the conferences are underwritten by the maker of Synthroid. (And this company is also a large donor to medical schools.)

    Here is a compilation of various studies on the topic:
    stopthethyroidmadness.com/medical-research/
    While this is not the forum which asked me to serve as moderator, and I’m not fond of the angry tone of the website, the anger arises from doctors who keep their patients functionally hypothyroid with poor treatment, causijmng continued suffering and so I understand it.

    The tone of your own article is haughty and appears as though you feel you have nothing to learn from your patients. As a private piano instructor (and active classical performer) with an M.M. from a world-renowned conservatory and 28 years of teaching, I find that my students teach me all the time and that I may derive growth as a teacher from not only my professional organizations, conferences, books, and professional journals, but also, from my students themselves. I am sorry that your forays into the use of exgenous T3 to assist your patients were relatively unsuccessful. If you were to sign up for a functional medicine training on its use, you might find some benefits for your practice.

    It requires a certain humility as well as courage to be willing to venture out into a new and somewhat professionally forbidden area of medical study. I wish you and your patients the very best with their thyroid treatment.

    I also am interested to know whether you have found Levothyroxine-only treatment to eliminate symptoms in most of your hypothyroid patients, and whether you do anything to test and treat Hashimoto’s Disease?

    Thank you.

    1. First, I’m glad that you and your family members have found what works for you. To address some of your points:

      – You and the 60,000 other Hashimoto’s patients on that forum are in the echo chamber. There are a multitude of reasons why those people may feel better and, frankly, you have no idea what they are. For that matter, I would suggest that there are probably a sizable number of people who don’t feel better, hence their involvement in the forum, still searching for answers. But that is merely conjecture, since I also have no way of knowing what’s going on with these folks other than what they choose to self-report in an anonymous forum on the internet.

      – Your conspiracy theory about medical education being suppressed by the makers of Synthroid is both laughable and frightening at the same time. People really believe this nonsense? Well, I suppose so. But since I can’t prove a negative, I guess there’s no way you’ll ever come around on this one.

      – During the time I trained, we were taught why T3 was thought to be unhelpful. But as new data has emerged, doctors who are interested in continual learning (as I am) have been more open to trying it. Contrary to what you suggest, there is no magic to using T3. And yes, I learned how to do it from a real doctor, not a functional one.

      – Just as I would never presume to tell you how to teach piano just because I’m a music lover, it amazes me that you have the hubris to suggest that if only I could find the right quack to teach me how to use T3, I’d have better results. The reason T3 doesn’t usually work is because most people don’t need it. If I wanted to enter full-on quack mode, I’d jack up the dose to heroic levels that have the potential to act as a stimulant, claim success, and call it a day. But I took an oath that said something about “doing no harm.”

      – To answer your last question, I’ve written a bunch of posts that address all that:
      https://hormonesdemystified.com/the-ultimate-guide-to-thyroid-function-testing-hypothyroidism-edition
      https://hormonesdemystified.com/selenium-and-the-thyroid-secrets-your-naturopath-doesnt-want-you-to-know
      https://hormonesdemystified.com/its-not-your-thyroid

      1. I have to agree with your statement, “The reason T3 doesn’t usually work is because most people don’t need it. ” It seems to me that most of the research that has been done to verify the efficacy of T3 as treatment for hypothyroidism has not bothered to check whether the participants actually need additional T3.

        I would suggest that future research conduct a full panel of thyroid blood tests and record entering and after-treatment values for free T3 and free T4. It might not be a bad idea, either, to test the thyroid antibodies.

        You might also want to check how far into the range the free T3 has moved due to exogenous T3. It may be that the FT3 needs to be in the top quadrant, tertile, or half of the range to effectively relieve symptoms.

      2. I know this is an old comment but since I get the emails for this post I see a lot of replies!!
        I wanted to affirm your comment about patient groups being an echo chamber… the one I “belong” to only has 2.5K members but it still astounds me that the same people who talk about all their unresolved symptoms, struggling to find something that works (and have been for several years) then turn around and tell any new members they need to get T3 checked and switch from levo to NDT or T3, give up a whole bunch of foods and take supplements. It irks me when this is what newly diagnosed members get as soon as they join – they haven’t even had a chance to see if levo helps them or not!

        The worst posts are the ones like “who else has bunions? Are these thyroid related?” and you get 100’s of people saying “me!!” then suddenly thyroid=bunions. Or sore ears. Or sunburn. I just saw one today someone said they felt 100% better yesterday when they skipped their levo so now a whole bunch of people want to try skipping their prescribed meds based on all that….rant over!

        1. Emily…great post. Of course this is true of all forums. When I first joined one I thought the “Admins” or “Moderators” were there to keep everything in check and correct. Of course they are not…that would be an overwhelming job. So consequently it is the wild wild west and everyone shoots from the hip. 🙂

      3. “ I’m getting at least 7-8 hours of sleep every night, I’m eating clean, and I exercise several times per week [this better be true]. ”

        Do you not understand why this question is problematic though? I was running suicides with my personal trainer with a 10 lb medicine ball the morning I was diagnosed with EBV and my life changed. I was EXHAUSTED constantly and still training anyway when I collapsed after a workout and slept for 3 hours – missing 2 hours of work – when my GP told be I had active mono and to CHILL for a few weeks.

        I got my Hashimotos diagnosis a few years later after having to leave my career due to the chronic exhaustion. And I had lifelong insomnia as well.

        As a former competitive swimmer and generally vain person who was constantly working to keep vanity pounds at bay — there is NO WAY I could had continued to train and exercise several times a week when my thyroid and adrenals tanked.

        I mean, how can you not look at that exhaustion and recognize it as a symptom and not a cause? That makes zero sense to me.

        I’d really like to understand a doctors reasoning with this because it baffles me. I get that there’s a lot of lazy people out there but I went to doctor after doctor with records of activity and my diet tracked and they all essentially shrugged their shoulders at why I was rapidly gaining weight and so tired, and simply told me “weight loss would fix your symptoms.”

        I mean – can you not see the order of events there?

        I’m not trying to be snarky – I would truly like to understand why doctors would dismiss a patient with a clear record of data because it happened all the time.

        T3 was absolutely the missing link for me, and it feels nothing like a stimulant LOL. Doctors at one point put me on 90 mgs of Adderall for YEARS so I could simply get out of bed to go to work.

        Reminder: former competitive swimmer here, this wasn’t general “laziness” or aversion to exercise.

        1. I appreciate you sharing your experience, but this is an impossible conversation for us to have. I have no visibility to your history and wouldn’t presume to rationalize why other doctors said what they did. Nor would I have any idea about whether your functional medicine doctor knows what she’s doing. All I can say is, I am truly glad that you feel better.

    2. My endo has kept me severely hypo since my TT in 2012 (TSH above 40)..he kept increasing Levo but I just felt worse and my tsh never came down… Until I self medicated on T3 in Feb this year and felt like it had my life back! My GP panicked and sent me to see and endo… Luckily for me it was a locum one and he was happy to prescribe combo T4/T3 based on how I feel and blood results. Unfortunately 2 months later my regular endo found out and took me off it (even though it’s dangerous to if not done gradually!) So, I’m back to self prescribing… And you know what? My blood results have never looked better and I feel brill! I’m just so angry that endos will take your thyroid out and then not let you be well afterwards! … in the UK it’s mainly due to the extortionate cost of T3! At least I know there’s a few good endos out there who actually listen to their patients… Unfortunately, it wasn’t my regular one 🙁

    3. I myself have found my symptoms of hypothyroidism have worsened even though the numbers have come back somewhat satisfactory to my endo. I have thinning hair and eyebrows, adrenal fatigue symtoms, severe dimpling of the skin, weight gain and this depresses me. I’ve enquired about T3 replacement to try to alleviate the symtoms but it falls on deaf ears. My poor mother has struggled with the same issues for way longer and she had severe bloating in the abdomen too. I’ve decided to try Biogeneics supplement with T3 to see if it helps. If it helps I feel like my mother should try it too. I feel that just Synthroid isn’t cutting it. Many endocrinologists on the net disagree with what you are saying. They say that some T3 is required or it worsens the thyroid and puts the brakes on the metabolism. Sorry doc!

      1. “Many endocrinologists on the net disagree with what you are saying. They say that some T3 is required or it worsens the thyroid and puts the brakes on the metabolism.”

        You’re going to have to back that statement up with references or retract it. The majority of people saying stuff like this are not endocrinologists.

  9. P.S. My apologies for my phone typos! I ought to have given my comment a good once-over prior to its submission.

  10. My endo has kept me severely hypo since my TT in 2012 (TSH above 40)..he kept increasing Levo but I just felt worse and my tsh never came down… Until I self medicated on T3 in Feb this year and felt like it had my life back! My GP panicked and sent me to see an endo… Luckily for me it was a locum one and he was happy to prescribe combo T4/T3 based on how I feel and blood results. Unfortunately 2 months later my regular endo found out and took me off it (even though it’s dangerous to if not done gradually!) So, I’m back to self prescribing… And you know what? My blood results have never looked better and I feel brill! I’m just so angry that endos will take your thyroid out and then not let you be well afterwards! … in the UK it’s mainly due to the extortionate cost of T3! At least I know there’s a few good endos out there who actually listen to their patients… Unfortunately, it wasn’t my regular one 🙁 For info, I was on 175 Levo and now take 100 Levo & 37 Lio split in 3 doses. I tried all the making sure iron etc is at optimal levels, checking adrenals and taking selenium.. All of which helped but T3 was the missing link for me.

  11. I have hashimoto’s. I was diagnosed in 2009 after going to the ER thinking i was having a heart attack and gaining 60 pounds. I was put on Synthroid then Armour neither of these worked and put me in a hyper state after taking them for a few weeks. Over the years i have tried every natural way known to man to reduce my symptoms of Hypothyroidism and to no avail. Until i was put on T3 only medication. I found a Naturopath who understood the T4/T3 conversion and saw how i was pooling instead of converting. My Reverse T3 was very high and my Free T3 very low. He wanted to put me on Armour and i said no way i want to try T3 only. I started 3 months ago on 2.5 mcg then raised it to 5 mcg taking 2.5 2 x’s a day. Initially my T3 went up when i was on 2.5 mcg. I had my blood work done a couple of days ago after being on 5mcg a day for 6 weeks and my Free T3 went down and my Free T4 has not moved. I feel better on T3 more energy and my stomach issues of acid reflux seemed to change for the better (not as many episodes) I also have SIBO that keeps coming back. Why would my T3 levels not change while taking T3 and why would my T4 not change while taking only T3?

  12. Such hubris and haughtiness. I can see why these qualities in a person can cause their work to suffer. It absolutely closes the mind to the thought that an alternative doc might actually have anything to teach one. Such suffering this hubris causes for patients! This just breaks my heart to see. And to claim that 60,000 patients’ amazing stories of transformation is a big “echo chamber”! This absolutely takes my breath away! To suppose that it is scientific to believe that your limited experience in your practice is more authoritative than that of 60,000 patients! I’m absolutely stunned! It is evident that you,re not using T3 properly, that you’re probably not treating fatigued adrenals and seeing to it that ferritin is at least 70 and vitamin D at least 50 (these three things must be optimized before a T3 preparation can be most effective), and for patients with Hashimoto’s, gluten must be fully renoved from the diet, at the very least. Ideally, the Hashi’s pstkent should be on the AIP diet. See Sarah Ballantyne’s books for 30 pages of references in small print from tbe peer-reviewed medical literature to establish for yourself the basis of the diet. The T3 medications will not work effectively without these things being first addressed. You’ve so much to learn, and it’s great that you tried to be open to T3 but you have learned only just enough to be dangerous. (“A little knowledge is dangerous.”)

    1. Antonia, this is not the site for you. Stick to your echo chamber. The rest of us wish you the best of luck as we cringe at your comments.

    2. I’m on T3 for depression, and I can assure you it’s pleasant enough to be classed as a recreational drug. You feel warm and flexible and strong. Your mood is elevated, you’re full of energy. Of course this only lasts a few hours as the T3 is burned off and the T4 production is down regulated to correct for the mild hyperthyroid. I don’t think I would class it as addictive because you don’t actually feel worse after the effect wears off so you’re not “chasing normal” the way you would with opiates or nicotine.
      BTW it’s poorly understood why T3 augments anti-depressants, but presumably it’s something that happens during that rush where your levels are too high. It’s also not clear if there’s a potential to permanently depress normal T3 production with long term use, which would class it as addictive.

      1. Thanks for that perspective, Christine. If only you had a doctor who was more knowledgeable about the use of T3 (as the previous commenter has suggested) you could spend the rest of your life never coming down from the high. Too bad none of us know what we’re doing.

      2. “BTW it’s poorly understood why T3 augments anti-depressants, but presumably…”

        if it isn’t understood, then why are you speculating?

        Pretty much all depressed people are hypothyroid, that’s why it works:

        “Of the mild 66.6%, 93.3% of moderate and all of the severe grade depression patients had low T3 levels. Of the moderately depressed patients 13.3% and 9.0% of severe depression patients had low T4 levels. TSH was increased than normal in 54.5% of the patients and all these patients were of severe grade”
        https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2958345/

        “It’s also not clear if there’s a potential to permanently depress normal T3 production with long term use”

        It is an internet myth that taking thyroid long term permanently suppresses endogenous thyroid function.

        1. Good article to bring to any doc, endo or other, who tells a thyroid patient it’s all in their head! That’s called…lazy medicine.

    3. Wow.
      And that is not a “good” wow.

      My thought today: Endocrinologists do not make enough money….
      (I am not an endocrinologist.)

    4. I take NDT with some levo and it has helped me significantly with many of my thyroid symptoms. I was on levo alone for 2 years without results. However, the diet changes I have to agree with. I tried AIP at the urging of one doctor and have never felt worse in my life. As an athlete I need carbs. Also it led to some vitamin deficiencies that took awhile to correct. Lastly, not everyone needs to be gluten free or dairy free for that matter. Yes they can be inflammatory in some people, but that’s should be evaluated on a case by case basis. As someone who was an active athlete and had pretty healthy lifestyle in advance of hashi’s all of the suggested lifestyle changes made me worse. However, I could see them helping if someone was not leading a healthy lifestyle or had weight issues.

  13. Thanks for the blogs….very eye opening after reading the woo stuff out there.

    “Five Types of People Who May Need/Like T3” and you mention “Patients who have had their thyroids removed have to rely entirely on T4 to T3 conversion for their T3 needs….”.
    So, would you include people who had RAI for nodules?

    1. I probably wouldn’t include those who have been treated with radioactive iodine for hyperthyroidism due to autonomous (aka hot) nodules. The reason why is, if these folks develop postablative hypothyroidism, they typically don’t develop complete thyroid failure. In other words, the nodules are ablated preferentially, and there may be some collateral damage to the thyroid tissue surrounding the nods, resulting in mild hypothyroidism, but the thyroid is still capable of some amount of function.

      Of course, this is a generalization, and I’m sure there are some people out there who have developed more profound hypothyroidism after RAI for hot nodules. But, in my experience, when people develop hypothyroidism after RAI for nodules, they often do not need a complete replacement dose of T4, and they probably don’t need T3 if that’s the case, either.

  14. Cannot tell you how much I appreciate this timely information. I have many questions but will limit myself to just one for now. Can supplementing with or with too much T3 cause Low Creatinine (via muscle loss)? That’s it…Thanks

    1. I don’t think too much T3 would be likely to cause low Cr, but it could cause muscle loss. Glad this has been helpful, Celeste.

  15. Really interesting article. I have hashimotos and have mostly seen what I thought were real docs but probably what you call quacks. Just went to a local respected endocrinologist who believes as you do and switched me to Synthroid. I had been on a compounded 100mcg T4 and 25mcg T3 for approximately the last 10 years before the switch. I have had uncomfortable heart palpitations for many years (thought that was because of being hypo) which my new doc said was because of T3 meds, as I’ve had a suppressed TSH for many years. They have gone away pretty much in a week since I’m off T3. So frustrating to learn, I’ve been on meds that could be harming me.

    Heres my questions to you. Is 25mcg of T3 for years considered a high dose? Also do you think my body and thyroid can recover from years of having a suppressed TSH and taking T3 meds. The endcrinologist did an ultrasound of my thyroid and said it was very small, but otherwise totally normal and looks like it was put to sleep by these meds. Hoping it will wake up.

    Thank you for this site and an endocrinologists explanation as usually the only info on internet is the alternative and opinions from non docs who are usually guessing.

    1. Yes, 25mcg of liothyronine (Cytomel) would be a big dose for almost anybody. But I have seen naturopaths put people on twice that much…

      I can’t really speak to the permanent damage issue for you, but I can say that for the average, healthy, non-elderly person, the body can (mostly) recover. Bone density can go down after years of taking too much thyroid hormone and may not recover to normal, but it can recover to some extent.

    1. Perhaps the over acidity in stomach and inability of conversion due to the SIBO made it impossible for final intestinal conversion to take place.

      Heal both areas and try t4/t3 again after healing to see if that’s the culprit. Perhaps by adding a Dr. a recommended probiotic may help with all these issues??!!

  16. I had a partial thyroidectomy at 19 and a total thyroidectomy in April, 2018 due to suspicious nodule that covered over 2/3 of my left lobe. I also have Hashimotos and could barely function. Path report revealed thyroiditis but no cancer. I am gluten, soy, sugar, and dairy (allergies) free. I am on 75 mcg Synthroid and my Endo just upped me from 5 mcg to 10 mcg Liothyronine, split dose. My TSH is 1.10 (Range: 0.27 – 4.20 uIU/mL), and my FT3 is 2.3 (Range: 2.5 – 4.3 pg/mL). I’m still very lethargic with brain fog. My body temp runs 95.5-96.5 and my blood pressure and heart rate are low. Since increasing my Liothyronine I’ve gone back to restless sleep and hot flashes but my digestion has improved. What would be my next step?

    1. I’m sorry, but I can’t provide medical advice for this type of question. There are just too many things I can’t know about you, so it would be best to talk to doctors who know you. Best wishes.

  17. As I told you, HD, I found this post incredibly helpful. It led me to question whether I was being overmedicated, and now I’m on a small dose of only T4 and doing better. (T3 made me jittery, I found, which was probably an indication I didn’t need it.) Anyway, I found this yesterday and wondered what you thought of it. It’s more evidence that there are a lot of people like me, being given medication unnecessarily, for Hashimoto’s (my TPO level was 292 on diagnosis). Now I’m thinking I may wean off entirely! https://drruscio.com/thyroid-autoimmunity-healthy-levels-thyroid-antibodies/

    1. What do I think of the post you linked to? Ugh, I feel like you’re teeing this up for me. Let me say that I am pleased to see that the DC who wrote it is attempting to bring some sensibility to people who are obsessed with trying to get their antibody levels down – that’s the good part. But otherwise, there are so many inaccuracies and half (quarter)-truths in that post that I’d have to write an entire post of my own to debunk them. Come to think of it, I already debunked some of it in:

      Selenium and the Thyroid – Secrets Your Naturopath Doesn’t Want You to Know
      You Can’t Eat for Your Thyroid

      I wish that chiropractors would stay in their lane – they can be a great resource for mechanical problems with the musculoskeletal system.

  18. My doctor suggested a T3-only trial for me when he could find no other obvious reason for my fatigue; my TSH results were in normal range. I wasn’t aware of what thyroid medication even was, and certainly wasn’t the one to suggest it – so I didn’t come to the table with any pre-conceived ideas about the medication.
    My thyroid medication (liothyronine) was custom compounded for me at a pharmacy due to the limitations of the off the shelf product. We started at 3mcg and went up in increments of 1mcg. At the first dose of 3mcg, my fatigue problems went away – for the sake of the trial of trial and error- we went up to 4mcg, then 5mcg then 6. At 5cmg, I started to experience anxiety but wasn’t sure if it was the medication. At 6mcg I had even more anxiety and also couldn’t sleep. Went back to 4mcg and have been on it now for 8 months or so. 4mcg seems to be the optimum dose for me. If the doctor had put me straight onto 5mcg – without the option of lowering the dose – it would have been a failure and I would have considered T3 to not be a success. Also – my T3 is compounded with a slow release agent – this means I only have to take it once a day and is a little more forgiving for not taking it at the exact same time everyday. My doctor suggests that T3 may not have such a high success rate because it is being administered to the patient incorrectly, 1mcg too much or not enough can make a difference, and he believes it’s essential to have it compounded with a slow release agent.

    1. Although I can’t speak to your situation, I do want to make a few general points for people reading these comments. T3 has been experimented with as a treatment for things other than hypothyroidism, but it is generally not recognized as an accepted treatment for any of these things. That said, there will be anecdotes of people who have felt better with T3 therapy for other conditions.

      As for compounded T3, I am skeptical that it is truly slow-release, as compounding pharmacies claim. If they would publish pharmacokinetic/dynamic data, showing their product really lasts all day, then I would be more receptive to their claims. The pharmaceutical industry has been working for years to make a reliably slow-release T3 product, probably spending millions of dollars in the process, and they haven’t nailed it yet. So the idea that someone in the back of a pharmacy has figured out how to do it consistently and reliably seems far-fetched.

      1. Although I have become reliably asymptomatic since adding Cytomel to T4, I work in big pharma. I, too, question why Pfizer, in its corporate wisdom, doesn’t manufacture sustained- or extended release. (True story: as a teenager, I dated the daughter of the inventor of Contac cold capsules–they worked.) Surely there’s gold in them thar hills and hundreds of thousands of patients for whom T4 just isn’t working who would buy specific doses of a T3 formulation. There is, however, a simple truth: compounded liothyronine SR is just one-third the price of Cytomel!

      2. Literally has told you that she has sustained release. She would know the effects better than you. She is on it. You are slow in the head. I swear to god lol

      3. Are you familiar with Ken Blanchard and his micro-T3 dosing protocol?
        His experience with over a 1000 patients is clealry very different than yours, and he was not a “quack” but a Princeton educated allopathic doctor. A real out of the box thinker.
        It’s possible that he catered to a particular population group but as he describes in his book “Functional Approach to Hypothyrodism” switching to compounded T3 has revolutionized his practice.
        In my experience, compouned slow release T3 feels like a completely different drug than immediate release, very different pharmacokinetics (and I’m also an allopathic physician though not wiht the same pedigree as Blanchard).

        1. I haven’t read his book, but I am familiar with many of the various iterations of approaching T3 dosing. My beef with “slow release T3” is that I have not seen any pharmacokinetic/dynamic data proving that anyone (compounding pharmacy or otherwise) has been able to formulate a product that consistently delivers the claimed extended release. Given that Pharma has been trying to develop such a product for years, it seems far-fetched to believe that a compounding pharmacy has figured it out.

          1. This is my worry, too. Cytomel is expensive; surely if big pharma had figured out a way to monetise reliable slow-release, they would have.

            That said, I’ve been taking compounded liothyronine SR for the past eight months. Haven’t slept as well since the start of thyroid disease in 1984!

            For me personally, I have to make my first dose genuine Cytomel not SR to feel right.

    2. Jessica, you post was very interesting! I really like the idea of starting at 1mcg and titrating up. Can you tell me the name of the doctor that treated you? Very interested in working with someone like that.

  19. Very interesting article, thank you so much for posting it!

    I have Hashimoto’s (diagnosed 18 years ago) and have tried every available drug and combinations thereof: T4 only, T3 + T4, T3 only, NDT, NDT + T4.

    I keep coming back to T4 only which keeps my FT4 levels steady close to the upper normal range and my TSH below 1.5 where I feel best.

    I don’t seem able to handle any amount of T3. The tiniest amount (even as little as 5 mcg) suppresses my TSH completely and makes my FT3 levels rise and fall within hours. I feel a rush of energy when the effects of the T3 kick in, I feel tired when they start to wean off so it’s a constant roller coaster.

    I am now back on T4 only (150 mcg daily) and don’t expect to go back on T3 again. I feel more stable on T4 only, without the constant ups and downs.

    Thank you for explaining how the body can make the T3 it needs from T4.

  20. Thank you for this very balanced piece about the T3 controversy. You probably saved me from trying pig thyroid – lol! I had my thyroid removed due to thyroid cancer 25 years ago . I have always ( before and after) had problems with fatigue but in the last few years ( just turned 64) my fatigue has gotten much worse. I continue to look for answers although I’ve pretty much accepted this is just the way I am. Recently, though, I was reading some naturopathy info about T3 and wondering if I should check into that more. After reading your information, though, I have come to the conclusion that with my life long anxiety issues it probably isn’t the right direction to go in. You have most certainly saved me money and time – so thanks!! Also thank you for taking the time to educate people with real facts and research rather than the hearsay and anecdotal stories that much abound.

  21. If the clinical reference paper for a 15:1 ratio of thyroid hormones is A Pilo, et al 1990, may I say that this paper has a major problem, with regard to the radioactive tagging of T3 and T4, and the large amounts of iodine that was used to protect the thyroid glands of the patients being studied. The iodine down regulated the secretion rate, as it should. So we can only assume that the results are incorrect. Not only that, but a paper in Toxnet from 1975, said that no radioactive tagging of liothyronine with either 125I or 131I for in vitro evaluation of thyroid function. Due to high specific activity required, radiation can easily occur……..Dose is not for internal use. Osol, A and JE Hoover, et al. (eds) Remington’s Pharmaceutical Sciences 15th Ed. Easton, Pennsylvania: Mack Publishing co. 1975
    Obviously RAI is now being used but when the thyroid is destroyed under a endocrinologists sayso.

    The A Pilo paper was an extra curve paper from a JJ DiStefano paper on rats. The conclusion on the JJ DiStefano paper being that the rat thyroid secreted 80% T4 and 20% T3, so a ratio of 3:1 – the rat being an equivalence for humans.
    Celi FS from 2010, Pharmacodynamic equivalence of T4 and T3… concluded 3:1 ratio.

    I know I am much better on T3, having tried it for two years. but my new Endocrinologist won’t prescribe. I’m back with hypothyroid symptoms… what a waste of a good life.

  22. I keep wanting to use T4 – I have tried multiple versions (commercial and compounded) with and without T3 (I have Hashimoto’s and if I am off thyroid my TSH goes up and I am very symptomatic) but every time I use any version of T4 I get a systemic allergic reaction. I have been on compounded T3 only for years and I keep worrying it is an issue (although I do have my thyroid panel checked regularly and have been able to keep in a normal range for TSH – suppressed T4 (as would be expected) – and normal T3) The one time my endocrinologist acccidentally sent the compounding pharmacy prescription for T4 instead of T3 without me realizing it – I had a systemic allergic reaction again. Any suggestions? While I am on straight T3, I don’t have issues with heart palpitations, tremors, sweating (although I did a few years back but I think it was from menopause), anxiety, or insomnia but I am concerned because unlike T4 it is not easy to tell from tests if the dose is right and articles like yours make me worry that I should be on T4. I think I am the only patient my endocrinologist has who has been on straight T3 and I think he wants me to be on T4 – but I keep having the allergic reaction to everything we have tried. We have not been able to find T4 that doesn’t cause me to have an allergic reaction. Going off T3 doesn’t work – I get really bad hypothyroid symptoms. I just started searching again but not sure what to do.

    1. I am unable to give individual medical advice, but I can say that people should be aware that Tirosint is a brand of levothyroxine in a gelatin vehicle. It is highly unlikely to be allergic to gelatin, and it is impossible to be allergic to levothyroxine itself. There are no other fillers in Tirosint.

      1. My husband tried Tirosint when it first came out and it did absolutely nothing for him. His endocrinologist didn’t know what to make of that. I watched him take it every day and wrote it on a calendar. He was faithfully taking it. Any ideas?

  23. Doctor, I am glad you have found a subset of patients who respond well to your training. That you sneer at the experiences of thousands of patients is terrible. There are more than just one site containing thousands of thyroid patients, by the way. There are at least a million thyroid patients total on these sites. All of them have not found health with the type of treatment you push.

    1. Does he train, or push?

      When has he sneered at patient experiences?

      Appealing to “thousands of thyroid patients” is fallacious.

      The fact that a patient has not “found health” by following only evidence-based treatment doesn’t mean there’s something wrong with the advice.

      In short, where’s your argument against the substantive information offered here?

    2. Unfortunately we humans place far too much weight on our own experience, to the point of ignoring the experiences that contradict themselves.
      For everyone on those sites, there’s someone who tried the same thing and didn’t get a result. Those people leave the site. You say there’s a million. I doubt that. There may have been a million if you count all the people who were there a long time ago and left after it sunk in that the T3 wasn’t actually working.
      Then there’s the fact that most of the posts on these sites are people wondering why the treatment isn’t quite so perfect as they’d thought. “Keep trying.” “Adjust the dose.” “You need to be treated for chronic Lyme.”

      Never “T3 doesn’t work and if it did, it doesn’t work for what you’ve got anyhow.”

      This is why doctors rely on controlled tests. You find some people who have not found health. You give some of them T3, or T4, or nothing, or something else. You don’t tell them what they’ve got, in fact you don’t even know what they’ve got because it came to you without labels. Then you see who really did get better.

  24. After many years of levothyroxine use (for Graves’ disease, ablated with radioactive iodine in 2005), I decided to try “natural” thyroid replacement. I took Naturethroid for a number of months and then suddenly ended up in the ER with my heart going crazy. I was taken off Naturethroid and put back on levothyroxine, which works well enough and hasn’t caused additional heart problems. However, I now have chronic (sometime daily) skipped beats and heart palpitations, which have occurred on and off for over 2 years (ever since the initial episode). Many tests later (cardiologists includes), nobody can say what exactly went wrong. My heart appears healthy in ultrasounds and since I “only” showed 11 seconds of a concerning heart rhythm while wearing a 2-week halter monitor, I’ve been written off as having harmless heartbeat irregularities. Sure doesn’t feel harmless when your heart starts going nuts while you’re just sitting down doing nothing! Btw, I’m almost 39 and this all started when I was 36.

    I’m wondering if you have any knowledge about dessicated pig thyroid hormone use leading to other health problems (like heartbeat irregularities)? What are other compounds in pig thyroid we might be unknowingly ingesting? Can you speak on the possibility of rT3 pooling and then dumping into the bloodstream and what effect that might have on the heart?

    I just wish I had an answer as to what really happened and why it’s ongoing, especially since I stopped the Naturethroid and my labs are all in the normal range now. Obviously you aren’t a cardiologist or my personal doctor, but I figure it’s worth a shot asking. Thanks.

    1. Although I can’t comment on your situation, I can say that high doses of T3 can cause/exacerbate heart problems. Sometimes, it may unmask a heart problem to which someone was already predisposed, and that heart issue may not resolve completely after stopping the T3.

      rT3 does not have any biologic significance, so no, it does not do what you’re suggesting. See this post: Everything You Never Needed to Know About Reverse T3

  25. I wonder if this blogger has any conflicts of interest relating to Levothyroxine . Many patients prefer Natural Dessicated Thyroid as preferable first line treatment. It was used before Levothyroxine ever came to market. First off Levothyroxine is a synthetic big pharma drug. NDT is a natural product in most part coming from a pig. Levothyroxine has an unnatural straggle hold over the market for Thyroid treatment and replacement. Its the inactive storage form of hormone for a start and needs to be coverted to the active T3. Alot of propaganda has been promoted to get this drug as the number one treatment for hypothyroidism. A hell of alot of corruption and kick backs no doubt. Conversion problems are extremely common. Hypothyroidism is vastly underdiagnosed because of “idiot” endocrinologists who have problems reading and interpreting labs values. Central Hypothyroidism is missed often because of overelying on TSH. Inflammation in the body can lead to Hypothyroidism. Conversion issues are actually common. Anybody who is claiming they ain’t is clueless?! Terrible article. Poster could have OCPD traits as hes refering to a statistic and ignoring what he would actually see in clinical practice if everybody was evaluated properly. TSH and T4 is a very bad way to evaluate hypothyroidism. It misses ton’s of people who are hypothyroid. Its idiotic. The current thyroid testing is not up to a very high standard of care in clinical practice and risks angina, coronary thrombosis and heart attacks in people who are untreated hypothyroid. The pituitary is pulsating for a start. There’s been a massive “propaganda” campaign to knock out Levo’s competitors. People like this blog poster just try to use peoples ignorance against them so that you submit to a so called professional’s expert knowledge. Most Endo’s reputations are in a state of disrepair online because of this vary issue. The argument in this blog post coming from the blogger is not a very credible rationalisation. It sounds like the blogger is gullible and has been conditioned by academia and is parrotting information that he’s been mind controlled with.

    1. Where is your evidence that “Conversion problems are extremely common”? In my own case, I was taking WP Thyroid (combo), and it made me jittery. I took straight T4 because of HD and felt a lot better. So I have firsthand experience and am grateful for this blog. Again, where’s your evidence?

      1. Thanks for trying, Amy. But if you’re hoping for a coherent answer from Ryan, you’ll be waiting a long while, I reckon.

        1. Yeah, I briefly considered doing a thorough, line-by-line shredding, as it might have been fun to point out all the fallacies and smears. But maybe it’s worth asking how expensive he thinks Levothyroxine is vs. something like WP Thyroid. I’m spending only a fraction of what I did before. Not a whole lot of money in getting people to switch to the cheap stuff, is there? Plus, if Levotyroxine already “has an unnatural straggle hold over the market,” why do the drug companies need you to shill for them?

          1. Exactly. Generic levothyroxine is anywhere from $12 to $30 for a three month supply. And there is no mechanism in place for me to see any of that money. Conspiracy theories abound, apparently, but there are no kickbacks for prescribing physicians. 😔

  26. Some people do alright on Levo alone with Primary Hypothyroidism. If its really simple and straight forward Levo works. Theres a blatant conspiracy around Levo. For instance in the UK Liothyronine cost so much to prescribe its been withdrawn on the NHS and Dessicated Thyroid isnt licensed. Corrupt as fuck. So the only treatment is Levo but nothing to see here. Literally removed the competitors. Chronically ill people can have conversion problems so need Liothyronine or Dessicated Thyroid. He’s deffo shilling for big pharma. I mean he starts of the blog with Levothyroxine is Natural (its a synthetic drug lol); NDT Isn’t (its natural to a pig as it came from a pig and literally has natural in the title). He starts the whole blog of by twisting reality ffs lol the guy’s a liar. If he can lie about something as simple as that he can lie about anything.

    1. You know, Ryan, I had a great English teacher in high school who used to say, “Life is one long reading test.” You, sir, have failed it for today. How natural is it to ingest something that has a T3:T4 ratio that’s completely different from that which exists in your own body? Particularly something that might damage your heart if you take too much? And you still haven’t brought any evidence that “conversion problems are extremely common.” In fact, you seem to be walking that back, saying “Chronically ill people *can* have conversion problems.” My own Endo, who’s been practicing for decades, told me that fewer than 1% have conversion issues. What evidence do you have to the contrary?

      1. I’ve wondered what a conversion problem actually is. Is it a genetic variant in the gene that codes for a certain enzyme? Is it a consequence of sickle cell anemia? A vitamin deficiency? HIV?

        The thing is that no one would call those things conversion disorder, they’d talk about how an HIV patient might need T3. Which so far as I know they don’t.

        1. Maybe HD can comment on that. All I know is that I apparently don’t have that problem, and I’m so glad that the amount of T3 I was taking before learning this was very small!

  27. Your blog is a breath of fresh air! I am a self-proclaimed health nut/ alternative health consipracy theorist, diagnosed with post-partum hypothyroidism years ago with a TSH of 14 and low T4. (Pretty straightforward hypothyroidism). I did all my “research”, and when my regular doctor refused to prescribe dessicated pig thyroid, I found another doctor. (I threw out the levothyroxine I was given because I had done my “research” and knew it was pure poison). Fast forward to 5 years after being on dessicated thyroid, developing panic attacks and suddenly being hit with extreme heat intolerance, headaches, high fasting blood glucose, and dizziness, I realized that these symptoms became pronounced every time I would take even the smallest dose of dessicated thyroid. My doctor couldn’t understand it because my labs looked normal, even though they were taken first thing in the morning prior to taking my dessicated thyroid. I could no longer tolerate the NDT so had to quit cold turkey! . Upon further research, I suspect that my T3 levels became too high for my system during the daytime and my body could no longer tolerate it. The only thing I could do was switch to T4 medication, and I am still trying to feel “normal”, as I also suspect that my body became accustomed to being overstimulated from the T3. In hindsight, I wish that I had just taken T4 from the beginning, as my hypothyroidism would have likely been very easy to treat and I wouldn’t be dealing with “withdrawal” from the T3, as it has been very difficult. Thank you for your grounded and rational articles…I wish I would have read this years ago (before I found the STTM website and demanded NDT!).

      1. One more question… if someone is on a full replacement dose of levothyroxine at 100mcg for hypothyroidism (not due to thyroidectomy, just plain hypothyroidism), and still symptomatic even with the TSH below 1-2, would a trial of adding T3 to a lowered dose of levothyroxine be justified? If someone requires a full replacement dose can we assume that the thyroid is non-functioning and that conversion of T4 to T3 would be impaired? Thank you again for all of your insight!

        1. if someone is on a full replacement dose of levothyroxine at 100mcg for hypothyroidism (not due to thyroidectomy, just plain hypothyroidism), and still symptomatic even with the TSH below 1-2, would a trial of adding T3 to a lowered dose of levothyroxine be justified?

          That’s reasonable, as long as expectations are kept low (given that it doesn’t do much for most people).

          If someone requires a full replacement dose can we assume that the thyroid is non-functioning and that conversion of T4 to T3 would be impaired?

          The function of the thyroid and conversion of T4 to T3 are separate issues. When someone requires a weight-based “full replacement dose,” we can assume that the thyroid is not contributing much to the overall thyroid hormone level. We cannot make any inferences about T4 to T3 conversion from that. But, given that T4 to T3 conversion is a generally efficient process that is not impaired in the vast majority of people, it’s not something that most people should worry about.

          1. Based on my experience, I would suggest keeping your T4 the same but adding T3 (perhaps compounded sustained-release) at around 15-18% to your morning dose. This is particularly effective when the thyroid tissue is absent due to thyroidectomy or long-term Hashimoto’s.
            IF you start to feel better within days, this may be the root cause of feeling unwell. If that case, I suggest following the protocols in Paul Robinson’s excellent books.
            Thyroid therapy is about the patient’s subjective experience. If you don’t feel well, it doesn’t matter what your bloodwork says. In fact, your body temperature, heart rate, & blood pressure give a far more accurate indication.
            Taking control of your health & finding a physician and/or endocrinologist who is willing to think outside the box is vital.
            Usually, a single T3 dose is not sufficient. Timing is everything, and a circadian dose at bedtime might do the trick to get you back to health.

          2. Paul Robinson is not a doctor, but his books give medical advice. Doctors do not think much of him.
            The problem with a trial and error protocol is that there’s only one of you, and the things you mention:
            feel(ing) better within days…
            subjective experience.
            (not feeling) well
            body temperature
            heart rate,
            blood pressure
            Do not and cannot give an accurate representation of anything. There are thousands of things that cause each of these symptoms, and collectively many millions of things, and the odds are far more likely that it’s a common cold than that it’s a T3 problem. That’s just odds–colds are so damn common that you’re more likely to have an unusual one that exactly matches the symptoms of a T3 problem than you are to have an actual T3 problem.

          3. Well, yes. But Broda Barnes who was a doctor discovered the temperature method for hypothyroid. Placebo effect is a short-term phenomenon. However, when one has been feeling better for months after a long period of adjusting T4/T3 dosages, it’s unlikely to have other etiology.

            In fact, thyroid testing, esp TSH, only provides broad indication of disease. Subclinical differences are often not apparent or ignored by physicians. There need be no other criteria than a patient’s own perception of health. Robinson healed himself over 30 years through trial and error.

            I urge all sufferers to read German endocrinologist Dr. Prof. Rudolf Hörmann’s conclusions here: https://kilpirauhaspotilaat.fi/artikkeli/professor-hoermann-responded-to-statements-from-finnish-endocrinologist.

            It’s about patients taking control over their own health. With some salt, the Internet has leveled the playing field.

  28. I am very grateful for this post. I have been on many of these thyroid Facebook groups and have been given the advice that T4 only treatment is killing me. Even though I feel very well, I looked at their optimal levels for TSH, FT3, RT3.,, and was sure I had a problem. My FT3 was not in the upper range and they claimed I needed T3 only treatment to reduce my high Reverse T3. After a few months of 10 mg of T3 in addition to T4, my blood pressure became elevated and had a horrible racing heartbeat that almost landed me in the ER. When I questioned the T3 treatment, people said my iron levels or cortisol levels… were off or I just wasn’t taking enough. People who disagree with the protocol stop posting or leave because they are attacked for questioning T3. Your post gave me a big breath of relief. My free T3 is in the low part of the range, but I feel well. Maybe it is OK for me. Also, years of being overmedicated has given me Osteoperosis. Very frustrating. I had radiation for Hodgkin’s lymphoma which caused my thyroid problem. Glad to be back on Tirosint and feeling fine.

    1. Glad you’re doing better. Thanks for sharing this, Shelley. Yours is a good reminder that most people do fine on T4 alone.

    2. I have the same experience. People wanting my FT3 in the upper part of the range (currently in the lower). But I’m cautious and am waiting to see how I do once my TSH gets to a better level. My current observations are my TSH doesn’t get to a level around 1-2 unless my FT4 is very high. Then I get anxiety and other bad symptoms. But if I drop my dosage I get hypo again. Also, my FT3 goes down the more Synthroid I take. when I lower it my FT3 rises (all still fairly low in the range). I figure that’s my body compensating for what it thinks I need. But either way, I generally don’t feel good in either situation. I think since I’ve focused on my nutrition things have improved. I am guessing I was deficient in something that is required for doing well on Synthroid. Are there any cases where someone’s body needs certain nutrients to do well on the medication (such as Iron)? I believe the Synthroid website mentions a few things like that.

      1. Generally speaking, there isn’t a specific nutrient to get more of to optimize the efficacy of levothyroxine replacement therapy. Obviously, if one is deficient in certain minerals, like iron, that’s a separate issue that needs to be addressed.

  29. Hello. I lost half my thyroid following surgery for hyperparathyroidism about 4 years ago, and the other half for a second bout of HPTH 1 year ago. It took a full year to recover the first time around, but I was able to complete a 10K and 3 short distance triathlons the following summer. (15 months later). This time, the experience is entirely different. I have been unable to recover my energy to the same extent even though my TSH is being managed well. I have a terrific PCP who subscribes, like I do, to mainstream medical philosophy and practice. We just started a trial of low dose Cytomel and will see if it helps with this crushing fatigue and depression. I’m also wondering what role calcium levels might play. My serum ca is low normal (8.3. Ionized 1.16) I know what hypercalcemia feels like (ugh) and wonder if swinging to the lower part of the range can have a similar effect. I’m a 66 yr old woman, retired, and an avid triathlete (been doing them for for 10 years.). HPTH was most likely caused by radiation for childhood ear infections in the 1950’s – no cancer.)

    I’m interested in your take on this. Thanks.

    1. Although I can’t comment on your situation, I can make a general comment. Low calcium can have some nonspecific symptoms, and it is occasionally (but rarely) challenging to keep the calcium level where we want it. I will also say that, when someone has been accustomed to a high calcium for awhile, abruptly dropping to a lowish level can be associated with more pronounced symptomatology than reaching that same level over a longer period of time.

      1. Thanks for responding so quickly. Yes, I’ve experienced hypocalcemia too as my next-in-line parathyroid took weeks to wake up and start doing its job. Your comment makes a lot of sense. Much appreciated. The non-specific nature of these symptoms can be maddening. Hard to know what the underlying causes are given the complexities.

      2. Hello again. After a year of Cytomel (very small dose in an appropriate ratio to T4), I decided to stop taking it. It helped a lot with depression but over time it seemed to contribute to symptoms of anxiety. My PCP and I thought it best to switch back to levothyroxine alone. I’m totally fine with that.

        My calcium levels have stabilized (no change.) I’m training and racing again and feeling reasonably energetic. Perhaps the best thing I’ve done lately is consult with a nutritionist about how to finally lose those pesky 7 pounds I gained after my last surgery (3 down, 4 to go), and to rethink my diet (talk about conflicting advice…). My PCP referred me to a psychologist to deal with anxiety – and depression if that recurs. We’ll see how it goes.

  30. You post Levothyroxine is natural but it is a synthetic (man-made) version of thyroxine. Is synthetic the same as natural? I’ve read that Nature-Throid is a natural product made from animal thyroid glands that has never been voluntarily or FDA recalled for inconsistent T4 or T4 hormones. You’ve stated in this blog that hypothyroidism isn’t difficult to treat so why are so many doctors baffled when it come to treatment?

    1. Given that levothyroxine has a chemical structure that is essentially identical to thyroxine (the main hormone produced by the thyroid gland), it is considered to be one of the most natural hormone replacement therapies available. Whether it is synthesized in a lab or not, it shouldn’t matter to the end user (the patient), because the user’s body cannot tell the difference between thyroxine and levothyroxine. To me, that’s natural.

      On the other hand, taking desiccated pig or cow thyroid – with ratios of T4/T3 that are foreign to the human body – does not sound natural to me. Sure, it is a biologic substance, so if you want to call it natural because of that, go ahead. But it sure isn’t physiologic or normal for the human body.

      To address your last point, I don’t believe that many doctors are baffled. Alt Med claims that mainstream doctors don’t understand how to treat hypothyroidism, which is essentially false.

      1. While I don’t think most doctors are “baffled” over hypothyroid, I do believe that few of them are willing to think outside the box. Most correlate T4 dosage to TSH, often with no other testing such as FT4 & FT3, antibodies. If the patient still feels unwell, it’s all in their head.

        We’re seeing an epidemic of suffering over hypothyroidism. I’m not suggesting anything radical here: the goal is to get patients symptom-free. Maybe for some that takes bioidentical liothyronine, maybe compounded sustained-release, maybe dessicated thyroid.

        The trick is to avoid dogma, to be open-minded, to listen to one’s patients rather than paint-by-numbers.

        1. As a primary care physician, I find this sort of response from patients to be one of the most difficult. There seems to be a lack of understanding that treatment of hypothyroidism is done to restore normal physiology, not necessarily to “get the patients symptom free,” given that there are many factors potentially going on there. Insisting on being symptom-free, and laying all the symptoms at the feet of the poor little thyroid gland (often at the exclusion of listening to other suggestions), creates a frustrating patient encounter.

          1. Yessssssssssss…thank you, Candace. While I’m sure all docs would love for their patients to be symptom-free, not all “hypothyroid” symptoms are due to the thyroid. However, all kinds of symptoms can be improved – temporarily – with stimulants such as high doses of T3.

          2. I’m going to chime in here. As a patient, I had RAI in 2015, became hypothyroid with all the symptoms….weight gain, depression, skin like an alligator, joint and muscle pain. I was put on T4 only for over a year and I still felt pretty miserable, so after reading all the websites touting T3, I asked my endo for a chance to try NatureThroid. The first dose had my T4 so low that my symptoms came back and brought their friends! He then added T4 to the NatureThroid and I was feeling so much better that I felt hope. Then NatureThroid was on backorder so he switched me to 75mcg Tirosint and 5 mcg Liothyronine. Tests showed my TSH was too low, and my endo said he can’t leave me on a dose that suppresses my TSH and if I wanted to stay on it, I need to see a naturopath (which led to me finding your blog, HD). We kept decreasing the T3 until I made the decision to stop taking it entirely.
            I have a scale that measures weight, body fat, water and bone and I track everything. I noticed that when I was on T3, my bone weight decreased. When I stopped taking T3, my bone weight came back up. Modifications to my lifestle made a huge difference. I stopped drinking wine, watched my caloric intake and started swimming 3 x a week. I’ve lost 20 lbs, depression is gone and I feel like myself again. I am grateful that my endo allowed me to experiment with T3. With the help of this blog and my own experience, I’ve realized is that T3 isn’t the answer and changing some bad habits will go along way to feeling great again!

          3. I agree with you completely. If normal physiology is restored, the patient is symptom-free, regardless of their lab values. Listen to your patients!

            Absolutely, there may be other factors in play, e.g. cortisol. But fix the thyroid first!

      2. I have found it’s useful to talk about this not as about being “natural” as much as it being about something being “bio-identical” with people who don’t understand that everything is made of chemicals and have mistaken ideas about nature being benevolent. Talking about how NDT isn’t bio-identical even though it’s natural can sometimes cut through the naturopathic propaganda. (I say this as someone who largely avoids highly processed foods and is not closed to unconventional ideas having grown up around medical research and neuroscience.) A useful comparison to make is how Premarin is “natural” (it comes from an animal source) but it isn’t bio-identical whereas newer forms of HRT are considered bio-identical and are less harmful. It can be very difficult watching people in thyroidectomy groups describe hyperthyroid symptoms when on NDT but ascribe them to all kinds of other things from not having a thyroid to nutritional deficiencies (a great way to sell people more supplements, though I don’t doubt that some people are giving themselves dietary induced problems from very restricted and not always healthy diets. I have Graves Disease and had a thyroidectomy late last year and I’ve noticed that a lot of people who had thyroidectomies due to cancer or Hashimoto’s seem be causing some of their own unnecessary suffering (those of us with Graves Disease who are familiar with hyperthyroid symptoms seem to both be less keen on NDT, partly due to anecdotal evidence shared among Graves sufferers that it can increase Trab, and are also more likely to stop taking it if we resort to trying it because we recognize hyperthyroid symptoms for what they are). It may sound like semantics but words can be powerful (as a writer I fully admit my bias in this area!) and sometimes simply reframing something but in a way that already fits into someone’s worldview can get them to start thinking a bit differently.

        1. Yes to everything you said – I’m hearing “guest post.” I especially like your points about distinguishing between natural and bio-identical.

  31. Hi HD,
    I’ve posted here a couple of times (I just love your blog so much, as I’m trying to restore my health and reverse years of “brainwashing” myself with dangerous info/protocols from some popular thyroid blogs). I spent many years with a TSH under 0.1 thinking this was ok, was forced to switch to Synthroid after my body just basically broke down and could not tolerate any dose of NDT anymore, and had horrible side effects from the Synthroid no matter what the dosage. I asked my Endo if I should try T3 and he actually recommend Tirosint instead. I almost didn’t try it because of the cost, but literally the day I tried it, the foggy, “drugged” feeling I had while on the Synthroid was completely gone, and I am doing so much better, without T3. I actually think I need to increase my dose, as I requested starting lower than recommend (I was slightly over medicated on 100mcg on Synthroid with a TSH of .2 and requested 75/50 alternating doses of the Tirosint due to fear of overmedication…. currently awaiting labs). My question is, have you found some patients to have such weird reactions to Synthroid and have symptoms resolve with Tirosint? And do you find it more difficult to find a patient’s optimal dose of Tirosint since it’s a gel capsule and cannot be cut? Thank you again for you blog, it has helped me so much during my recovery!

    1. Hi Sandy,
      Synthroid gave me chest pressure and anxiety, so my endo switched me to Tirosint. Same dose, but no issues with Tirosint. I was put on 88 mcg but my TSH was .37, so we started a protocol of Monday- Saturday I take 88 and on Sunday, I take 75. TSH was still low at .40 so now I am taking 88 on five days and 75 on Wed/Sun. I think we have have found my sweet spot.

    2. I have had people report just about every symptom/reaction under the sun to every preparation of levothyroxine, including Tirosint, which makes it very difficult to generalize. My overarching sense is that most people are “reacting” to either the dose of whatever they’re on (too much or too little), OR they are reacting to the delta between whatever they were taking immediately before a dose change and the “new” dose. Or, they are reacting to being changed from NDT to LT4 or LT4 to NDT.

      In most cases, I don’t think people are truly reacting to an excipient in the LT4 or NDT pill. However, there is a small minority who will have such a reaction, and for that reason, I occasionally try Tirosint. It is pretty unlikely to react to gelatin, which is the only excipient in Tirosint.

      1. Thank you for your input HD, it’s so interesting, literally everyday 2 hours after taking Synthroid, I’d feel this heavy “drugged” feeling take over me and it lasted until the evening, whether my TSH was 3.9 or 0.2. But it’s also possible that I was either underdosed or overdosed (I increased from 75mcg to 100mcg) so maybe I’m just like Goldilocks and needed the dose to be perfect. 🙂 Either way I’m amazed by Tirosint, as I thought I would never be ok on a T4 med. Thank you for the reply!

  32. Great to know, thank you so much for your input, Irishcurls! I think I have underdosed myself taking 75mcg 4x/wk and 50mcg 3x/wk (I have very little to no thyroid function left although still feeling much better than when I was on Synthroid), now it’s the waiting game of changing the dose, waiting 6 weeks for labs, repeat :). I’m glad you have found your sweet spot!

  33. Using t3 is evidence based for argumentation strategy to antiperspirants
    https://academic.oup.com/ijnp/article/11/5/685/968677
    https://www.mdedge.com/psychiatry/article/64366/depression/augmenting-antidepressants-triiodothyronine-underutilized

    It is not “high”, but neural mechanism regarding neurogenesis and BDNF

    Triiodothyronine role is medicine is still present and whoever was though as you claim that is useless or dangerous was wrong

    1. I think you mean “antidepressants” – I haven’t come across anything claiming T3 will help your deodorant do it’s job 🙂

  34. So glad to find this website, there is too much pseudoscience blogs in the Internet. I have fallen for them at some point.

    The high feeling of t3 is real, and even tho I got heart palpitations from t3, when taking novothyral (5:1 ratio of t4/t3), I keep taking it for years.

    Now I’m on levothyroxine, feeling better and the anxiety is gone (with t3 I was full paranoic)

    Science have not reach the formula for an steady formula of t3 to incorporate with levothyroxine.

  35. The problem with evidence-based medicine is that the evidence is constantly and continually changing. Not so long ago that cut off for TSH used to be 10.0, now we are talking 2.5. Big difference, right?
    I can easily see someone very “left-brained” like HD claiming back in the old days “that people with TSH of 8.0 who claim they benefit from thyroid are simply having a placebo effect”.
    I actually had a bad experience with T3 but I can’t dismiss that other people’s experience is very different than mine because we are all different. This was ok for me when I was a physician but it was no longer ok when I was an acutely suffering patient.
    My life experience pushed me to look outside of echo chambers. For anyone who is interested in a more middle-of-the-road perspective on thyroid from someone who has been on both ends of this (as a physician and as a patient) check out my blog Chronic Fatigue Diagnosis (including an article on SPINA software available for free download that can help you analyze your thyroid lab values in a more comprehensive way).

    1. In reviewing your blog, I would suggest that your perspective is not “middle of the road.” You advocate for patients ordering their own labs, because “they know what they need.” As for analyzing “your thyroid lab values in a more comprehensive way,” I have posted ad nauseam about this sort of claim, but I think something I’ve said previously sums up my feelings perfectly: “The competence of your healthcare provider is inversely proportional to the number of thyroid tests she orders for you.”

      1. HD, you haven’t answered Voyager’s comment regarding the changing reference ranges for TSH and the disagreement on recommendations for upper and lower TSH limits presented by endocrinologists in the Journal of Clinical Endocrinology & Metabolism. Additionally, what about the fact that TSH levels can fluctuate over the course of 24 hours? Just how much trust should a thyroid patient put in such a standard? Would you trust your health to it?
        I’ll bet that there is not one doctor out there who would pronounce weight gain, puffiness, hair loss, and a drop in mental sharpness in themselves as acceptable because a value from a hotly debated reference range told them they were fine. Would you accept that for yourself?
        The mighty TSH test has already fallen. Taking a blood test and reporting its values to a patient and not being curious about their continued symptoms is not being a doctor. That’s just reading numbers. Your “inversely proportional” comment about competence and the number of lab tests may express your feelings (and sound clever), but I think it smacks of a lack of due diligence. Patients have every right to order their own tests and investigate for ourselves. We paid doctors to do it, and they didn’t. Shame on them.

        1. Regarding the controversy about what constitutes a normal TSH, this is a nice summary of the issues: https://academic.oup.com/jcem/article/98/9/3584/2833082/

          As for the diurnal variation of TSH: we know that the peak TSH occurs sometime at night (when blood is typically not drawn to check it). The nadir TSH, which may be up to 50% lower than the peak, occurs between 10:00 and 16:00. Given that most people have their blood drawn between 08:00 and 18:00, and the reference range is established with samples drawn during this timeframe, we typically don’t worry too much about the diurnal variation of TSH. The “mighty TSH” has most definitely not fallen: Is TSH the Best Test?

          As for doctors not accepting distressing symptoms in themselves and patients having the “right” to order their own tests…this is a large topic to tackle in a comment, so perhaps I’ll post on it (thanks for the inspiration) another time. Suffice it to say that I think doctors can be just as stupid about their own health as patients can be, which is why all of us should partner with a physician when we’re trying to figure out what’s wrong with us. For more on just how dumb we all are when it comes to making decisions about our bodies: Top 10 Reasons Why Smart People Are Stupid About Their Health

          1. When comes to testing the most important thing is to know exactly what tie results mean. Let me give you an example.

            I was very sick years ago, at that time I belonged to an on-line group for Fibromyalgia, and one member mentioned that her physician had done a IGF- 1 bloodtests and found she had very low results showing her pituitary gland was not making enough growth hormone. She was put on growth hormone injections and was feeling much better.

            I was very sick, so I asked my physician to order the test, which he finally did after much back and forth arguing . The results came back and he told me that “the results are a little low but that is ok “.

            Now my habit is to get copies of all bloodwork to give to my other physicians, so I for not have to get the same tests repeated for each physician. And when I saw the bloodtests result, I almost yelled at my family doctor. My IGF- 1 was only 29. Now the range of IGF- 1 is from around 70 to 215, it varies according to age, with 70 being the level of a 100+ year old person waiting to die . Having been a Respiratory Therapist taught in a teaching hospital of a medical school, I have always done research before getting a test done, so I would be able to interpret the results. Having a IGF-1 meant that I was in serious medical trouble, so I called my endocrinologist and he immediately put me in the hospital to do the IV challenge test to confirm that my pituitary gland was not making adequate growth hormone. The test was done and in only a day I was put on daily growth hormone injections.

            If I had not done my research and knew what the IGF-1 test results meant, I could have died. As it was, I had already been having problems with my heart rhythm and felt like I was dying. And I had been dying, without enough growth hormone your heart will fail. It is now twenty years later, and I find I have to prod doctors to do the necessary tests, the state of our medical care is so abysmal since they are now encouraged by insurance companies to do so little for the patient as possible.

            But for a physician to tell a patient a IGF-1 of 29 is “only a little low” , that is the new sign that our medical establishment is in very sad shape. Nowadays, if you want good medical care you need to teach yourself medicine, so you can know if your physician is doing their job. Thankfully there is PubMed, and you can even read medical textbooks on-line and the latest medical studies to expand your knowledge to the point you often know more than your doctor does on a condition. I find myself giving my physicians print outs, do they will know the latest information on how to care for me properly. Sadly most physicians have no time to keep up with new medical knowledge, getting it after medical school mostly from the pharmaceutical reps that come around with the latest drug they have developed. Most physicians look at you sideways when you give them printouts, but I now have a group of physicians who actually listen when I open my mouth, instead of patting me on my head and saying a IGF-1 of 29 is ” only a little low”.

  36. Hi, this is such great info, thank you fo all the time you’ve put in to make it available. I had Graves’ disease and was given RAI twice, in 1977 and 1979. I was fine on about 100 mg of synthroid for about 25 years. I started lacking energy and was tired, increased to 125. Still fine, but started putting on weight, feeling tired, depressed. Went on antidepressants which worked. Slowly weaned myself off them. Still fine but lacked some energy. Decided to try desiccated thyroid. My functional doc prescribed anywhere between 60-120 of Erfa Thyroid over the next few years. I consistently have higher heart rate and feel jittery, we’ve tried changing, reducing, increasing. My TSH goes between .05 and 3, but my FT3 and FT4 never get above midrange. Right now my TSH is 2.8 and FT4 is below range and my FT3 is on the edge of too low. Now my bone density tests are not good, and fasting glucose is on the edge of too high. I feel tired and my heart rate is 80-100 at rest. It used to be around 60 because I’ve always been active. I’m so tired of trying to find that sweet spot and figure out how to feel better. I’m thinking I should just go back to my regular doctor and ask her to put me back in synthroid. Ifeel like maybe I just can’t handle that much T3. I wish I had found someone to help me a long time ago. I’m 62 now and would just like to feel normal again.

      1. Thanks HD, I appreciate that.

        In thinking about why I didn’t take my doctor’s advice and instead tried to figure it out on my own and with a naturopath, I came to the following conclusion. I never felt like my doctor really listened to how I felt or tried to really explain her reasoning. It was like she couldn’t be bothered. I’m a curious person by nature and like to understand things. By going to a naturopath I finally had someone who listened and tried to explain her reasoning. I felt heard, and not talked down to.
        I know doctors have a limited amount of time but treating me like an intelligent person would have gone a long way.

        Also, I feel like if I had felt that they were actually listening and not just impatiently waiting for me to leave I would have taken much more ownership of my treatment. I feel like I’ve wasted years and thousands of dollars. I’m angry. But I don’t really know who to be angry at.

        Since I last posted I have gone off ndt and onto synthroid. I already feel better. Placebo effect? I’m not as shaky.

        Somehow the system of patient care is messed up. Thanks for taking so much of your own (unpaid) time to help me and others understand.

  37. After about 2 years on levothyroxine I became a shell of myself. My body and soul were in a dark place that I didn’t recognize is the only way to describe those sad days. My doctor assured me it couldn’t be my thyroid because my TSH was fine at 1.5. Why did I have high cholesterol suddenly, constipation, always cold, fatigue, a stiff painful body and anxiety amongst other symptoms if my thyroid med was working so well?
    I switched to a doctor who wouldn’t dismiss my concerns and tested all my thyroid hormones to see that my T3 was low. He switched me to NDT and my brain woke up and my body healed. I will never go back to those dark days on levothyroxine. I am happy and healthy again with a T3 level like a healthy person has. That’s all we want – I get so tired of reading this nonsense making it sound like drug seekers of getting a high. I feel like I did for the 49 years before I got sick. My antibodies dropped over 800 points also.
    I live in this body every day and know what works for me. I will always be my own best advocate also and try to help others who are struggling. If levothyroxine works for some patients that’s great but we are all different and unique and some of us do best on NDT or synthetic combo (which I tried also but do better on NDT).
    There are so many thyroid support pages with thousands of members because so many are struggling and not being heard or helped. Let’s be more open to the ones who need help and find out why. There are many reasons why we don’t convert T4 well and that should be part of treatment for any thyroid patient not doing well – identify those causes and work on them. I am so thankful to my doctor who wants his patients to feel their best and listens to our concerns. We just want to be healthy and I am again.

    1. This is an excellent anecdotal report that mainstream endos need to pay more attention to as opposed to being rooted in their obsolete dogmatic one-size-fits-all treatment approach. Conversion defects are more common than most endos realize:
      ” A single nucleotide polymorphism, namely Thr92Ala (rs225014),has been reported in the general population, and the prevalence of theDIO2Ala/Ala homozygous variant ranges between 12.9% and 14.9%.”:
      https://academic.oup.com/jcem/article-pdf/102/5/1623/16629879/jc.2016-2587.pdf
      To what degree such defects actually impacts T4 to T3 conversion in each individual is highly unique and only a trial of combination therapy would bear the final truth to ascertain the bottom line wherein lab markers and patient response improves with addition of T3 for those that have responded unfavorably to T4 monotherapy.

      I, myself, have identified several deiodinase polymorphisms in my genome and am treating my hypothyroidism with NDT, closely monitoring my lab markers and symptoms. Not surprisingly, I worsened when adding T4 to my NDT in an attempt to match the “human thyroid ratio”. My protocol, may, of course, change over time.

      Current research is showing that these deiodinase conversion defects are also positively correlated with several other comorbidities (i.e. hypertension, insulin resistance/T2D, bipolar disorders, osteoarthritis). All the more reason such defects are not to be cursorily tossed off as “clinically insignificant”.

      Therefore, one should see for oneself and be screened for the pathological SNPs with DNA testing before accepting blanket statements from so-called experts that tout conversion defects as being too rare to consider and blindly following the SOP with T4 monotherapy indefinitely. There is just too much of a complex interplay between various phenotypes and environmental factors to make any one treatment protocol for hypothyroidism standardized.
      It is good news to see that some endos are finally starting to think and treat outside the box of the Orthodoxy and accompanying pharmaceutical company influence, and taking into account individual genetics and tolerances for their patients which opens the door to customized treatment of hypothyroidism: https://www.ncbi.nlm.nih.gov/pubmed/30375273

      1. Much of this is correct. I would only caution people about doing DNA testing to discover mutations that we still don’t understand very well. Often, certain mutations may have the potential to be clinically meaningful, but they may very well not be meaningful. People who are science-minded and willing to accept that not every “abnormal” test means there is something wrong or something to do differently may be able to pursue this type of thing. Unfortunately, many people get carried away by “abnormal results” and create worry and stress for themselves. This sort of thing happens frequently when pursuing testing that is not well-understood by medical professionals, let alone the layperson.

        1. Agreed. I would regard the current consumer-based DNA testing and one’s resulting SNPs as guides not gospel, certainly not a get-out-of-jail-free card nor death sentence. For every SNP categorized as pathologic, there may be a thousand known or unknown benign or beneficial ones that cancel out the potential pathology. It’s much too complex and pointless to go into here. To the unsuspecting and naive layperson and practitioner alike, however, lies the potential for misapplication based on such results, as we are only at the tip of the tip of the iceberg when it comes to all that is genetic. But it is and will continue to be the future of major advancements in medicine. For now, all we can do is use such data to err of the side of caution to facilitate sensible harm reduction protocols as adjunctive measures or to augment or replace existing treatment regimens, keeping in mind the power of environmental impact and self-imposed actions (a.k.a. epigenetics).

    2. You saved me the effort of typing Tracy, agree with you 100%! I spent 2 years on levothyroxine and your description about feeling like a shell of your former self and that very dark place are exactly how I felt while I was on it!

    3. I’ve had similar results on NDT (naturethroid). I was on Levothyroxine for 36 years for Hashimotos, and felt well on it. But then, over the course of three years, I began getting more and more hypothyroid symptoms. My TSH was increasing, but a higher dose of Levothyroxine was not helping. Finally, I switched to NDT, and immediately my labs showed improvement. I feel fully human again! I am alert. I have energy. I am slowly and steadily losing weight. Why did t4 alone stop working for me after all those years? I have no idea. Perhaps aging negatively affected my ability to convert t4 to t3?

      I think it’s important to remember we are all uniquely affected by a multitude of factors at any point in time. A “one size fits all” approach is not ideal. And, what is helpful at one point in time might have to be tweaked again later. One day at a time. I’ve been on Naturethroid for 16 blissful months now. So far, so good!

      1. Tamara…you have had Hashimotos Thyroiditis for a long time and thus your autoimmune attack on your Thyroid may have destroyed it. Plus…”use it or loose it.” I have had a diagnoses of Hashi’s for about 30 years and my Endocrinologist has diagnosed me (courtesy of an ultrasound) with literally no Thyroid Gland of any significance. If that is the case for you… your Thyroid may not be producing any T3 at all. Reread HD’s original post. He does state that there are 5 types of people who may “need” or “like” T3 therapy. One of the five is someone who has had their thyroid removed. Or…does not have a Thyroid. From experience…I would say be careful. It took me a few years before I became aware of the negative effects of taking T3. I took 5mcg 3X a day. Close to Nature Throid’s 2 grain tablet I believe. A ratio closer to 4/1. I am down to 1- 5mcg. tab of T3 and 88 mcg of T4 which is pretty much a 15/1 ratio which HD says is a physiological dose. (Hope I got the math correct) And I am even hoping I can get off of that. I think many people who read HD’s original post misunderstand what he is saying. It sounds like your TSH was high or you had low thyroid. If elevating your T4 did not correct that then I do not understand him to say he is not opposed to a trial of T3. One last thing…as we age our digestion and absorbtion of our food may not be optimum. I am currently on Tirosint which is more readily absorbed. So for me…88 mcg Tirosint and 5 mcg T3.

        1. Correction: If elevating your T4 did not correct that, then I understand him to say he is not opposed to a trial of T3.

  38. Yours is a great story, Tracy, and one all docs would be wise to listen to. It’s all about symptoms and it’s NOT in your head!

  39. I didn’t ask for T3. Really. And, sorry, but I do appear to be different. Not that I asked for that either.

    I went hypothyroid rather abruptly after a year-long stay in the Philippines. My doctor sent me for a pituitary MRI, which came back negative, and then put me on Synthroid.

    My hypothyroid symptoms remained. I started getting several respiratory infections each year and several urinary tract infections each year. I developed Meniere’s. I became hypoglycemic.

    After about ten years, one of my doctors switched me to Armour Thyroid and set the dose based on my Free T4 levels. (My TSH runs low. See my exome data as to why.)

    My Meniere’s went into remission. The infections stopped. I’ve had one in the last fifteen years on desiccated pig thyroid. But I started getting allergic reactions to seemingly random triggers. And my hypoglycemia became mild insulin resistance.

    Eventually, I was diagnosed with atopic / extrinsic asthma and put on a twice-daily inhaled steroid. My lungs calmed down, but the allergic reactions stopped as well. I’ve had none since going on QVAR. My digestion improved. My hearing improved (damage from Meniere’s). And my A1c came back down into the normal range. No infections. No allergic reactions, except to medications. Life is good.

    Finding a doctor would be much easier if my body truly were the same as most people’s. But rare cancers (e.g. mediastinal adenocarcinoma), hypothyroidism, and high cholesterol run in the family. Twins run in the family. Our DNA was sequenced by the Chromosome 22 Project.

    I have Mixed Gonadal Dysgenesis. I’ve been on estrogen since 1974, because at 22 I was Tanner 2. Most of my breast development came while on testosterone. I have osteopenia, but have had it for a very long time. Getting my E,P, and T levels right stabilized it.

    I have Dysautonomia, which showed up the same time as my hypothyroidism. It has to be pretty cold for me to exercise. I have labile hypertension.

    My body wastes potassium. If I don’t eat enough salt, I get cramps and pre-ventricular contractions. After surgery, my BP has been known to drop to 60/40. I’m a carrier for aldosterone synthase deficiency, but I’m told that shouldn’t matter.

    I have hypermobile joints, excess skin, greater than average lung capacity, and my exome data shows a pathogenic variant common to mild, classic Ehlers-Danlos.

    All of that makes it nearly impossible to find an endocrinologist. The most recent one that I saw ordered a TSH. That was all. Even after I told her it would be low. It was. She didn’t think I should be on pig thyroid, testosterone, or progesterone, but her only alternatives were drugs that have side effects. My list of adverse reactions is already too long; why risk another if what I’m taking works?

    I’m told that my history is too complicated. I’m told that I read too many medical journal articles. What I need is a doctor who is willing to work with me, have a rational discussion, and figure out how to proceed.

    Unfortunately, most doctors don’t like me asking questions until I’m in their office. And then it may be too late.

    I enjoy your style. I can understand your frustration with some of what’s on the Internet. Some of the support groups seem to think that their way will work with everyone. And that there are no risks in doing things like self-medicating with hydrocortisone. I’m glad that you’re providing an alternate viewpoint.

    Now if I can just find an endocrinologist who will work with me…

    1. Thanks for sharing your story – I’m sorry you’ve had such a rough go with the medical system. I wish you the best.

  40. I would like to share my experiences regarding T3 or, more specifically, NDT:

    Diagnosed with Hashimoto’s in 2001 and put on levothyroxine. Worked my way up to 150 mcg daily and felt quite all right for years, but then started reading blogs about how wonderful T3 was compared to levothyroxine, and that all cells in the body need T3 and most hypothyroid patients are T3 deficient since T4 to T3 conversion is often impaired, especially if you have Hashimoto’s…so I found a doctor to put me on Armour, and was later switched to Erfa after the former was reformulated and said to work less well.

    To cut a long story short, I spent a couple of years on NDT but never felt quite all right. My energy levels kept going up and down, and not even multi dosing the NDT helped. I was always feeling hot, my hands were too warm, my body temperature slightly elevated and I could feel my heart beat. But, as long as my FT3 levels stayed high-normal, I told myself I just needed to adapt to the T3 in NDT, and also took adrenal glandulars to treat (self-diagnosed) adrenal fatigue as I’d read that can make the body use T3 less effectively.

    One day, I fell to the ground in a shopping mall in what seemed like a violent epileptic seizure. I was rushed to hospital where tests (EEG, CAT scan, MRI, PET) were all normal, but my FT3 levels turned out to be twice the upper normal limit. So the doctors concluded that the seizure was caused by drug-induced hyperthyroidism.

    I am now back on T4 only (150 mcg daily) and feeling much better. I feel normal, have stable energy levels and don’t feel agitated all the time like I used to.

    For a short while, it felt strange without the rush of energy I used to get an hour or so after taking NDT, but now I appreciate having stable energy levels all the time, without the constant ups and downs.

  41. Hi HD,
    Thanks so much for what you’ve said here. I am currently on T3 and I feel GREAT! I was diagnosed with RA with an overlap in 2016. My Rheumy told me that the overlap is because I have something more than RA but he doesn’t know what. I started taking T3 to help me lose weight but then found it cleared up a number of other issues I was having as well namely the nasty muscle weakness I was having and the constant tiredness. I decided to check out Hashimotos and what the symptoms are and it turns out I have them all bar one. My basal temperature is always around 36.1 which I told is a very big clue. All my levels are normal.

    I am in the process of waiting to be diagnosed, my doctor says that it’s very possible that my TSH and T3 and 4 are normal (TSH is closer to max but T3 closer to min) but to still have Hashimotos. He knows I am on T3 but not the dose, he didn’t seem worried or bothered about it and if it was an issue he would have said. I don’t want to stop taking T3 because I feel so brilliant and normal on it. My moods are ten times better, I was always down and depressed before well I felt that way but I’m not one to show it. I am a positive person, I feel T3 let’s me feel who I truly am but I am worried. I do notice that my eyes are twitching a bit and my throat is a little bit tight. I am not sure if the two are to do with T3. I’ve only been taking T3 for three weeks, two tablets a day so just wondering if it’s okay to keep taking while I wait for my endocrinologist appointment (not sure when that will be yet). I worry about how I will feel if I stop taking them. I only have slight joint pain on T3 as well, I’m not able to take my biologics at the mo (recovering from an op) and I haven’t felt this good in years despite taking more meds! And I’ve lost weight too. I got up to 335lbs due to steroids and immobility but now I am down to nearly 325lbs I am proud of me and my efforts are being rewarded, I am at last getting the results I deserve, I feel like T3 makes life fair for me lol!

    I appreciate hearing anything you have to say. Your insight is so useful and so has this post been to read. Kindest regards and Grüßen aus Deutschland 🙂

    1. Zaun, I’m happy to hear that you feel well. It is my policy to not dispense personal medical advice, so I’m sorry that I can’t comment on the safety of what you’re doing.

  42. I came across this article shortly after I convinced my endo to prescribe Cytomel in addition to the Levothyroxin. So much makes sense now!
    I had thyroid cancer 18 years ago. I had a total thyroidectomy and RAI, then RAI again 6 years later to kill off the small amount of remaining tissue (my mom also had cancer and my oncologist felt it was prudent to be aggressive).
    I had an older endo who initially prescribed cytomel with something else, then later prescribed dissected pig thyroid (armour). I always felt amazing when I was taking armour. About 8 years ago, I changed insurance and now have a different endo, who is a much younger doctor. He immediately changed my meds to Levothyroxin, which I was fine with even though I gained weight.
    I am now peri menopausal and was tired all the time. I asked my endo about a change in meds and he agreed to do so, but he was reluctant. I am now on 125mg of Levothyroxin and 5mg of Cytomel. I feel amazing and I’m losing weight. I should note that I either swim or lift weights 4-5 times a week and eat a low carb diet, but I was doing that before with no results.
    I’m wondering if the cytomel is working for me because I have no thyroid tissue at all, or if this is really just a temporary feeling and I’ll sink to a new low after a few months.
    I appreciate the information presented here. I’ll know what to watch for and if things change, I’ll have to humble myself and ask my doctor to change my prescription again 😂

    1. DJCNME…If you reread HD’s original post (at the top) he states that “Five Types of People Who May Need/Like T3 #2 Patients who have had their thyroids removed have to rely entirely on T4 to T3 conversion for their T3 needs. In other words, an absent thyroid can’t make any T3 at all, so patients with postsurgical hypothyroidism occasionally feel better with combination T4/T3 therapy. Contrast this to the typical patient with an under-functioning thyroid (primary hypothyroidism), who probably makes enough T3 such that exogenous (supplemental) T3 won’t make a difference.”

      My husband also had Thyroid Cancer and feels and does fine on T4/T3 therapy.

  43. Date: 25/02/2019 Time: 14:25
    TSH: 8.19 H after 6 weeks-> TSH: 5.96 H
    Free T4: 10 -> Free T4: 13
    TPO Ab: 141.7 H ->TPO Ab: 113.9 H
    TG Ab: 68.9 H -> TG Ab: 67.3 H
    I took levothyroxine for 6 weeks but it made me tired and depressed. Every negative emotion was 3 times worse. I was low thyroid/hash. When I got off it I appreciated living and life, and thought which evil doctor invented levothyroxine. I do also take dexamphetamine and there is probably a reaction. Need to stop dex.

    1. Austin, I suspect you were tired and depressed because you were and are still Hypothyroid. Your antibodies are still elevated indicating inflammation. And you are taking “speed.” Only a matter of time before you completely crash. You probably need more Levothyroxine not none. Give it time. You were headed int he right direction. IMHO

    2. Hello, thanks for this free source of info, people like me are craving this.

      It would be interesting to explore the T4/T3 combination for patients without thyroid. I had TT due to cancer, plus had Graves disease previously. My TSH is suppressed now, the oncologist told me that I could decrease my levo slightly, but we agreed not to change it for now as I don’t feel at my best, sometimes I feel exausted at the end of the day, I eat well and exercise a lot, but don’t lose any weight, have joint pain and gastritis.

      My FT3 is 4 in a range of 3.1-6.8 and my FT4 is 20 in a range of 12-22 . Would I benefit from lowering my levo of 25 mcg and add 5mcg of liothyronine? I know that my hormons look just “fine”, but I never feel “fine”

      I don’t find enough info in the UK and the doctors simply don’t prescribe liothyronine because it’s too expensive, but I wonder if that would support my health? Would have long terms effect? I don’t want to talk about the pig hormons, just talking about sintetic liothyronine.

      I always find a lot of info for people with hypothyroidism, not so much for us without thyroid, who actually are the ones struggling more.

      Thanks anyway for your blog 🙂

      1. Hi Georgia,

        I had a TT due to Graves disease. A few months ago my doctor changed my prescription from 175mcg Synthroid to 150mcg Synthroid + 10mcg T3.

        I can’t say I’ve noticed a huge difference. I noticed a way bigger difference in energy and general health by really cleaning up my diet (eliminating dairy has helped, I was already GF). By changing diet alone my T3 increased from around 2.8-3.4 up to around 4.6. T4 was up around 20-27 as I was on 200mcg levo for a while.
        After starting T3 my blood results look basically identical: T3 was 4.1, T4 dropped to 18, TSH 0.18. It made me think the body may have a “setpoint” for FT3 which it tries to maintain, much like the body weight setpoint. Maybe HD can comment on my pseudo-science 😛

        I totally understand the hope one can pin on a different medication, as I felt like that for years after my TT. But honestly, the reasons doctors don’t routinely prescribe it is because there isn’t evidence that it is better (and the placebo is strong! I often see people in patients groups feeling great with WTE or T3 then a few months later they are looking for something more).

        Also to think about – if it’s hard to get it prescribed then every time you move, or change doctors you have to go through a rigmarole of trying to get it again.

        However, as HD mentioned in the post, you may benefit from a trial, I just thought I’d chime in because my situation basically reflected yours. 🙂 Good luck!

        1. Regarding T3 levels in someone taking T3: the liothyronine will achieve peak blood levels around 2-4 hours post-ingestion, so T3 levels will vary a fair amount depending on when they are drawn. And yes, the body may very well down-regulate peripheral conversion of T4 to T3 if circulating T3 levels are already “high enough” from the exogenous T3.

          1. Thanks for replying HD. My levels were about 26hr after last dose so I don’t know whether the T3 result is even useful in that case?
            Would you recommend having bloods 4hrs after last dose to capture the peak, or before daily dose (as I have) – or some time between the two?

          2. I’m not sure how helpful T3 levels really are, other than to check them 2-4 hours post-liothyronine, to make sure that they are not higher than the upper limit of the reference range. The concept here is that tissue exposure to high T3 levels is probably not a good thing. I still use mainly the TSH to guide my overall sense of how someone is doing (biochemically) on their regimen.

        2. Thanks Emily, I’d love to hear about your eating habits? I don’t drink any alcool, no fizzy drinks, no cheese, no coffee or tea. Eat red meat just a couple of times per month, chicken, legume and eggs on a weekly basis. What I eat every day is vegetables, bread, yogurt, fruit, pasta, olive oil. My only problem is treat :/ I do like chocolate and biscuits, but I only eat some in the morning.

          1. Hi Giorgia

            Nothing too crazy. Like I said cutting back on dairy, which for me cut out my favourite junk foods (chocolate and icecream and cheese), just generally avoiding too much sweet or processed foods, not too much alcohol, getting lots of vege, legumes, fruit. I eat on the lower carb end, but nothing extreme (been there done that). I generally get my carbs from legumes or veges

        1. Thanks a lot for the comment, I didn’t see it till now! I will surely read this article as well 🙂

          Sometimes I think that I just should go back to live at the tropic and probably vitamin d and fresh tropical fruit and sun would just make much more than any T3 addition! I leaved at low latitudine for a year and my body never felt so good.

          Anyway, thanks for your blog. I have so many questions, but don’t want to take advantage of your kindness

  44. Hi! I found this post to be really helpful. I did see a naturopath only after my doctor said that she couldn’t help me (this was over the course of about three visits and trying different things including going on birth control for the severe PMS I was experiencing. The Naturopath suggested T3 treatment–she is an endocrinologist focused Naturopath. I get that there’s tension between the two philosophies but as a patient, I wasn’t living a normal life. I was tired, the insomnia was real, etc. I’ve also been taking Levothyroxine for several years. That being said, my Doctor, after sharing that I had been to a Naturopath and wanting to talk about the treatment, said that the Naturopath was a quack, etc. and that T3 was unsafe. That really concerned me because the T3 has been a game changer for me–my severe PMS is limited to two days instead of 2-3 weeks. I left really heartbroken and wasn’t given clear answers. I don’t want to be doing something unsafe but I also feel like I have my life back.

  45. I got back on the Levothyroxine after 4 weeks off it because I was getting tired again. Taking the medication again was a good idea. I’m pretty sure I have Hasimoto, this time Levothyroxine is working differently, no tiredness or depression. Levothyroxine is the same hormone our body utilises, only difference is its a fragile molecule so when its in your stomach it can change easily, especially into beta beta blockers, I’m keeping an eye on my diet for potential reacting foodgroups etc.

    Its this article above that contains all the truth and wisdom to operate by. You see I’m only on T4, incidentally my sister has hashimotos too, but she fasttracked to a T3/T4 combination, which isn’t a good idea. I plan to take T4 for at least a year because T3 is a last resort.

  46. I have had hypothyroidism for 13 years. I was put on a small dose of t3 5 years ago when my doc saw I wasn’t converting t4 to t3 efficiently. all I can say is wow. I have haven’t felt this great since before my hypothyroidism diagnosis. I am gluten free, eat clean and exercise 5 times a week. the combination of hormones have been a lifesaver to me.

  47. btw my end is 82 years old and renown NYC doctor. I trust him implicitly. your endo should look at your conversion of t4 to t3. if you are symptomatic and your doctor doesn’t prescribe goes elsewhere.

  48. Thank you! Because in reality they refuse to be in our shoes, why endocrinologists refuse to check for t3 is beyond me but taking levothyroxine for 20 yrs and losing weight would take me a yr to drop 30 pounds but eating within a day! Even if I eat couple slices of regular bread I gained 5 pounds the next day and hard to bring it down and I am under antidepressants..so realized I have to be gluten free and my TSH AND T4 says “NORMAL” but I feel like crap…I am on my wits ends because these doctors are great in prescribing but refuse to listen and I am doing the best I can to advocate myself..

  49. This is great information and thank you for actually taking the time to explain it. There seems to be an overwhelming amount of us who don’t feel well taking only Synthroid. And too many doctors who won’t take the time to even explain their reasons for not wanting to add anything else to it. I have Graves Disease and my thyroid was removed 2 years ago. My Synthroid dose has been changed many times due to TSH being either too hypo or too hyper. My Endo will only test for Free T4 and TSH since my thyroid was removed. I was refused a full thyroid panel with no explanation given. Although after reading this article I now understand that the test for T3 is not accurate. There’s lots of hormones out there. If T3 isn’t the answer couldn’t there be other things ‘off’ that would make me fat, foggy and achy? What other tests should I be asking for if they aren’t offered to me?

    1. From what I understand, people with no thyroid sometimes do better on combination therapy. If I were in that situation I’d probably want to get TSH, FT4 and FT3 tested and do a trial of Cytomel with Synthroid.

    2. Fat, foggy and achy…. Lots of women get the problem and it may be related to your thyroid levels, however the thyroid problem could be coming from something else.

      The body has to convert T4 into T3, and it is the methylation system that does this. If you have one copy of MTHFR C667T or A1298C, then the methylation system efficiency drops to 60%. If you have two copies then methylation drops to 20%.

      Now the methylation system is sort of an all-around “handyman”, it converts hormones, detoxifies chemicals and metals, and converts vitamins, such as turning the artificial vitamin folic acid into the folate that the human body can actually use.

      Since around 1998 the US government has required flour to be enriched with folic acid. Now if you do not have the MTHFR genes C667T or A1298C , then the folic acid would not be a problem, however about 60% of the population has one or more of theses gene variants. Which means everytime you get a dose of folic acid, the methylation system will be busy trying to convert folic acid to folate. Throw in some chemicals in the air, food and water and the methylation system will also get busy with that, etc …. And soon converting T4 into T3 will be on the tail end of the things the body has to do, with not enough methyl molecules left to turn T4 into T3. Especially if you have two copies of those pesky MTHFR varients. So you end up with little T4 finally get turned into T3 throughout the various areas of the body where it needs to be done.

      This is why many people who do not have Celiac Disease often feel much better on a gluten-free diet, they are avoiding the folic acid that was put in the wheat flour. Without the folic acid mucking up the methylation system, T4 gets converted into T3 much more than when the folic acid was needing to be processed.

      If you can not convert folic acid into folate well, then your body will not have the correct amounts of folate to go with the B12 and B6 the body needs for the nervous system to operate properly… and you get really tired. Your energy levels drop, your brain cells misfired and thinking gets foggy.

      And in the brain ….. it has to change the T4 into T3 in the brain, in order to make dopamine and serotonin. If your brain does not have enough serotonin and dopamine available, then it can not dampen pain signals…. and you get achy. And after enough time lack of T3 will cause the achiness to become outright pain, and you will start asking for your physician to prescribe pain medication to you, so you can function and get to work.

      Your doctor may be depending on your body converting T4 into T3, but your body may not be converting enough, due to the pesky MTHFR varients C667T and/or A1298C. You could have one copy of each varients. Most people who do not feel well have one copy, and people who get really sick are most often found to have two copies of the MTHFR gene varients C667T and /or A1298C.

      I have two copies of C667T, and I was on three different pain medications at the same time at one point in time, and my pain level was still at a constant 8-9.

      When they finally gave me enough T3, four Cytomel 5mcg a day, (due to a new endocrinologist stopping my two times a day 5mcg Cytomel, my hair falling out two days later and me crying non-stop from sudden on-set severe depression from a lack of T3)…. My entire world changed. In three days of taking Cytomel 5mcg four times a day, my pain level dropped from excruciating 8-9 level non-stop, down to a 2-3 pain level, and I was able to cut the amount of pain medication my pain management specialist was giving me in half. Down to a half tablet of 75mg Nucynta every 6 hours, from the whole tablet every 6 hours I had been taking.

      I was curious why the T3 reduced my pain, and found the answer in a basic endocrinology medical textbook I read on PubMed. It clearly in black and white stated that ” when T4 and T3 blood levels are raised into mid-range, pain levels will drop”.

      I had suffered for decades with my T4 and T3 at the low end of the so-called “normal” range, and Endocrinologists are taught right in school that if they get T4 and T3 into mid-range, that their patient’s pain levels will drop dramatically. Just let me say, I wish I could strangle all the Endocrinologists who let me and other people suffer in pain, because they are too chicken to get the patient’s T4 and T3 into mid-range…because it might depress TSH levels. To hell with TSH levels, when you are in pain, give me enough T3 to get into mid-range so my pain levels will drop to a tolerable level I can function at.

      So, you can go gluten-free in order to avoid folic acid, avoid multivitamins containing folic acid, reduce the chemical load your body has to deal with by not using scent things like room fresheners, scented dryer sheets, etc and then see if your T3 improves, but you need T3 bloodtest levels beforehand to compare with. You can get the MTHFR bloodtest to see if you have these gene varients, it is a inexpensive single gene test.

      You can also see if your problem is related to suddenly developing Celiac Disease, it is another simple, quick bloodtest, as Celiac Disease will make it harder for your body to work properly. Celiac causes your intestines to be more permeable and you could absorb food and waste particles not meant to be absorbed, which will muck things up.

      But my bet is on your body not converting enough T4 into T3. Lack of T3 covers all your symptoms. Just harass your physician until they order the full thyroid panel, if your Endocrinologist will not order it try your primary physician. Most doctors will finally order the test just to get you to shut up and get you out of the office.

      That is how I finally got the Celiac Disease bloodtest done, we argued, he said my gastroenterologist would have found the Celiac Disease when he scoped me, and I finally said if it came back negative then I would pay for it out of my own pocket. It came back positive and my doctor wrote me a letter of apology, which I still have framed on my wall. Along with two other letters of apology from other physicians. Sometimes you just have to be in their face, and not take “No” for an answer. Sometimes the physician needs to think “zebra” instead of “horse”. And a patient often knows something hunky is going on, so just keep prodding your doctor to do more.

  50. I have been on 200mcg of Levo for many years. Total T3 was 88 and Free T4 was 1.16. TSH 2.27. I also had a TPO over 400. I felt horrible with chest pains and anxiety attacks. Dr checked my heart and other things to rule out. The doctor wanted to put me on anxiety medication. Which I refused. I know from being on this medication for so long it’s the medicine or my thyroid making me feel this way. I went to a natural path doctor who gave me desecrated hormone. So far the anxiety attacks have decreased however my TSH is at a 32.38, T4 is 0.731, and T3 4.85. Just seems like there is not a dose of the desecrated hormone will level this out. If we raised the dose my T4 would be good but that would raise my T3 well over the normal range. Maybe I need to go back to the Levo with a small dose of the T3 added. This is so frustrating.

    1. RM…I think you mean Desiccated Thyroid Hormone…not Desecrated. However…HD has certainly Desecrated Both Naturopaths and the Hormones they offer. 😉

  51. Hi and thank you for this article. It’s interesting.
    Do you think that there can be withdrawal symptoms to decreasing the Cytomel after more than 10 years of use? I was put on it while in depression and being so tired from the antidepressants, but now that I have weaned myself off the AD, I have crazy insomnia and some of the symptoms of cytomel overdose, but when I have tried to decrease, although it helped at the beginning, the symptoms ended up being worse. Is it possible that one needs to go REALLY slow decreasing as some need to go really slow increasing?

      1. Thank you for your reply HD. I am glad that someone confirms what I have experienced, after my doctors denied the possibility. Do you know of any known method to minimize those withdrawal effects while lowering T3 dosages, on a very sensitized system? (Time table? Quantity?)
        Thank you!

        1. I’ve weaned people off T3 over the course of weeks to months, just depending on how much they took and for how long.

          1. Were your patients successful in cutting in exact halves the 5mcg cytomel tablets or were they using other methods? I have a really hard time doing that and I think it’s quite important that we get the exact amount of T3 every day, especially when weaning off?

          2. Cutting those 5mcg liothyronine pills can be tough, I agree. Many people report that they just crumble, depending on the manufacturer (I don’t know of any particular manufacturer that is better than another when it comes to that). I just tell them to do the best they can to get the crumbs – not ideal, I know.

  52. Thank you for your answers HD.
    Do you think too much of cytomel (or cytomel even if not too much) can cause severe insomnia? Even if in theory the T3 is gone from the blood during the night?
    Thanks, this helps a lot.

    1. Too much T3 can cause insomnia, but usually I see this with people taking T3 late in the day. It doesn’t seem to be much of an issue if taking it early enough in the day at a reasonable dose.

  53. So I was reading the guidelines study mentioned in the article…which by the way I think is an excellent paper. It kind of comes to the conclusion that they don’t exactly know why FT3 is lower in T4 mono-therapy than say someone without a thyroid issue, and are not sure if that’s an issue or not. So I find that’s quite interesting. I also see a lot of folks who are on NDT or combo therapy end up with high FT3 and lower FT4 (than say someone like me on monotherapy). So that’s also interesting. Did any other studies get created to cover some of these mysteries mentioned in that study? I’d like to see that paper revisited or aspects of it investigated.

  54. so my question comes, I have been on levothyroxine for 30 years, on and off. my previous doctor, kept taking me off and putting me back on. I am on synthroid, .112. My TSH has been going between .151 and .5 for the last couple of years… so low to below threshhold, but I have been getting the symptoms back of hypothyroid for the last 6 months – hair thinning out, tired, cold, etc, even though my TSH is low. I called my endocrinologist, and she told me my tsh was fine, so it wasn’t my thyroid. After this long, I know my symptoms. I finally broke down and convinced my dr. to try me on T3. Also for the last couple years, I have been having burning sensations in my arms and legs. Anyway, she agreed to let me try, but finally checked my free t4 and free t3. My free t4 is at 17 (out of 19) and my free t3 is at 3.2 (below low-normal of 3.3) During my trial, the burning has let up a little. It is not gone, but it isn’t quite as intense. I can’t measure, other than it isn’t keeping me up at night. But the endocrinologist does not believe in T3, probably because of things that you talked about above. It is frustrating. I am wondering if lowering my dosage of levo would help. but I want to lower levo, and increase T3. Like I said, at this point, I know my body and know my symptoms, but drs are really not into patients directing the conversation. again, it is frustrating. I am screaming for help, but nobody is listening. I have a friend who is a pharmacist. I asked her yesterday, how many people in your pharmacy are on cytamel? 1. Out of all the people who have prescriptions at her pharmacy (a busy pharmacy) 1 patient. Sometimes I really wonder how I will go the rest of my life like this. This is not living, it is surviving. My doctor is willing to prescribe cream for the dry skin, prescribe antidepresants for depression I don’t have ( I am exhausted, and have some pain from the burning, but not depressed), started to look up stuff to help me stay awake during the day… anything but treat the source, just the symptoms. How does this help?

    1. You may need to keep looking for an endo more experienced in combination therapy. It could be a bit hard to find though. Still, it’s worth checking for someone who can help. I have not tried adding T3 yet, but I think I will likely need to at some point. I’ve found adjusting diet and avoiding processed food and processed sugars has helped quite a bit.

  55. Thanks- the original post is informative and the fact that there are still on-going comments speaks to how much misinformation there is out there about appropriately treating thyroid disease. When I was first diagnosed almost 15 years ago, especially because it was taking a long time to feel better, I read all those alternative thyroid treatment sites and found a doctor recommended for “progressive” views on treating thyroid problems. That doctor, who was not an endocrinologist, could have done some serious damage with her philosophy that all that mattered were symptoms and actual lab results didn’t interest her. The only test she did, in fact, was a bone density baseline– which I understand now was to make sure that as she progressively increased the dosage she could be sure I didn’t develop osteoporosis (in my 20s!). She kept increasing my T4 dosage and if I recall correctly added T3. I developed severe GERD, which presented as a breathing issue and eventually, when I suggested to her that the GERD was a result of over-medication, she tried to insist that I cease taking all medication immediately. I pointed out to her that while she may treat plenty of patients without lab results indicating an actual thyroid problem– I did have such documentation. I mention this story because there are plenty of doctors who claim to be “helpful” but any thyroid treatment that doesn’t include testing thyroid levels should be considered highly suspect.

    I rectified that situation by finding an actual endocrinologist who I was able to list as PCP— I still miss working with someone as knowledgeable and helpful as she was. And from there I was on T4 and a very small dose of T3 ….

    Fast forward about a decade and after I became pregnant, my current PCP took me off the T3 because she clearly went to medical school in the era referred to in the article– particularly a belief that even a small dosage will destroy the heart– and I still see that doctor.

    I found this site because as probably many patients experience as they age– an inexplicable shift in lab results — with a new pattern of low free t3 alongside normal free t4 and TSH. I’m due for new labs and am curious what the reaction will be if the TSH is now too low, even if the free T3 is just in the right range, so even though I haven’t missed the T3, I am wondering if it may be beneficial to introduce the topic but also know that I may face resistance from the PCP.

    And for that reason, the original post from 2017 is the most informative and down-to-earth post I’ve seen about Armour and T3 and also the best approach to introduce the topic with a care provider.

    I think it’s particularly difficult with thyroid disease because there are so many aspects of health and wellness that are wrapped up in the functioning of that tiny organ — and it’s hard not to believe that the answer to feeling well is going to be solved with just the right dose of medication—but even that can be a moving target.

  56. I have Graves’ Disease and had RAI 10 years ago and I’ve been hypothyroid ever since. I have been on both T4 only and combination therapy (NDT). I am now on T4 only.

    But the strange thing is, that my TSH has been suppressed ever since my RAI, no matter how high or low my FT4 and FT3 are, even when they are clearly below range. Why is this? And how common is this? I never got any explanation.

  57. You lost me at Lyme being an imaginary disease. You are woefully ignorant. I imagine you also don’t believe in Myalgic Encephelomyelitis/Chronic Fatigue Syndrome. Shame on you. There is no excuse for your lack of knowledge.

  58. Very interesting information, thanks; however; now I’m more confused. I have Graves Disease and only have a tiny bit of thyroid left after receiving radioactive iodine. I’ve been on synthroid for 30 years and never really felt well and have always had weight issues since the procedure. A functional medicine doctor put me on NP thyroid about two years ago and I must say do feel better. However; the need to increase the thyroid meds tends to put me into arrhythmia as I do have A-Fib. TSH is way below normal, yet I have still gained 10 lbs. I’m so frustrated and I have two different doctors telling me two different things. There are no endocrinologists in my area so I’m at a loss of where to turn for help. I guess my question is if it is ever normal to have such low TSH for so long? I don’t want to be doing something that will hurt me in the long run. Thank You!

  59. I appreciate your article. I was misdiagnosed as having that fake “Chronic Lyme Disease” thing, and it was only through that experience that I learned to properly discern information on the internet. I was fortunate enough to sort through my labs and realize that I had a thyroid problem (autoimmune) and that my symptoms were from not treating the thyroid on top of taking unnecessary (high dose) antibiotics for “CL.” I now try to serve as a patient advocate for those that think they have CL. I have a hard time trusting any naturopaths and I look up quackery often. I have become a very science-based gal. Having said that, the people that actually saved me from Lyme were a group of thyroid patients on a support group that is wrought with lots of claims of Armour, NatureThroid, etc. being the best method of treatment. It is hard for me to argue with the very people that saved me from Lyme, but I know that their claims lay in the same sort of reasoning as those of Chronic Lyme. When I was initially diagnosed with Hashimotos, they recommended I add Liothyronine to my dose of Synthroid. I have to admit that my labs looked pretty stellar once regulated, but I continued to have this very small symptom of creepy crawly feeling on the skin on my legs that I couldn’t shake. My very science-based doctor (yes, I had learned by then) told me we could try a trial of T3 and voila! That did the trick. I don’t think that I show in my labs any sort of conversion problem, but I do have to admit that it worked. Placebo? Maybe. I had been pretty hard on myself not to believe in quackery by this point.
    Now I am in a different state and have a new Endo and she is very much a non-believer of T3. Recently, I increased of my dose of synthroid (just because I was slightly run down and gaining weight) and my TSH lab showed 0.29 on a 0.28-4.0 range after a month or so on the increase, which is very low for me. I started having palpitations, anxiety, and dizziness. She said it wasn’t my T4 dose increase, but my T3, and that I should stop the T3. I had been on T3 for three years, so I have a hard time believing this. I feel she just wants me off the T3. So I stopped the T3 (I would be happy not to have another medicine cost anyway) and lowered my dose of T4 back to what it was before the increase and have been having some air hunger. Could the stopping of the T3 cause air hunger? Or just the ups and downs of the dosing? Or just being low on T4? I have a lot of people saying stopping T3 will cause air hunger, but I really would appreciate some scientific studies related to air hunger and thyroid.
    I appreciate your article. I would just add that it is also important for endocrinologists to admit that thyroid deregulation can cause all kinds of serious symptoms. Had my endocrinologist admitted this at the time, I would not have been taking in by a quack lyme doctor and I could have been easily treated with thyroid hormone. Thyroid issues can sometimes be very tricky and very serious! I find that many endocrinologists skim the subject of thyroid issues. We need more thyroid specialists.

    1. Hi Dee, I wrote the earlier comment about a Dr who just kept upping my T4 dose without checking blood levels. I developed GERD as a result. That sounds like what you are describing as “air hunger”, but maybe not. I did not know it was GERD, I thought it was asthma and my PCP even put me on an inhaler before referring me to a pulmonary specialist, who quickly determined it was GERD. I cannot remember if I was on T3 at the time also or not.

      Getting the dosage to the proper blood levels helped resolve the issue. At times, adding other hormones (for example hormonal birth control pills) could set it off dore as well.

      The feeling is like you are trying to breathe in but can’t get a full breath, right?

      If you cut out the T3 and the T4 is at an appropriate dose, evaluate other causes such as diet, not smoking, etc.

      Hope that is helpful.
      A2019

      1. Thank you for your response! I have heard that GERD (and associated breathing issues) may be caused by thyroid imbalance. This is what I am primarily focused on, so I appreciate your experience. I have noticed a tightness in my stomach as well, but no real heartburn or symptoms like that. I do notice that I burp when I am having the air hunger, which seems to help. The problem for me is that I started getting this air hunger when I was over medicated, but now my TSH was recently (only about a week and half later) found to be at 9.4. So I went from 0.29 to 9.4 in a matter of a week and a half! I have read studies showing that both hyperthyroidism and hypothyroidism has caused air hunger in patients. I now don’t know whether it is because I cut out the T3 and reduced my dose (and therefore low in thyroid) OR if it is because I am just now coming down from the hyper symptoms that started all of this. My endocrinologist refuses to acknowledge that it may be thyroid related (even though it started along with the other hyper symptoms). I understand her stand on this, as there is so much out there that is incorrect information, but I think it is also very important to listen to a patient’s symptoms (and when they started!).

        I went to the ER and they tested my heart and lungs, I carried a heart monitor, and I am having a CT scan of my abdomen to rule out any obstructions, etc. Having had bad symptoms when I was first diagnosed with Hashimotos (all which resolved with thyroid replacement), I tend to believe that it is simply my thyroid. It would be so helpful, however, to have solid studies that back up my thoughts on this. This is where I feel endocrinology is failing thyroid patients. I want to be smart, science-based, but there simply is not enough information on thyroid related symptoms. My family doctor agrees that it could be related to my thyroid, but also is being smart by doing the CT scan. In the meantime, I suffer with an uncomfortable and concerning symptom.

        1. Hi Dee- A week and a half is not long at all. I can’t remember how long it took me to feel better after I lowered the T4 and T3 doses, but it was more like a month *at least*. I was prescribed similar to Prilosec, and something like that can help. Also in the short term being even more attentive to keeping coffee drinking and other irritants of GERD minimal.
          Absolutely do what you’re doing and make sure it’s not something more serious, but if it turns out to be GERD, be a little patient with it– just lowering the dose doesn’t fix everything magically.

          1. A-2019, Actually I was about to ask that exact question. I have only been on the lower dose for a couple of weeks now and know that it takes time to regulate, so I did wonder how long it took for your symptoms to subside. I am trying to resist the temptation to raise the dose. I will be careful with irritants (I love coffee, for example). And will ask my doctor about GERD medication in the meantime. I appreciate your comments!

    2. Dee, great points throughout your comment. I can’t say that I’ve ever seen much written specifically about air hunger – probably because that sensation could encompass symptoms of many etiologies (cardiac, pulmonary, anxiety, etc).

      1. 83ug Selenium plus 600mg Myo-inositol helped in subclinical Hashimoto’s in this 2017 journal article: “Myo-inositol plus selenium supplementation restores euthyroid state in Hashimoto’s patients with subclinical hypothyroidism.” available at PubMed.
        It should be considered that some 97% of hypothyroid patients are suffering from Hashimoto’s (sorry, I can’t find where I read that figure), many undiagnosed because a rigid endo is only concerned over the numbers. These endos don’t much look at the subclinical aspect nor much order antibodies testing.
        T3 and hypothyroidism were taught in Australian med schools through at least the 70s so docs of that vintage are more open to considering T3 therapy alone or adjunctive with T4.
        it is common knowledge that hypo- and hyperthyroid can result in depression, anxiety/panic, insomnia, and other conditions unmeasurable, insoluble, and intractable in many patients. We need endos & GPs who listen to their patients’ symptoms and act decisively and with compassion.
        Some patients take multiple T3 sustained-release doses every day, dispensed by compounding pharmacies. I doubt those are as effective for depression as straight T3. Readers may want to refer to Paul Robinson’s books. (Full disclosure: I take T3 SR, no effect on depression!) The author, not a doc, has interviewed literally thousands of sufferers who are not coping on T4.
        He has found that at least two up to five T3 doses are required for most patients and would disagree strongly that Liothyronine 2.5-10 ug would be sufficient for nearly anyone. Look at the enormous variances in just getting one’s T4 dose right. It’s personal trial and error, the way we used to do science in the old days. Patience, of course, is hard to find when one is feeling so unwell.
        I’m back to the Barnes method: If one’s body temp is very nearly 37° C, one’s thyroid levels are right, whether taking T3 or T4. That may not mean a patient does not have all sorts of other inscrutable symptoms, some of which may be the result of Hashimoto’s or comorbidity with other autoimmune diseases such as hypoadrenalism. Most maddeningly, many of the symptoms of these are identical!
        Yes, we need more GPs & endos who think of themselves as thyroid docs. That’s a speciality we find in precious few doctors.
        I had great hope in the only functional medicine MD in my area. My contact was too brief to determine is he was a duck (quack!) or not but he was certainly in it for the money.
        (I have reread all the comments & replies again today. Forgive me for replying to several posts here at the same time.)

        1. I did review that 2017 study in this post: Selenium and the Thyroid – Secrets Your Naturopath Doesn’t Want You to Know

          As for T3 doses, remember that the physiologic ratio of T4:T3 in humans is somewhere in the neighborhood of 15:1, give or take. When people recommend that hypothyroid patients push their T3 doses up beyond a total daily dose of about 10mcg (maybe slightly higher in rare cases), it usually means that the patient’s tissues will be exposed to higher than physiologic levels of T3. Over the long run, that could be bad for the bones, heart, muscles, etc.

          I have no doubt that depression could improve for some people at supraphysiologic T3 doses – because T3 acts as a stimulant at those levels. So let’s be clear: high T3 doses are a drug therapy with potential serious side effects – not a safe form of hormone replacement therapy.

      2. HD-
        Thank you for your reply! I was hoping that you might have come across some studies on this. I appreciate your article.

  60. might it be possible for tissues to be resistant to t3 rather like insulin resistance? so in rare cases these high doses of t3 (75mcg + ) are helpful because these patients have cells and tissues that have become “hard of hearing” for some reason. i belive this is the main suggestion made for trials of t3 therapy for people with fibromyalgia.

    1. Think about it this way: with insulin resistance, before hyperglycemia/diabetes develops, insulin levels can be quite high while blood glucose remains normal. The high insulin levels are able to overwhelm cellular receptors that are “resistant,” thereby causing enough uptake of glucose from the blood to keep the blood glucose normal.

      If T3 resistance was a “thing,” (outside of genetic syndromes that I’ll touch on in a second) then before the onset of overt hypothyroidism, T3 levels would be expected to be high, while the TSH would be normal. I don’t know of any data that have shown that to happen.

      There are syndromes of thyroid hormone resistance (TR-alpha and TR-beta), which are VERY rare and would not be relevant to anyone with garden variety hypothyroidism. These syndromes typically present with elevated T4 and T3 levels, with a TSH that is mildly elevated or inappropriately normal. There is also an x-linked syndrome in which the MCT8 thyroid hormone transporter (the thing that allows T4 and T3 to get inside the cell) doesn’t work, but that manifests only in males and is obvious from a very young age, given that the broken transporter does not allow for T3 to get into brain cells, causing severe neurodevelopmental problems.

      1. Thank you for answering this! This is exactly the sort of thing you find in patient groups and on the surface it always sounds somewhat plausible so the myths spread!

  61. I was diagnosed with hypothyroidism & reverse T3 syndrome 6 months ago.

    After trying armour thyroid for a few months, my condition worsened as my body was not converting the T4 to T3. I was switched to a T3 only protocol. I felt no difference on 175 mcg of Liothyronine.

    Further tests were done & it turns out I have a rare syndrome called partial peripheral thyroid resistance. Some of my organs & tissue are not absorbing the T3. Today I am on 300 mcg of Liothyronine & expect my dose will need to increase again. For those people who are on high doses of T3 without relief, I urge you to get tested for this. I’m still on the road to recovery & imagine it will be a long road ahead but at least now have direction!

          1. For those following this thread, I have not heard from Miriam regarding her unusual diagnosis. Although I have no knowledge of her situation, I feel I should make it clear to readers that I have never heard of that diagnosis, nor have I ever seen a mainstream physician use the dose of liothyronine she describes.

          2. Hi. I’m not sure how to e-mail you without this going on the thread. This is however the second doctor I’ve been to as I wanted to get a second opinion.

            The first doctor was an endocrinologist in NYC who got me up to 175 of liothyronine. I then went for a second opinion to a very well known neuroendocronologist also in NYC who slowly increased me to 300 mcg. I take this dose with an extended release beta blocker.

            I agree that this is incredibly rare so wanted to see if anyone else out there had a similar diagnosis or was also on such a high dose of liothyronine.

  62. What about the hypothyroid patients who have been on levothyroxine for years and haven’t gotten better, in fact in some ways I’ve gotten worse (weight gain, exhaustion, still have depression on and off). What do you tell those patients? I’m tired of doctors acting like they know everything and saying that this medication works for everyone when it obviously doesn’t! Some doctors believe t3 can help others don’t, it’s really frustrating for the people with hypothyroidism who aren’t sure what to believe and are still sick.

    1. I agree with you, Ashley – it’s really frustrating for people who don’t know what to believe and still feel poorly. Many of the posts throughout this site touch on that subject. Sometimes it is your thyroid, and sometimes It’s Not Your Thyroid.

      As a doctor, I have no problem telling someone “I don’t know,” and I believe all of us should be able to say that. The problem is, sometimes we do know – and the patient knows too, deep-down – that there are lifestyle issues that need to be addressed. Obviously, this does not apply to everyone with hypothyroidism who still feels poorly, but it does apply to many. Sleep quality/quantity, diet, exercise, and stress management all need to be optimized for optimal health. I think most people think they are “close enough to good enough,” as a wise frequent commenter on this blog has written (thanks, Sadie).

      1. I still find myself in an awkward position here, but have to reiterate to HD that it is important to also not play the complete opposite of the field. In other words, there is an article “It’s Not Lyme Disease” which I use quite often as an advocate against this supposed Chronic Lyme Disease. However, having JUST been through an awful experience with my own endocrinologist, I must point out that a doctor cannot always immediately take the stand that it isn’t your thyroid, especially being that the symptoms are so non-specific. I find with my current (but about to be fired) endocrinologist, there is the thought that if it isn’t the standard symptoms, such as weight gain and fatigue, that it can’t possibly be thyroid related. When I went to her for the first time, she told me that a lot of people have symptoms that are “in their head.” I think that she comes immediately from that very strong opinion, and has a closed mind. Now, just to give you a little more to my recent story, my dose was increased a few months ago and I started having heart symptoms (palpitations, dizziness, anxiety, weakness). I went in and found that I was 0.29 on a 0.28-4 range TSH. I had never been that low and my family doctor said that it most likely (see, I love her- most likely) was my thyroid and to consult my endocrinologist. My endocrinologist said it wasn’t because of my recent increase that made me over-medicated, but rather the fact that I was on T3 (which had not been increased and I had been taking for years- a small dose of 5 mcg). She STOPPED everything for a week- both my synthroid and my T3. I then started having Dyspnea about 2-3 days later and when I called (on vacation from Canada), her assistant told me she said to go the ER because this could not possibly be thyroid related. This cost me a bucket of money and a lot of worry. I had heart and pulmonary issues tested in the ER (nothing found) and then came home from vacation and my primary doctor said that it could still be thyroid related and yet wanted to rule out other things (see, smart doctors operate like this). I then had a heart monitor, blood work, and a CT scan of my abdomen area. Nothing found. I had resumed my lower dose (before the increase) and started getting very slowly better and better each day. I am now almost regulated and at the same time the Dyspnea is almost gone. My family doctor does feel this is thyroid related. I guess my point in saying all of this is that (as you remember) I am a very science based gal. I think it is important for everyone to continue to search for the true causes of their illnesses, and not to jump the gun and believe in a fake disease. However, I find in endocrinology, the doctors tend to be overly skeptical and jump the gun in the opposite direction way too soon. Could my Dyspnea be caused by other things? Yes. We will research this. Could my Dyspnea be pure anxiety? Yes. We continue to leave this as an option. Could my Dyspnea be thyroid related. YES! There are known studies that point towards thyroid issues and Dyspnea. Should my thyroid doctor have given me that absolute and then left me on my own. Nooo. And so I guess it is important for this message to get across to doctors to ALSO be open minded to the fact that sometimes people (like me) get really severe or even weird symptoms associated with their thyroid and sometimes people (like me) are still in range, but have to be within a very small area within that range to feel well. I think in order to get their message across, doctors tend to be very firm with this idea of other causes, but I think the way that my family doctor handled it was much more competent and scientific in methodology. In summary, I strongly agree with the idea that patients need to fully embrace the true cause of their symptoms, but I also think that the doctor needs to be just as open-minded about the possibility that it can be thyroid related.

  63. Way back in 2010, I was diagnosed with Papillary Thyroid Carcinoma and had total thyroidectomy in 2011. I had iodine therapy and I am free of the cancer now. I’ve been put on Levothyroxine since the big surgery. Until a few months ago, when I visited my family doctor who is also a cardiologist for a check up, he suggested me to take T3 supplement. According to him, T3 is more important compare to T4 and it takes longer for T4 to be activated compare to T3. I’ve been taking T3 and Levothyroxine since then. Recently, I feel like my memory is worse, my language and speaking is sometimes stirred up (which is unusual and had never happened before) and simple math like addition involving a bigger number is a big challenge to me. I came across an article (http://www.tiredthyroid.com/rt3-7.html) saying how too much T3 is not good for your brain. I am worried. I hope someone could give me some insight about this issue.

  64. I ended up in the ER after being on Armour for about a year. Had been taking one grain, increased to 75 mg for about two weeks and had an episode of tachycardia along with soaring BP. Was having similar attacks almost daily for 6 weeks even though I was only taking 25mcg of Synthroid to rebalance, went back into hypo.Fast forward, now on 50mcg of Tirosint doing okay but have fatigue. Doc tried adding 5mcg of cytomel, felt okay. Increased to 7 mcg and I had another tach attack one week later. TSH is normal at 1.05 with a low normal t3 2.4. What the heck…..Going to stay on just 50mcg Tirosint for a while. Scared to do any more of anything after those attacks !!! Also does anyone else feel Tirosint is stronger then Synthroid at the same dosage ? So want a SAFE solution..

    1. Alice, I am waiting to post my journey until I am stable. But I have been on Tirosint for about 4 months. I have had life-long digestive issues and it appears that for the first time in a long time (knock on wood) I think I am stable. I do not think Tirosint is stronger than other T4 medications but I think it is absorbed better. I am currently taking 88 mcg of Tirosint and 5 mcg of T3. I have been weaning off T3 but did up my dose of Tirosint which gave me a “normal” TSH…first in years. I am relying on the generosity of samples right now because my insurance does not cover Tirosint. If you consider HD’s ratio of 15-1, I’d say stay at the 5 mcg of T3 and up the Tirosint to bring your TSH into the normal range. Good Luck.

      1. Thanks Celeste-It helps to see what other’s have experienced with all this stuff. I’m starting an increase tomorrow of the Tirosint, an extra 25 mcg, total of 75mcg . Stopped the cytomel as my endo doc really doesn’t like it. Thinks t4 is better in the long run with better results. Here in the states there are mail order pharmacy’s that have special coupons for Tirosint, and deliver free of charge. Very affordable if you can do it. I do prefer this brand for sure, don’t trust anything else. Had bathroom issues with Synthroid (-:

        1. Hope, Alice, you will let this community how you do with your new protocol. My Endo gave me information on Highland Specialty Pharmacy in Hattiesburg, MS, who can fill prescriptions for Tirosint at $120 for a 90 supply. When I am stable long enough to feel comfortable ordering 90 days worth, I will look into it further.

    2. What always amazes me is we flood the human body with a single dose or two of T3 and expect that to work, it is like flooding an engine with gasoline, the car coughs, bucks and then dies. Thankfully the human body does not die, but it warns you not to do that again by having a heart arrhythmia or anxiety symptoms, etc.

      I found this out when I was put on 5mcg four times a day, in addition to the 1/2 tablet of 112mcg of Synthroid I normally take. About 30-60 minutes after taking 5mcg of Cytomel my body temperature would spike from it’s normal of 96.2°F up to 99.0°F and I would be feeling way too hot, stay there about one hour, and then drop back to 96.4°F and I would be cold and freezing again for hours, until the next pill was due. After a few days of this, it was obvious I needed the T3 but I was getting too much at one time. Afterall, the body normally makes a very tiny amount of T3 here and there throughout the body as needed for the different processes requiring it, converting hormones, converting vitamin forms, detoxing chemicals and metals, making dopamine and serotonin in the brain, etc.

      I never do well on any slow release product as my intestines are so messed up from years of suffering from having undiagnosed Celiac Disease, so the solution for me was to cut up that 5mcg pill and take a smaller amount at a time. I started out with 1/2 tablet of 5mcg Cytomel every two hours and for awhile that was working well, and my temperature was 98.5°F steady. Then my temperature started to go up, then down to freezing again, and so I decreased it to 1/4 tablet of 5mcg Cytomel every hour, which is what it is at now and my temperature stays a steady 98.2- 98.6°F. I have been dealing with my temperature always being 95.8° to 97.2°F for decades, with dry itchy skin, constipation, and all the rest of the Hypothyroid symptoms which are now resolving nicely.

      All that has gone away, plus my pain levels have dropped to almost nothing (when they were a constant 8 to 9 before), and my IGF-1 which is only 100 with my daily injections of human growth hormone is finally rising above 150, so my pituitary gland is functioning much better and finally making more HGH of it’s own apparently.

      I have not lost any weight, but thyroid medication is not meant for weight loss, however it is now much easier to exercise and no longer be wiped out for 3-4 days afterwards. I can spend an hour or two exercising and feeling great afterwards when leaving the gym. My Fibromyalgia pain is almost nothing, a 2-3 pain level is a piece of cake after decades at 8-9 and sometimes I feel no pain at all, which is amazing. What a huge relief to finally no longer feel like I had just been beatup by a baseball bat, I wish I had known about getting T3 into mid-range decades ago.

      I am no longer exhausted all the time, and sleep 7 hours straight instead of waking up every hour or so, no more tossing and turning, and I now wake up feeling rest and able to face the day. Getting the correct amount of T3 has certainly changed my life for the bettEr. Having to take a piece of pill every hour takes some getting used too, but thank goodness for the alarm feature they have on smartphones, it goes off every hour and makes doing this so much easier and convenient.

      As regards Armor thyroid or pig thyroid, my understanding is the T4 and T3 amounts in it can vary widely, so I would hesitate to take it.

      And if you take T3, then you will not need as much T4, since ideally it is the T4 that your body makes T3 from. In some cases, whether from a lack of enzymes, a gene varient like MTHFR C667T or A1298C like I have, then the T4 does not get converted into T3. So if you take T3, then your physician should think of decreasing the T4 to avoid causing the Hyperthyroid effects.

  65. Hi-
    I have a question about reverse T3. I had my thyroid ablated (recommended due to Graves), like lots of people it took a long time to get a dose of levo that was in the normal range and at that point my endocrinologist was like well you’re good medically, how are you feeling? I was still feeling really tired and cranky, not like ‘myself’ and I had read about T3 and he is old school so he was willing to partner with me and try it. That helped a ton; fast forward 5 years later and 60 pounds more (I am healthy, am a runner and cyclist, could not lose weight with calorie restriction) I reached out to a new doc bc my old one retired, who started looking at reverse T3, my levels are high- 24- in your opinion does it make sense to add more T3? Maybe all that T4 I’m taking is just not effectively converted to Active T3? My T4 is mid-high normal range, free T3 is in the low end of the normal range and my TSH is in the lower end of the normal range? In addition to struggling w weight gain I am also feeling really tired and a bit cold in the extremities.

  66. After reading the article and majority of the comments I can’t help but feel a bit hopeless…i had my thyroid removed in November 2017. The 1st year I was doing fine mostly but gained weight like crazy. In June 2018 I was told I had become diabetic and that I needed to drop carbs and sugar so I did. I went keto (which is an anti inflammatory diet) . I lost 65 lbs and then stalled in December 2018 but at the same time I started having unexplained pains and inflammation, bouts of depression, joint injuries, inconsistent sleep patterns, weird chills at night causing intense pain throughout my body and drop dead fatigue that hits suddenly. I mentioned all this to my endocrinologist and she had labs drawn with T4 normal and TSH normal…here we are October and everything mentioned above is worse with no explanation. My physical therapist for my injured Knee insists that something autoimmune is happening. My primary drew labs to check for lupis and rheumatoid those were negative yet inflammation markers were all high…his response will check you again in 6 months…so basically sometime next year. The pain is making me miserable lack of sleep from pain is making miserable and the only light of hope was a possible issue with T3 or reverse T3…which my endocrin won’t test nor will my primary. So I feel at a loss and tired of hurting!

    1. You have every right to get T3 tested by an Endo. Gluten causes Leaky gut causes inflammation. Use appsTheUteFreeScanner and findmeglutenfree. Keto was a great move but something is causing inflammation. Stress likely a factor. See my post below for tips. Increase organics. Functional medicine more likely to heal you than western. Heal the gut with L-glutamine, Turmeric is anti inflammatory. Rhodiola Rosea great supplement for stress, fatigue, diabetes and weight loss. Just see reviews for a good one.. bad taste so take capsules. Ashwaganda too for anxiety. Lookup. There is hope. lisamarcheseyoung on Facebook to connect you to support groups

      1. The keto diet is highly inflammatory. Meat and dairy are the most inflammatory foods. Fruits and vegetables are anti-inflammatory. Grains are moderately anti-inflammatory.

        Gluten has not been shown to be inflammatory for people without allergies or celiac disease.

        1. …people who haven’t done significant research on Keto shouldn’t comment on Keto… But thank you for your opinion. I have been Keto since June 2018. I have a significant allergy to gluten as it triggers severe asthma attacks. Clean Keto is plenty of healthy leafy greens and yes we eat fruit, moderate protein and healthy fats. It doesn’t mean we sit around eating meat and cheese all day. Moderation is key in anything.

          1. What makes you think I haven’t done significant research on keto?

            There are keto evangelist sites that will tell you anything you want to hear. That’s not research. I suggest you look into the Dietary Inflammatory Index which is the highest quality research on inflammatory diets.

          2. Because your comment is stereo typical. Prior to starting keto I filled my plate with research and I continue to do so reading medical reports, studies and not just what did you call it ” Keto Evangelist” sites, wow seriously? That right there speaks volumes on your biased opinion and that you personally have your own person vendetta against Keto. If you noticed above this is about thyroid not Keto so your personal driven opinion is not warrented or welcome. But nice try trying to to attack something that has saved my life. My diabetes is controlled without medication and my inhaler is no longer glued to my hand. I also can’t remember the last time I had to take antibiotics or prednisone because my respiratory system was a wreck. So thanks anyway and bless your heart…

          3. Ketogenic diets are useful for diabetics but the main benefits are because of the weight loss and many people find it easier to lose weight on a ketogenic diet. However they are difficult to sustain. Many people who claim to be keto are actually just low carb.

            I’m not the one that made the false claim that ketogenic diets are anti-inflammatory. If your research led you to that I would question the sources. Typically these sources assume the only alternative is eating excess sugar.

          4. Still miss informed you are but that’s okay there is one of you in every bunch…bless your heart peace be with you! Have a nice life and try not to troll so much. This is still a thyroid discussion but if you insist and posting pointless nonsense that will make absolutely no difference in the world…be my guest.

    2. The brain needs T3 in order to make serotonin and dopamine, so if you have a enzyme problem, or one of the MTHFR gene varients C667T or A1298C which about 60% of the population have, then your body will have difficulty turning T4 into the T3 it needs. In that case, your pain levels will go up and you will feel more and more pain over time from the lack of T3. Also, you start to feel cold from the lack of T3, have trouble sleeping etc.

      So you are going to have to push and argue with one of your physicians to do a complete thyroid panel which includes T3, free T3 and reverse T3 to find out what the problem is. A simple MTHFR gene test will tell you if you have one or two of the MTHFR gene variants that make converting T4 into T3 just difficult (one copy), or very hard (two copies). If you can not get them to do the tests, then look for a physician who will do the tests.

      Doctors assume the body will turn the T4 into the T3 it needs, and you know what assuming does, it makes a ass out of your physician and you will have to be as stubborn as an ass to get them to treat you right.

      A note about Keto. ….. Many of the low carb green vegetables, and fruits, and especially all nuts and seeds on the diet are very high in oxalates. I went on the Keto diet and developed kidney problems because the oxalates damaged my kidneys from eating spinach and beets and beet greens, almonds, etc.. Many people will develop joint pain, etc from eating too much oxalate. So if you go on-line to Yahoo, there is a group called Trying Low Oxalate (TLO) where there is support and a free list of tested foods by the University of Arizona, and you can even get foods tested if they are not on the list. Oxalates will also cause inflammation. There is a TLO Facebook group also, if you are on Facebook, so check out TLO as they may be able to help you, in deciding if high oxalates from the Keto diet are part of the problem. Lots of people on TLO are doing the Keto diet.

      1. To focus this thread of Alexa’s – since this post is about whether or not to try T3 add-on therapy – I would ask that she provide a medical/journal reference specifically addressing the relationship of MTHFR mutations to T4 to T3 conversion.

  67. T3 is never made in the thyroid. T4 is made in the thyroid and the body converts it. That’s why my doctors, for the past several decades, have usually prescribed T4 only, and I’ve had T3 readings usually in range despite my thyroid not functioning at all due to a radioactive iodine treatment I never should have let them do. That said, having sup-par levels of T3 is a common problem. Best to let a functional doctor treat the root cause. For more watch AskDrKan, especially episode 125 on Gluten removal to improve Hashimotos. Watch Autoimmune Secrets on youtube to learn how to heal.

  68. Thank you Lisa I will look for the group. I am gluten free. I do have a thyroid support supplement coming tomorrow that includes ashwaganda. I did try Ashwaganda on it’s own with no change. I am also trying essential oils and have a turmeric capsule on it’s way as well. New to L glutamine and Rhodiolia Rosea. My physical therapist agreed with the right move on Keto. I was fortunate she actually had a high understanding of it being Paleo herself.

  69. “BTW it’s poorly understood why T3 augments anti-depressants, but presumably…”

    if it isn’t understood, then why are you speculating?

    Pretty much all depressed people are hypothyroid, that’s why it works:

    “Of the mild 66.6%, 93.3% of moderate and all of the severe grade depression patients had low T3 levels. Of the moderately depressed patients 13.3% and 9.0% of severe depression patients had low T4 levels. TSH was increased than normal in 54.5% of the patients and all these patients were of severe grade”
    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2958345/

    “It’s also not clear if there’s a potential to permanently depress normal T3 production with long term use”

    It is an internet myth that taking thyroid long term permanently suppresses endogenous thyroid function.

    1. Standard of care for T3 for depression is a full thyroid panel before beginning treatment and at regular intervals thereafter. I have normal thyroid; if I didn’t, I wouldn’t be on T3.

      That article notes that all their patients had normal TSH. HD has a lot of info as to why TSH is the standard for thyroid testing.

  70. I had mild hypo (looking at numbers), but severe symptoms. I have increased doses the past 2 years. Lately My T4 stays low around 0.77, my T3 never goes above 2.5, no matter how much the dose goes up. My heart rate is always 75 or less, no signs of hyper. I take 90 of NP thyroid and 18mg T3 only slow release. I started at only 5mg t3 slow release. My TSH is ideal now, but my T3 never goes up and little symptom improvement. Why would taking so much T3 not raise my levels (and no signs or high T3)???

    1. Lots of things could be affecting your medication. For example are you storing your medication properly? Humidity , heat and light will degrade your medication, you need to keep your meds in a dark, low humidity, low heat area, like a drawer in your bedroom dresser as long as you keep the room fairly cool. Do not put your meds in the refrigerator, the meds get too cold and when you open the bottle, the meds will absorb extra moisture from the air. If you get a three month supply from your pharmacy, take a a few weeks worth out to put into a bottle you use to for your daily meds. The less you open the main container, the less those pills will degrade.

      My T3 pills are hard as rocks when they come from the pharmacy, but after a few days in a regular pill bottle, the yellow or green ones with child-proof caps, I can easily break them in half. So pills can degrade fairly fast if you are not careful in storing them. If your thyroid pills fall apart easily or crumble to a pile of dust, they have degraded badly and will be a much lower strength, and you will end up with low bloodlevels of T4 and T3.

      My physician orders me Synthroid for my T4, because the generic T4 seems to not work as well for his patients. Generic medications can vary, and studies on PubMed show even a very slight difference in strength can affect T4 and T3 levels blood levels strongly, ask your pharmacy to always give you the same manufacturers when dispensing your thyroid medication.

      When do you take your medication? PubMed studies on the NIH website show you should be taking thyroid medication at least an hour before your breakfast. Patients who took it less than an hour before breakfast, had low blood thyroid levels. Food, Coffee, Calcium and iron were all found in studies to decrease absorption of thyroid medication, you need to wait four hours after any these before you take your thyroid medication, or take the thyroid medication four hours before having coffee, calcium or iron supplements or foods containing them.

      Certain asthma medications, such as Theophylline, will affect thyroid medications, and again four hours are recommended between the two medications.

      If your medication storage and when you take your medications is good, then health conditions can cause low T3. Patients with chronic illnesses were found to have low T3 bloodlevels in studies published on PubMed. The more chronic illnesses you have, the lower the T3 bloodlevels were in those patients.

      If you have IBS, Celiac Disease, low stomach acid or take medication for any of these conditions, or to reduce stomach acid, then these will all affect absorption of slow-release medications. In that case, you should use regular T3, instead of the slow-release T3 form.

      Then there are a few genetic varients which will lower T3, by decreasing T4 to T3 conversion. But there is no cure for those genes, other than taking more T3 and taking it more often, as the body needs T3 in very small amounts over the entire day for the various uses in the different areas of the body.

      Hope you find some of this information helpful.

      1. I do wait an hour to eat and 4 hours for supplements. My Dr has never brought up T3 that’s not slow release

        I do have absorption issues. Have been taking high D (this is good now) and double Iron for 2 years. Ferritin has still only moved from 14 to 28. Stool samples show 40% fat and it should be less than 15% so I’m not making enzymes to absorb food. I take enzymes with meals- but this is recent. Not sure why I don’t absorb anything. I feel like my mom is the same way. At 58, she has no quality of life, B12 so low she can’t hardly walk (refuses shots), has fallen, mental health issues, hasn’t been able to work in a decade, all of teeth have fallen out. Gained tons of weight on synthroid. She eats terrible though. Even though she’s overweight, she’s so malnourished. I’m trying to not get that bad.

        I work nights once or twice a week, so maybe that can cause my body to want to keep t3 the same to “force” me to rest. Just another theory.

        1. The body needs iodine to make T4, so are getting iodine in your diet? It does not matter how much TSH the pituitary gland releases, if the thyroid gland is not getting iodine it will have problems making the T4 your body needs.

          The main source of iodine for most Americans is iodized salt, so if you are using no salt at all due to blood pressure concerns, or using another salt, like Himalayan pink salt that does not have added iodine, you may require a daily iodine supplement. Iodine also is in fish, and fish oil supplements, so if you have none of these things in your diet, you might need to look for an iodine supplement. But be careful not to get more than the daily requirement, too much iodine can be worse for your body than too little.

          My supplement capsule contains 667% of the daily requirement, so I open the capsule and sprinkle a small amount on my food each day. One capsule lasts me a week.

        2. In order to absorb fats from the foods you eat, the body uses bile, made in the liver and stored in the gallbladder, to emulsify the fats in the foods you eat so they can be absorbed. Do you have gallstones or a gallbladder problem at all?

          The body uses the fats you eat to make the bile, it then uses the bile to first emulsify and then absorb the fats you eat. So you need eat good quality fats to make good quality bile.

          What kind of fats are you eating? I use organic extra virgin olive oil, organic virgin coconut oil, and grass-fed unsalted butter.

          Corn oil, and other vegetable oils are too high in Omega-6 which promotes inflammation, so switching to a good oil can help your body make better bile.

          You can also add taking a ox bile supplement, until your body gets better at making bile. Enzymes by themselves will not help with absorbing fats, since bile is needed to emulsify the fats first before the fats can be absorbed properly.

          Low T3 is a condition that is caused mainly by serious acute and serious chronic disease, the body uses up the T3 in the process of dealing with the disease.

          The idea that the body is keeping your T3 low in older to force you to rest, or even to punish you, is not in keeping with what is known about Low T3 Syndrome.

          It looks more like your thyroid is not getting enough iodine to make thyroid hormones in your thyroid gland, and so your major source of thyroid hormones is from the prescription T4 and T3 that you are taking daily. And if you have absorption problems and are taking a slow-release form of T3, then most of the T3 is likely not even getting into your bloodstream.

          A trial of regular T3, instead of the slow-release form, may improve your blood T3 levels. If it does then you will know you need to avoid the slow-release T3, and stay on regular T3 instead. Talk to your physician about doing a trial of the regular T3 a few times a day.

          1. But if iodine was the issue and not enough T4 was being made the TSH would skyrocket?? Doesn’t make sense to me.

        3. About your mother’s B12 problem, a lack of B12 can cause mental problems, along with other nervous system problems.

          You do not need B12 shots to get B12 into the bloodstream. In order for the nervous system to work correctly it needs B12, B6 , and folate. Many people, about 60% of the population, have the MTHFR gene varients C667T or A1298C, which makes it hard to impossible to turn folic acid into folate the body can use. Getting Methylfolate in a single supplement or in a multivitamin gets around this problem. And for B12, a simple sublingual methylB12 tablet dissolved under the tongue, where the B12 can connect to the transport molecule in the saliva, will improve blood B12 levels fairly fast. B12 needs to be attached to the transport molecule in the saliva in order to survive the stomach’s acid environment undamaged. Get the B12 from the mouth and finally into the cells where it can work is a complex process involving over 6 hookups and various transport molecules, but the first step is always attaching to the transport molecule in the saliva. Also intrinsic factor for B12 transport in the intestines is limited and only made in small batches about every four hours, so taking huge amounts of B12 once a day is a complete waste of money. One sublingual tablet lasts me days, as I only chew a small amount of it at each meal to mix with my saliva.

          Even if your mother is eating badly, at least taking a decent multivitamin once a day would help improve her condition.

          Avoid vitamins that contain cyanocobalamin, as it is cyanide combined with cobalt, and no one needs cyanide in their body. Look for the methylcobalamin form of B12, along with Methylfolate instead of folic acid, and B6. Life Extension makes a good multivitamin called Two-A-Day multivitamin that is inexpensive and contains methylB12 and Methylfolate. I use it, and only take it once a day since it is a high potency vitamin. But I still use a sublingual B12, since B12 really needs that transport molecule in the saliva, as I said.

          1. Thanks for all of the info. I do most of this already, but it does give me a couple things to think about. Appreciate it.

    2. The body has mechanisms for clearing out T3, whether it’s from your own thyroid or from pills so my guess would be that your body “wants” your T3 at 2.5. From my own experience I’ve seen this. Cleaning up diet and exercise raised my T3 levels while on Synthroid only and once I added T3 the levels are exactly the same.

        1. Maybe it means thyroid levels aren’t the answer, or at least not the whole answer. I wouldn’t underestimate the stress the shift work could be doing either (I’m a shift worker too)

          1. Yeah, shift work is tough on the body. I’m starting to think myself that maybe thyroid isn’t the whole story either. It’s frustrating. You feel like you work so hard eating, exercising, drinking water, avoiding chemicals, taking supplements etc. to try to feel good. Thanks for the input .

          2. Yep I feel your pain. It’s so easy to get caught up in the hope that something like thyroid is the answer, and it’s disappointing when it doesn’t work 🙁 Good luck!

      1. The hypothalamus in the brain senses how much thyroid hormone is in the brain, if it needs more thyroid hormone in the brain to make neurotransmitters, like dopamine or serotonin, then it releases TRH (Thyroid Releasing Hormone), the TRH then stimulates the Pituitary Gland to release TSH (Thyroid Stimulating Hormone). The TSH travels via the bloodstream to the Thyroid Gland telling the Thyroid Gland how much T4 and T3 to release.

        The Hypothalamus can not tell if the thyroid hormones it senses in the brain are from a pill you take, or if they were made with iodine in the thyroid gland of your body. All the hypothalamus knows is that it needs more neurotransmitters, and to make the needed neurotransmitters, the brain needs T4. And the T4 it gets, it then converts in the brain into T3. It then uses the T3 to make the neurotransmitters.

        Think of T4 and T3 as food the brain needs, it is hungry for food so it sends a message from deep inside where the hypothalamus is over to the Pituitary gland (think of the Pituitary Gland as “room service” in a hotel), the Hypothalamus saying “I am hungry” and the Pituitary gland releases TSH which tells the Thyroid Gland (think of the Thyroid Gland as “the kitchen”) that the brain needs more T4 and T3 (think of T4 and T3 as being “bacon and eggs”). Actually the Thyroid makes alot of T4 (eggs and bacon) and a small amount of T3 (a pat of butter).

        Now you are giving the brain bacon and eggs and butter via the T4 and T3 in the prescription pills, but the bacon and eggs and butter are also needed in other parts of the body as fuel to run those systems. T4 and T3 are used throughout the body in all sorts of different places as fuel.

        So the T4 and T3 you are taking by mouth in a pill are not enough for all the body’s requirements, most of it gets waylaid by other systems before it can get to the brain. Think of it as the room service guy is bringing the food to the room, but when the elevator stops a floor below where he is supposed to deliver the food, someone gets on the elevator. And when he turns to press the button to close the door, that person lifts the lid of the plate and takes half the food he was supposed the deliver to the brain. The delivery guy gets to the brain, pushes the cart into the room (brain) and leaves. The brain gets to the cart, lifts the lid, and darn! only half the food the brain ordered is there. But the brain can only order once a day, so the next morning it tells the Pituitary Gland (Room Service), “hey, I need twice as much food as I ordered yesterday, so tell the kitchen to send double what they sent me yesterday”. And so the Pituitary Gland sends twice as much TSH out to the kitchen ( the Thyroid Gland).

        If you take more T4 and T3 than the brain needed that day to make neurotransmitters, then the Hypothalamus tells the Pituitary Gland to tell the kitchen that all it needs in the morning is some coffee, and so in the morning the Pituitary Gland releases so little TSH that the TSH level is below the normal range.

        But if what you take by mouth in your prescription T4 and T3 is not enough for the brains needs, then your TSH will be higher, more to the middle of the TSH range, as the brain is saying “I am not getting enough food (T4 and T3), send more food in the morning!”

        And if it is sending this message for more food, and the T3 and T4 are still low, then the Thyroid Gland (Kitchen) is not making enough food (T4 and T3) to make up the difference between what you are sending by mouth, and what the brain needs and is requesting via TSH.

        And that can only happen if either the Thyroid Gland (Kitchen) does not have the supplies to make T4 and T3 (iodine being the main supply to make the bacon and eggs) , or the Thyroid Gland is malfunctioning (the stove is broke).

  71. Hello people.
    I had a total thyroidectomy 20 years ago and I have been trying around many different doses.

    I have been shifting bodyweights between 79kg to 95kg, due to bad eating habits and I noticed that the T4 medicine is “required” differently to body weight.
    When I was over weight with 90-95kg, I had combination medicine with 125mcg T4 and 15mcg T3. I felt better on this then single treatment of just T4 medicin with a dose of 162,5mcg.

    Then I exorcised (running 40km a week) and started with intermitting fasting and lost 17kg. I’m now down to 79kg from 95kg (a year ago).

    This also changed my reaction of the thyroid medicine. It was no way to keep my dose at 125 and 15mcg, I was overheating and sweating a lot. Felt somewhat weird due to overdosed Thyroid meds.

    So we lowered the dose to 100mcg T4 and 15mch T3. Now this should be equal to approx: 150-160mcg T4, and close to the recommendation of 1,6-2 mcg per kg body weight.

    I felt fine for the next 5 month of that dose, maintaining my regualr training and weight. Still on 79kg. But.. now after 5 month, I feel that something is wrong.. I believe that some depression is there, not a heavy one but its there.. And I also noticed my “sex” life to be troubled.. Both with the desire and the practical part.

    Why? I have a pretty accurate Idea.
    First, when I was overweight and had combination treatment and the amount of t4 was still enough for the body to convert t4 to t3 when needed, specially on the evening when my T3 wore off in the afternoon (I took my meds in the morning on a an empty stomach). So I did function pretty well with my overweight.

    Now when I’m “healthy” and have exacly the weight I should have, my dose is completely wrong. 15mcg T3 is ok, but once it wears off, my T4 dose is way too small for my body to convert enough t3 for steady life quality 24h. And since it probably is more then 12hours of “non sufficient” t3 hormones (converted) in my body, problems occur.

    So the only way for me is to switch back to basically only t4 meds to ensure that the body has enough fundamentally t4 hormones to convert when needed. That would be according to me, minimum 150mcg t4.
    Then there is no more room for t3 meds, since that would make me hyper in an instant.
    Unless if I would have a dose of 2,5mcg of T3, which I very doubtfully think would make any difference.. Since the body might need this “2,5mcg” (coming from the thyroid gland if I had one) in different timing then when I take it orally.
    So it no way to predict when to take the small amount of T3 to copy the true body natural function.
    The t4 hormone from the meds, can at least “copy” the body natural process up to 95%, since it is basically the same.
    My conclusion is this for me as a thyroid patient without a thyroid gland for the last 20years.
    Make sure to have enough T4 meds before even think about t3 and that being overweight or having the “right” weight has a big role in all this.

    What do you think?
    Best regards
    Michael Le

  72. “On top of that, when on levothyroxine therapy, the blood level of T3 is usually low-normal and sometimes even slightly low. But there has been no evidence showing that these levels correlate with any symptoms.” Given the claim that there are no true hypothyroid symptoms (everything the patient is suffering from could be caused by something else), there never will be any such evidence. If you aren’t looking for evidence, chances are 100% that you won’t find it.

    I realize that one patient’s story is a mere “anecdote”, but when you add up hundreds, thousands, or even millions of similar anecdotes, you might see a trend.

    So here’s my story: I have been treated with levothyroxine for decades. During that time, the only blood tests administered to measure thyroid function has been TSH, which has been in range throughout. Meanwhile, however, my hypothyroid symptoms have piled up. When I asked my doctor to do something about my hair loss, fingernails literally disintegrating at the tips, cold intolerance (including episodes of Reynaud’s syndrome), and fatigue, and also expressed concern about the swellings under/around both eyes, she agreed to a trial of T3. Furthermore, despite being on a low carb diet for over 2 years and exercising 5 days a week, after losing 34 pounds, my weight loss came to a standstill.

    When my doctor administered a full thyroid panel, my TSH was found to be 0.968 (0.320 – 5.500 uIU/mL), free T4 was 1.6 (0.60 – 1.70 ng/mL), and free T3 was 2.3 (2.57-4.43 pg/mL). Now I gather from this article that you believe that my FT3 being below range has absolutely no effect on my health, but my body disagrees.

    Adding Cytomel to my treatment had the effect of relieving cold intolerance, including frequency of attacks of Reynaud’s, healing my oft-broken fingernails, and assisting my weight loss efforts to the tune of an additional 10 pounds lost. I have also noticed a significant improvement in my lipid profile. I am hopeful that if we can bring my FT3 into the upper third of the range, additional symptoms will be relieved.

    1. Every time we increase my T3 dose, by the 2nd or 3rd day all of my symptoms go away. I can make it through work, do the dishes, no depression, normal heart rate, sleeping well, regular daily bowel movements, clear thinking, focused, interacting with my kids, I even feel like I actually “see” sharper. I feel like a normal person.

      After a few weeks, I’m back to normal- lying on the couch for hours all day long, can’t get daily cleaning and hygiene tasks done, depressed, spacing out, taking wrong turns driving normal routes, crying at home and work, constipation, have to pull over and take a nap to make it home from work, etc. I’ve increased my T3 dose from 5mg to 18mg over 2 years and it happens every time. Just increased to 25mg 4 days ago, so today I feel great (my T3 level was similar to post above- 2.2)

      I guess according to the author of the article this is the “stimulant effect”. But what is the solution? I would rather deal with potential effects in 20 years from long term T3 than make it through the next 20 years with zero quality of life. I have to be able to work, drive, and take care of the kids and house.

      1. You may be having the problem I have, my body uses and then inactivates the T3 fairly fast. And since my body also does not absorb time release medication well, it changes how I have to take my T3 medication. I take my T4 in the morning with a 1/4 of a 5 mg Cytomel (T3) tablet. Then every 1-2 hours I take 1/4 tablet of 5mcg Cytomel. It was a bother in the beginning to have to take this little piece of the Cytomel tablet every hour or two, but now I no longer suffer from being cold and can function like a normal human being.

        I have two copies of the MTHFR gene varient C667T which makes it very difficult for my body to turn T4 into T3, so on just Synthroid(T4) my blood tests of T4 are good and my T3 bloodlevel is low to below normal and I am cold and have no energy.

        My TSH will be normal but my pituitary gland does not work well. I say this because my pituitary gland makes almost no human growth hormone (HGH), before going on growth hormone shots, my IGF-1 was only 29. Normal range of IGF-1 is 70-215, and 70 is the bloodlevel of an elderly person close to dying. My endocrinologist never saw a person walking aroundcwit a IGF-1 of only 29 and was surprised I was alive.

        TSH is not a thyroid hormone, it is a secretion of the pituitary gland, and if the pituitary is not functioning correctly then a TSH level is of no use at all. To evaluate thyroid function using TSH is stupid in my opinion, since it is not made by the thyroid gland. If the pituitary gland is working correctly, then the TSH is only a indication of the brain getting enough T4 and T3 to make enough serotonin and dopamine for the brain to function properly.

        I am prescribed 5mcg of Cytomel(T3) four times a day. But if I take a whole 5mcg of Cytomel, my body temperature goes up to 99.9 °F for an hour, and my body temperature then drops down to 96.4 to 97.6 for the next three hours until my next 5mcg of Cytomel is due. So by taking a 1/4 piece of the 5mcg of Cytomel every 1-2 hours, my body temperature now stays at 98.2 to 98.8°F while awake and I no longer feel awful.

        There are other genes than the MTHFR which can affect converting T4 into T3, and affect T3 utilization, so there can be various reasons why some people do well on T3 and other people still have symptoms when taking T3. To tell people that T3 is not effective in correcting low thyroid symptoms is common , however what is needed is finding out WHY the T3 is not helping the individual.

        Sometimes you have to take the T3 in unusual ways, in order to get the benefits from the medication, such as my 1 to 2 hour schedule.

        A side effect of my taking the T3 in this fashion is my pituitary gland is now making more of it’s own HGH, my IGF-1 on HGH shots before taking the T3 was 150, and after taking T3 every 1-2 hours my IGF-1 on HGH shots is now 198.

        My pituitary gland likely does not work well because I have had over 6 traumatic brain injuries from falls and car accidents, and brain trauma is a common cause of pituitary malfunction. So if you have ever had a brain trauma or concussion your pituitary gland may not make TSH properly, thus thyroid monitoring using TSH a suspect and questionable procedure in patients with any history of falls or accidents.

        It may help to have an IGF-1 bloodtest done to see if your pituitary gland is making enough HGH. If the IGF-1 is down, then this may be affecting your body’s use of T3, thus requiring slowly increased doses of the T3 as time goes by. None of these hormones work in isolation, so checking IGF-1 may be a clue to the need to keep increasing your T3 dose.

    2. A few points of clarification:

      – There is a large body of literature looking at T3 levels and symptoms, but the literature fails to show a consistent/clear association between the two.

      – For every one anecdote of someone on levothyroxine with a lowish T3 – who has hypothyroid symptoms that improve with the addition of T3 therapy – I can provide 100 anecdotes of people on levothyroxine with a lowish T3, with no hypothyroid symptoms.

      – The point here is that there are some people with hypothyroidism who will benefit from the addition of T3 to their T4 therapy, but having a lowish blood level of T3 does not help identify this subset. Doing a trial of T3 and looking for a durable response is what identifies this subset.

    3. It seems that yourT4 conversion to T3 is a problem here. In that case its obvious that T3 would have a huge inpact on your well being. How ever, those with T4 to T3 conversion problem are an absolute minority and that itself should be a highlighted own category.

      Most people, like me included don’t have conversion problem, just a problem with setting the right dose based on right weight.

    4. You should be careful in getting T3 above the mid-range level, especially if your body has been operating at the very low end of the range for years.

      T3 is used throughout the body for various hoelrmone, enzyme and metabolic processes , if all these processes have been barely creaking along with only tiny amounts to function, then if you throw alot of T3 at them, then these processes can go into overdrive and overproduce various hormones, enzymes, etc. This will cause all sorts of problems as things go haywire, things that are way worse than a small spike in temperature.

      Being impatient will easily put you in the hospital, you need to slowdown and have patience with the process of recovering from many years of having a very low T3 level. Many people I know have developed Hyperthyroid symptoms once their T3 level got above mid-range, so I would recommend you stay at the level you are now.

      You want to keep slow to allow your body processes to settle and get used to finally have a relatively normal amount of T3 to work with. More is not better, especially if you have been barely getting by on little T3 for do long. Adding more T3 could be like throwing gasoline on a fire and you burn your house down. And babe you only get one body in this lifetime.

  73. Thank you for this Website HD ! This article may be life changing for me….. I switched myself from NDT to T3 meds because of constantly high RT3 and still feeling hypo. For 10 years I have been taking 20mcg twice and three times a day. I now have osteopenia at only age 53. I have never felt ‘well’ and now I’m perimenopause I feel hideous. Having read your article, I will now try find a good Endo and see if I should be on T4 instead. One question I have; Is it normal to have consistently low FT4 levels while on T3 meds ? I’m assuming because I’m taking T3 meds then my body isn’t making T4 now ? Is that how it works ?

    1. I was diagnosed with osteopenia in my 30’s. I had been on t4 meds for 2-3 years and a small amount of t3 for maybe a year. My severely low D3 level since childhood probably contributed to the bone loss. I’m sure my T3 deficiency didn’t help either as I’m a very poor converter. We don’t hear about this as much but hypothyroidism also causes bone loss.

      1. Yeah, I just think I’m so scared to slip back into anything else. And I’ll be honest, with all the change of the medication I haven’t taken very good care of myself and I haven’t been exercising. Even now, I just walked into the kitchen and did a few things and walk back and I feel out of breath. I’m only forty-four and I know I’m out of shape. I was always a runner and an avid exerciser until I got sick. I’m just wondering if part of it is my body is just tired and out of shape and I’m not taking good care of it.
        I just don’t know what to do because when I added the T3, I actually felt like doing things again. I felt like running errands and being out. I hadn’t felt like that in a long time.

        This morning I only took 2.5 MCG of liothyronine.

  74. I’ve been on Liothyronine for over 2 years (31y/o Female), and worked my way up to a 22.5mcg dose + 125mcg Levothyroxine while I was pregnant. After giving birth in Dec 2017, my dose has not changed, based on lab work. My TSH is suppressed, but my T3 and T4 levels have been “optimal” (I see an integrative doctor) and symptoms have been nearly non-existent. This summer, I was pregnant again but miscarried (end of July) and for a short time directly after the miscarriage, felt really good but then slowly had more hypo symptoms and bloodwork indicated a need to increase meds. I increased my Liothyronine by only 2.5mcg and within 5 days I experienced severe anxiety, irritability, and heart palpitations. I do have a history of palpitations, but have always been told they’re not harmful (PVC’s?). I’ve since reduced my Lio to previous dose and also reduced levothyroxine to 112mcg (only two days since that change). Obviously, my body couldn’t tolerate the extra T3, but how come I’m still experiencing the symptoms, mainly the anxiety and palpitations, over a week after reducing T3? I figured with how fast acting it is, I’d feel better by now. Could postpartum thyroiditis set in after a miscarriage and cause me to swing hyper really quickly like this or is it more likely triggered by the T3 dose change? I don’t have bloodwork for another few weeks. Also worth noting, I have only had instances of palpitations while on T3 meds twice, once in the beginning while establishing correct dose, and once while I was pregnant this last time. My menstrual cycles have regulated some and ovulation restored to more normal time frame since starting T3 medication as well so I’m hesitant to cut back or cut it out completely since it has provided fertility benefits and we are still wanting to grow our family.

  75. Assuming one has.. due to aging.. other shifting hormones (perhaps a damaged pituitary) a conversion issue. Clearly is producing thyroid to beat the band based on a TSH of 0.91 (never above 1.0); however, has lower end both T3 and Free T3 levels along with higher levels of RT3 (think 19 to 21). In trying to take T3, a little weight loss (few pounds immediately) but depression, anxiety, muscle aches and oddly a new development disrupted vision (like not blurry? but more a foggy sensation and with a definite decrease in acuity where prescription had actually improved with age, it’s like it’s backtracked to level from 20 years ago.. severely nearsighted except now with this added “fog” layer on top of the nearsightnedness).

    Is there a manner to improve the thyroid conversion process but NOT to supplement ANY form of thyroid itself? Extremely sensitive to anything external. Took forever to get sex hormones kinda normalized. Can’t support adrenals with steroids for example.. totally intolerated. Speaking of.. Vitamin D is likely not good (like less than 30) and same with ferritin (30 or lower but other iron panels are fantastic)

    1. A low ferritin level low iron stores in the body, usually due to not getting enough iron in the diet. The ferritin level will drop first, and as the low iron continues then over time the regular iron test will become low also.

      TSH is a pituitary hormone, if you T4 is in the low end of normal, then the Pituitary is not producing enough TSH, and you have a problem with your pituitary gland. If your IGF-1 is low, then your pituitary gland is not making enough Human Growth Hormone (HGH) to keep your heart healthy. Then you need daily HGH injections, I have had to take a daily HGH shot every day for the last 20 years, without HGH I would have died 20 years ago.

      Conversion of T4 into T3 can be due to having one copy of MTHFR gene C667T or A1298C which drops conversion to about 60% of normal. Having two copies will drop conversion down to 20% , and as we get older cell replication becomes more imperfect, causing aging and decreasing the body’s ability to do conversions of hormones. Nothing I have read will improve conversion, in my case with two copies of C667T, I have to supplement with Cytomel (T3). I take 1/4 of a 5mg Cytomel tablet every 1-2 hours to get around the conversion to rT3.

      You vision problem can be due to cataract development from aging or high blood sugars, you should have your eyes checked. After 45 most people who are near-sighted develop in the other direction, and vision improves for a time. Then either macular degeneration or cataract development can occur after 60. Seeing your eye doctor is the only way to determine the cause and to treat the “foggy” vision you are developing.

      The only constant you can depend on is that nothing stays the same, there us always change and you will need to adjust and deal with it as needed. And as we get older, multiple things will go wrong, and one will affect the other but will not be the cause of the changes. Your vision will likely have nothing to do with your thyroid, it just occurred around the same time, sobyou connect the two.

      Please see your eye doctor soon.

      1. Great information, thank you! I would say my Free T4 is higher end of range while the Free T3 is lower end. I do have the one MTFHR copy: C667T.

        I will definitely see my eye doctor. I just signed up for a VSP vision plan (self insured, currently between jobs).

        Thank you again 🙂

  76. Hello, I’m sorry if this is a silly question, I’m very new to this. You said that T3 acts as a stimulant. Since T4 converts to T3, why doesn’t T4 act as a stimulant too? Thanks

    1. Not a silly question at all. T4 is a long half-life hormone that does not have significant peaks and valleys over the course of one day. Basically, if taking a stable dose of T4, the level in the blood stays stable.

      Contrast that to T3, which is a short half-life hormone that peaks 2-4 hours after ingestion. Any time you take something that has a peak of that nature and then wears off in the hours after, it has the potential to act as a stimulant.

      The T4 does not act as an immediate stimulant because it has a “flat” profile in the blood, ie no peak. That said, T4 use in someone without true hypothyroidism sometimes makes that person feel better for awhile, but that type of stimulant effect is not as acute or dramatic as the T3 effect. And, of course, that effect also wears off after a few weeks or months.

      The conversion of T4 to T3 in the body is highly regulated at the tissue level, so endogenous T3 production by the body is not going to give you huge spikes of T3 like taking T3 pills will. Hence, no stimulant effect.

    2. Called T3 a stimulant is a misnomer. T3 is the active form of thyroid hormone, T4 is the thyroid hormone makes mostly and it has a iodine atom attached to it. When T4 gets to a part of the body where active Thyroid hormone is needed for functions, the methylation system works to take the iodine atom off and turns T4 into T3.

      So if you have too much of the T3 medication wandering around in the bloodstream, it will be immediately available to the body to increase metabolic processes. It is like throwing gasoline on a fire, your metabolism will increase, raising your body temperature, making lots of dopamine and serotonin, heartrate can increase, etc

      It is not a stimulant, medications like methamphetamine are classified as a stimulant.

  77. HD,
    I recently saw a new doctor, the Chief of Endocrinology, and he did want me to stop the T3, and I want to as well, and he did a math conversion equating 5 T3=25 T4. In other words, he added 25 mcg per day of T4 to my dose and took me off the T3. He started me low, and asked me to raise to that dose as I felt well enough to do so. By the time I reached the goal dose after several weeks, I felt over-medicated and I have since reduced. He didn’t really spend that much time with me explaining this conversion and I was wondering if you would like to explain how this conversion is calculated (in other words, what does it represent?) and your thoughts in regards to stopping T3 meds for anyone that would like to get off of T3 and try T4 only? It concerns me taking a medication that may cause additional problems (T3), but I also can’t find that sweet spot with T4 alone. I am suffering all kinds of symptoms now, depending on where I am with my dose and it is now interfering with daily functioning. I did consult my endocrinologist’s office again, and they simply said to lower the dose, but now I am having under-medicated symptoms. (I should add that we are talking about a dose of 500 to 550 to 600 mcg per week). And another question- he insists that there have been studies that show that taking your entire weekly dose of T4 is safe and he encouraged me to try this. I had read this before (possibly even on the ATA website?), but I have also read opinions that state that this should only be used with a non-compliant patient (someone that forgets their medication) and could cause heart complications and cause the patient to swing from hyper-hypo. To me it seems dangerous. Any thoughts on all of this?

    1. I can speak to some of this in a general way:

      – There is a widely used calculation for converting liothyronine to levothyroxine of 1:4 or 1:5. It doesn’t always work out perfectly, however.

      – I have no problem with someone stopping T3 if they want to or continuing a small dose if they want to. When stopping, I will usually do a taper, with the length of the taper dependent on how high the dose is and how long the person has been on it.

      – I have had patients take their entire week’s worth of levothyroxine once weekly, ONLY when they absolutely cannot remember to take a daily dose. I have never done this in someone with heart problems. But it has worked out fine the few times I’ve recommended it.

  78. I had TT ten years ago, and I am taking levo only. My tsh and free t4 are fine, but my free t3 is 2.2 (range is 2.2 to 4.2), which would suggest conversion issue. How do I get my free t3 to increase? Even 2.9 would be improvement.

    1. Lisa…did you read HD’s separate post on “Optimizing Thyroid Hormone Replacement after Surgery?” It may answer your questions where he cannot personally do that. Just wondering what your TSH and Free T4 numbers are?

      1. If you have conversion issues I only know of one way to increase blood levels of T3 — take a medication that contains T3

        1. Thanks, Lisa, for replying. As I am sure you are aware, your numbers do not reflect that you are under medicated. For me, and I know everyone is different, I would feel over-medicated with a TSH that low. Was your TT due to Thyroid Cancer which dictates a lower TSH? From what I have read of HD’s posts, he never would have even checked your Free T3 (in the blood) to begin with. “The conversion of T4 to T3 in the body is highly regulated at the tissue level…”(HD) Or…it occurs within the cell as the cell requires it. Consequently, what you are seeing “in the blood” does not represent your rate of T4 to T3 conversion. What made you check your Free T3? and how do you feel? under-medicate? or over-medicated? Often times slightly over-medicated symptoms and slighty-undermedicated sympotoms can feel the same. You can be fatigued from being undermedicated or from sleeping poorly because you are over-medicated. As I understand it…HD’s position is…if you are not feeling well it may not be your Thyroid that is responsible just because you have a Thyroid problem. If you haven’t already done so…I would read all of H.D’s post on Thyroid even his responses in his blog and I think you will feel educated to the extent that you can make a truly informed decision. I came here with the intent of proving him wrong but he has really opened my eyes. I am almost done with weaning myself off of T3 supplements and am so much better for it. Know what you are getting into…it is not pretty.

  79. Hi, great article. I found you after googling ‘is there any real benefit of taking T3 over T4’. I’m in the Uk have had Hashimotos for 10 years. The first 4 years I was so ill I was practically bed bound, but my GP refused to accept I had a thyroid problem as my TSH was around the 5.0 mark. Anyhow finally got referred to an endo, who agreed I indeed have a thyroid problem. Have gone from 50mcg of levo up to 150mcg levo over the years. So much better than when not treated, but have always felt unwell, achey etc. I have also heard about conversion issues and how T3 is so great. I so really want a trial. My TSH has been a steady under 1, my FT4 is always over range at 36 (top of range is 22), my FT3 has always been rock bottom – 3.7 (bottom of range is 3.7). GP only interested in TSH, so thinks I’m over medicated, endo is more amenable but gets uncomfortable with FT4 so high. I always feel best when bloods are like this, I have dreadful symptoms when FT4 is lower. What do you think? Am I a case to argue Trial of T3? I don’t think I am the norm. You say endos have seen it all, and I’m not special! I know that when my T4 is upped high, I feel amazing for about 5 days a week and a half after an increase which then tapers off, and feel ill again. Any advice?

    1. Hello, I’m guessing you can’t comment on individual cases, but do you often see such a discrepancy between T4 and T3 with a low TSH? I definately feel so much better when my TSH is really low, but the doctors don’t like it because my T4 is so high. Can you direct me to articles to read that may be helpful? Thanks

      1. It sounds like your body has problems turning T4 (T4 is the form made for transport to the various areas of the body) into T3 , which is the active hormone the body uses to make other things, like serotonin and dopamine in the brain.

        The methylation system is involved in the conversion, and if you have two copies of C667T and/or A1298C, then the methylation system only works at 20% of normal. It sounds like you might have two copies of MTHFR.

        You might do better if you were given less T4 medication and a time-release T3 medication. I can not take a time-release due to digestion problems, but instead I take 1/4 of a 5mcg Cytomel every two hours. If I take a whole Cytomel tablet my temperature goes up to 100°F high for an hour, then my body turns the excess T3 into reverseT3, and my temperature drops to 97.0°F and I have no energy and am freezing. So a little T3 every two hours keeps my temperature up at 98.6°F and steady with not alot of energy but feeling ok.

  80. Just wanna leave my experience with measuring free T3… after some years and some T3 measures what I noticed is that free T3 increases with caloric superavit and decreases with caloric deficit even if TSH go in opposite way… seems to agree with your view about TSH being the best test.
    By the way I was looking for your text when you talks about TSH and its ranges and you said you never consider someone hypothiroid with a TSH below 3.0, 2.5… I don’t remember which text you put this… I remember you wrote something saying that a TSH above X value could indicate a early hypothiroid, but never below X, but i’m not finding the text.

    1. I don’t believe I ever said that, Ricardo. I’m usually pretty careful to avoid saying things like “never.”

  81. HD,
    I seem to feel bad at a low TSH, such as at around 2 or 2.5. I feel best when it is borderline high, such as around 4. Everywhere I turn, I hear that patients want a lower TSH, but not me! I was recently taken off of T3 and given an “equivalent” dose in T4 (Synthroid) and I am having hyper symptoms (anxiety, ringing of ears, dyspnea) even though I had my TSH tested this week and it was around 2. Shouldn’t that be perfect? Have you ever heard of patients feeling better at borderline high TSH numbers? Just a little history- When I was first diagnosed, Synthroid 75 was too high and 50 was too low, producing symptoms, so my doctor put me on 62.5 daily. That eliminated all symptoms except for chills on my legs. We decided to add Cytomel (5) just to try and that did the trick. Blood work said I have no conversion issues. I don’t know why it worked and he said that sometimes it simply works for patients and we don’t really know why. This was a very science-based doctor and he actually was the first to save me from another doctor that was telling me I had Lyme Disease. Unfortunately, I moved across country away from him. I really felt perfect for years with a combination of T4 and T3, but now with all I read, I really want to stay off of T3. I feel like I have such a narrow window where I feel well. Is this all unusual? I agree with all you are saying, but it is so hard when symptoms persist.

    1. I do see patients who feel like they have a narrow window, and sometimes they do feel better with a higher TSH, absolutely.

      1. That is helpful. Thank you! I am going to talk with him about possibly slightly reducing Synthroid dose. Continuing on my quest to be T3 free…

  82. Hi everyone, I’m sure I’m late to the game here but I’m just really confused. I’ve been to numerous doctors and recently an endo. She took me off nature throid which was not making me completely optimal even though my numbers were decent, I still felt like something was pulling me down all the time. She put me on tirosint (88) and cytomel and now, I notice my chestis having what seems like gerd issues but also if I walk or do anything that has a cardio like affect. It’s like my chest is feeling it tremendously I can’t even explain it. So now I’m confused as which step to take next. Naturethroid again? even though my numbers were good, I didn’t feel that Energy I felt very lazy all the time.

    Or is this too much T3 (only on 10mcg)

    1. I also did the Naturthroid route, then 75mcg Tirosint plus 5mcg cytomel. Never felt right, so I opted to get off the cytomel. Now I’m just on 75mcg Tirosint and feel better than I have in 3 years. No more “wired but tired” like I was with cytomel. I’m also cognizant of all the other healthy lifestyle choices that can make a big difference. Exercise, sleep, eating a balanced diet at the right caloric level and limiting wine to once a week. My thyroid was ablated in oct 2015 and now I’m down 50 pounds, grew my eyebrows back, and increased my bone and muscle substantially. There is hope and your lifestyle makes a HUGE difference in how you feel.

      1. Can i ask what changes you made? The depression And changes in meds are definitely getting to me. the cytomel caused huge anxiety so she’s reducing my tirosant and hopefully that will help. I will actually be on 75 myself. Also, white blood cells showed up in my blood along with Others which is something that could happen with hashimoto. I did gluten free before but didn’t notice much of a difference. I’m just curious if you could share them with me?

        1. I made one small change at a time. First thing I did was start an exercise program. For me, it was deep water aerobics class 3x a week. Being in the water and sunshine did wonders for my state of mind and brought me to a happy place. After a month of being consistent with exercise, I started counting calories. I use MyFitnessPal to determine what caloric level I needed to be at to lose .5-1 lb a week. Then after about 6 months of water aerobics and counting calories, I started fasting for a 24 hour period, 2 times a week. I would do my aerobics class, have a protein smoothie and then begin fasting for 24 hours. This “Eat Stop Eat” method allowed me to eat everyday. Brad Pilon is the author and it’s an excellent book to learn more about it. Then after fasting 2x a week for a month, I added prayer time for my mental health. I’ve since added rebounding and weight training to my exercise regime and my physical and mental health is excellent. My weight went from 158lbs to 108lbs. My body fat is below 20% and my bone weight went from 3.8 to 4.4 lbs. No more knee pain and tons of energy!

          1. Wow, thank you so much for sharing with me. I’m looking forward to feeling great and fit again. I hope to get where you are very soon!

  83. If I may runs something by you and see what your take on it is.
    I take levothyroxine 25mg a day as I am hypo and I need it. Just on 11/13 my endo suggested to take a small dose (2.5mg day) of free t3 -cytomel because my free t3 was slightly under the normal range at 66 instead of 71+.
    I started it on 11/14 and had to stop it on 12/4 as I had the overdose symptoms of too much thyroid-headaches, irritability, sweating, hot flush like symptoms, and messed up my cycle. My endo suggested it because she said it would not mess with our trying to get pregnant and it really all it does is give me more energy and potentially help to slightly lower my already controlled TSH. My TSH was at 2.4 at the end of October.
    I know the half life for cytomel is 2.5 days, when should I expect my cycle to regulate as I am pretty sure I am not ovulating this cycle because of it and we are trying for a baby, this is not helping our case.
    Have you had any previous instances like mine?
    Appreciate your input.

  84. I was diagnosed with hypothyroidism in my mid 20s and I took Levo for 10 years with great success. However, I started to feel unwell which persistently become worse for about 8 years. During the time I felt unwell I had a ft3 level that was either low in range or low out of range. However, my tsh and ft4 was in range. My doctor didn’t believe that my low t3 levels were a concern. I felt horrible and had a long list of hypo symptoms. I did switch to ndt (with the help of a naturopath) because I had no support to try anything else from my dr. I was desperate. I initially felt worse on the medication than before, I certainly had no placebo effect! However, after about 3 months and a couple of dosage adjustments I started to feel amazing! My complete long list of symptoms disappeared which remains after about a year on the medication. My tsh is suppressed but my ft4 and ft3 are in range.

    I don’t want to take any chances of returning to how I was feeling before. However, I do want treatment that will be the most beneficial for me in the short and long-term. In your opinion is someone who has normal ft4 and tsh but low ft3 a good candidate for combination therapy?

  85. I was diagnosed with hashimotos 12 years ago. The first two years I was on T4 only. Worked myself up from 25 to 50 to 75 mcg. Ft4 was in the upper range but my endo pushed me to increase the dose further: 100 than 125 mcg. Hypo smptoms worsened. Ft4 was above normal and ft3 went low. Now my endo figured to introduce T3 medication.

    For the last 10 years I was on T3 in different form. Different Pig Stuff, Cytomel – always in combination with levothyroxine. Most of the time I ended up in the range of 1:5. As soon as I took less T3, I felt “hypo”. Bloodwork always resulted in supressed TSH, high normal ft4 and ft3.

    Right now I’m looking back and wondering if actually I felt best with 75 mcg T4 only? With a moronic feeling of wasting away some 10 years. In these years with T3 I never felt quite right. There were short bursts free of symptoms. But to be honest these were days, not weeks. Energy levels, depression, weight Issues … it was never really solved. I’m afraid I was blinded by the stimulant rush. Because you can feel glimpses how it could be like. And then you want it to be true.

    Right now, I try to go T4 only again. Hope the withdrawal will be not that hard. My gut feeling is that I will only get a light sense of feeling normal with the right thyroid medication. Not perfect wellbeing. If I can find that kind of stability without hypo symptoms, I’ll be ok with that. In the last years I learned a lot about exercise, nutrition and psychology. My hope is I can use these modalities to reach a state of wellbeing that I’m happy to live with.

    1. Everything you said is totally true. I’m honestly confused about all the information at this point. I do feel better on the T3 but then after a little bit with my body get used to it I’m right back to feeling the old way again. I’m not sure if it just means I’m not on enough dose or not. Anyways, it’s hard to find a doctor who isn’t just guessing at what they’re throwing at you. Raising and lowering your dose hoping that it actually does something. I’m stuck right now and I don’t know where to go. I’m Moody and depressed most of the time.

      Even my own endo tried to put me on antidepressants. I mean come on, you know this is a side effect of my thyroid issues. Like why would you not try to solve it.

  86. Hi HD, hi guys, me again,

    I’ve been trying to reduce my Cytomel because I believe it might be the culprit to my severe insomnia and wired/tired feeling. But I haven’t been successful. I have been on 25mcg cytomel for almost 20 years, so I wanted to go slow. I decreased by 1mcg every 2 weeks. The first couple reductions I was feeling better, but then I crashed, I lost all sleep, having panic attacks etc. Is this withdrawal from T3? Is it my adrenals reacting?

    Is there anything I can do to help this process? Iodine to support thyroid? Magnesium and vit C to support adrenals? Or should I go even slower, like decreasing 0.5mcg or 1mcg a month? I have a scale and I weigh and cut the pill so I can make this kind of reduction. Yes, I am very sensitive to meds and meds changes, it has given me a lot of problems.
    Thank you so much for any suggestions and help.

  87. I’ll simplify my question:
    Why can it be so hard to decrease Cytomel/T3 even if our bodies have too much and suffer from it?

    1. Because T3 has a short half-life and reaches a peak within 2-4 hours, large doses of it taken over long periods of time can create a dependency that the body gets used to seeing on a daily basis. Cutting that off cold turkey is like withdrawing from anything else that we’ve become dependent on – it doesn’t feel good. It has occasionally taken me years to wean people down from high doses of desiccated thyroid or liothyronine.

      1. Thank you for your reply and your work here HD. It feels good to know there is at least one person who understands decreasing T3 can create withdrawal.
        So what I hear is that there is nothing much more to do than decrease slowly and be patient?

        1. That’s hard to answer without knowing all details, so I’m going to pass on giving a definitive answer.

      2. I just wanted to chime in and agree 100% that T3 can cause withdrawal symptoms. I had to quit dessicated thyroid cold-turkey after being on between 90 and 120 mg (alternating) for almost 6 years (with a suppressed TSH for years) and had to immediately switch to T4-only, due to debilitating headaches, vision changes, and dizziness after taking even the smallest dose of NDT. The first week or so I had no idea what was happening and thought my symptoms were all due to the T4 medication (I had subscribed to Alt-med for a long time and thought T4 alone would kill me! Even my functional medicine doctor didn’t know what was happening, which was incredibly frustrating.) I remember shaking dramatically while laying in fetal position in bed trying to sleep, and had a host of other symptoms such as anxiety, depression, weakness throughout my entire body, terrible insomnia and body pains…my husband said I looked like someone who was coming off of hard drugs! I have never experienced anything like it and thought I would never be ok again! During the experience, I found a conventional endo who explained to me that the T3 and suppressed TSH was probably having an antidepressant/stimulant effect all the years I was on it, and that’s why it was so difficult to get back to “normal”. This was about a year ago and I am happy to say I am doing fine now on T4-only (Tirosint, 75 mcg) and the whole experience scared me out of ever using T3-containing medication again! I’m not sure if everyone will have such a dramatic experience, but I just wanted to say that the T3 withdrawal was very real in my experience!

        1. Thank you Sandy for sharing your experience, and I’m glad you’re feeling better now. How long did that experience last?

          I was put on antidepressants years ago for depression and cytomel was added because I was limit hypothyroid and had no energy. After a very long and difficult antidepressant withdrawal, the side effects of cytomel have come to the surface. My sleep is awful, some nights no sleep at all. And many other side effects from taking the cytomel. But each time I try to reduce I end up in withdrawal and I am much too weak for that now, so I am going to go extremely slow. I have no choice but adding a small dose of an antidepressant that helps with sleep, increasing as my body tolerates. The last years have been hell and I really hope that that will give me sleep and permit me to decrease the cytomel over the next years. I really hope I will get out of this but I sometimes doubt it.

          1. Also, was there anything you did that helped with that withdrawal process? My doctors dont know what to do with me.

          2. Hi GD,

            Withdrawal from antidepressants can and will cause anxiety that can last years, especially SSRIs which decrease anxiety, so stopping the antidepressant can be your cause of the anxiety.

            Likely the Cytomel has nothing to do with causing your anxiety, in fact T3 will increase neurotransmitters made in the brain and decrease anxiety.

            You need the T3 (Cytomel) and the lack means no energy, an obvious hypothyroid symptom.

            The tendency to blame the thyroid medication is often incorrect, other meds could be the cause of the anxiety symptom.

            Another cause of anxiety is taking statin medication for high cholesterol, which will cause anxiety, trouble sleeping, even cause increased anger problems and road rage. Statins have been shown to make these brain changes, and stopping the statin will make the symptoms disappear in about two weeks.

            There are a host of medications which have been found to cause mental changes, review any other meds you are taking as the possible cause of the anxiety.

            Also, many people who have thyroid problems, have problems with the brain making melatonin, and this is made worse by the blue light from LED lightbulbs, TVs, computers, smartphones, etc. You may need to take up to 3mg of Melatonin before sleeping, to replace the melatonin not being made in the brain. I have to take 3mg of melatonin, in addition to 500mg of L-Tryptophan, and 100 mg of 5-HPT in order to sleep.

            My brain’s pituitary gland does not make Human Growth Hormone (HGH) either, and I have to give myself a shot of that every night. An IGF-1 blood test level of only 29 showed I was dangerously low on HGH.

            Multiple problems with brain chemicals of various kinds can occur in the brain at the same time, not just thyroid alone.

            Not everything is being caused by thyroid medications.

          3. Hi GD, what helped me the most was having a team of really good doctors to help me through. I’m not sure if you have an endocrinologist who monitors your thyroid levels, but if you were hypothyroid 20 years when placed on Cytomel 20 years ago, you will likely still need to take something, so replacing the T3 (Cytomel) with T4 medication would be necessary, rather than going from Cytomel to nothing. I have found Tirosint to be wonderful for me, but I know that everyone is different. For me, the really severe withdrawal symptoms lasted about 2 weeks, and my doctor prescribed me sleeping medication to help me through. My insomnia was complicated by a bladder pain disorder, Intersistal Cystitis, that I suddenly developed when I went off the dessicated thyroid, possibly from the stress of everything. So I worked with an endocrinologist for my thyroid, a doctor for the Intersistal Cystitis/pain, a psychologist for my mental state, an acupuncturist for the pain and sleep (with mixed results) and had the support of my family to help me through. I also eat as clean as possible and exercise 5x a week to help with my mood and help me sleep. Sleep is still a struggle sometimes, and I do occasionally have to take medication for sleep unfortunately, but overall doing much better. I hope this helps and I hope you find a team of supportive doctors who can help you through, I would not have been able to do it alone.

        2. So how long was this withdrawal? I stopped both my Synthroid and Liothyronine in September suddenly for a few days per doctor order. Then I had shortness of breath and a slew of other symptoms. I went back on both, but my doctor insisted that I stay off of the T3. So I did, and I really want to continue to do this, and I am gradually getting better, but I still have just a tiny bit of shortness of breath, tinnitus, and sometimes slight dizziness. Not only this, but chills on my legs have returned, which is why I started the T3 years ago. I can’t help but feel like I need to add in that T3 but am trying so hard not to. Could I still be suffering from withdrawal from the T3? Just so you have an understanding of where I was… I was at 62.5 Synthroid/ 5 Liothyronine daily when I was perfectly regulated. When I had my T3 stopped, my dose was raised to 600 weekly for synthroid alone (my new doctor likes weekly doses, but I don’t take it all at once) but this was too high and we reduced gradually now down to 475 and feeling better and better. Six weeks now at this dose. But I still feel over-medicated but don’t understand why. I also will get my bloodwork done soon, but I know that it will be a high TSH because it was right at about 2 right before I reduced again (I was really feeling anxious at 2). I have had every other test done under the sun, so no other health issues. Could I be a rare one that just needs a little T3 or could this still be withdrawal months later?

          1. Hi Dee,

            It may be that your body has difficulty turning T4 into the action form T3. I have this problem, the MTHFR genes C667T and A1298C are the cause, and one copy decreases methylation to 60% of normal and two copies will drop it down to 20% of normal.

            Thus you will wind up with a high T4 and low T3, and meanwhile TSH will be high as the active T3 in the brain is low, so not enough serotinun and dopamine will be made in the brain. You need the T3 to make those neurotransmitters.

            The pituitary gland senses the T3 in the brain, not enough T3 and the pituitary gland releases more TSH . More T4 being released from the Thyroid gland or oral medication will not help, since the problem is the body can not turn it into T3, due to the MTHFR genes decreasing the process of converting the T4 hormone.

            The low neurotransmitters cause depression and anxiety, it is not withdrawal symptoms in the classic”drug withdrawal ” sense. Your brain is not getting enough T3 to make neurotransmitters.

            The only solution is to take more T3 to givevthe brain the T3 it needs to make the neurotransmitters.

            The high TSH when you were taking the T3, was the sisignafrom the pituitary gland that the brain was still needing more T3 even then to make neurotransmitters.

            I will bet that you have two copies of C667T and/or A1298C, like me . I do not even take any T4, only T3 Cytomel 5mcg 1/2 every two hours. No more anxiety, no more coldness, and my eyelashes, eyebrows and hair grew back.

            Unfortunately I was too low on T3 for too long and the hair starts are very thin and weak, but they at least grew back. The hair on my arms and legs and pubis are the same, went from no hair to sparse and thin growing back.

  88. I always have a low normal T3 and a high normal T4. Is there a T3-T4 ratio that our bodies should normally have?

    1. The short answer is no. When looking at the typical FT4 and FT3 blood tests, there isn’t a typical/optimal ratio for those numbers.

      1. Thank you..
        I guess if my T3 is low normal and my T4 is high normal that maybe I am not converting the T3 as well as I should be.
        Free T4 1.38
        T3 Uptake 28.70
        What is the difference in T3 Uptake versus free T3..
        Are these the same blood test?

        1. Hi Ry,

          The T3 Uptake test is a measurement of a binding protein that transports T3 throughout the body, just like a car will move you from home to the grocery store. It is not really a thyroid test at all, it is measuring a protein and not a thyroid hormone.

          1. What is the best T3 test. I am on 187.5 Levothyroxine and my T4 is in high side of normal while my TSH is a 2.5. I have bad brain fog and get anxiety bouts like I did when my TSH was in the 30’s. I also have hashimoto’s. I can’t seem to figure it out. Dr doesn’t want to make any adjustments because my TSH is perfect he says

          2. Hi Ry,

            My understanding is the best test would be “free T3” .

            If you have Hashimoto’s then you might add taking 200mcg of Selenium, as studies found the thyroid gland uses alot of Selenium, and that taking Selenium reduces the antibody counts, which means less inflammation in the thyroid gland. A natural source of Selenium is two Brazil nuts a day, or you could buy a supplement.

            The thyroid gland also needs alot of retinoic acid form of vitamin A, so taking that with the selenium could help you. Try the two for a few months, see if you observe any changes.

    2. Hi Aelxa,

      Are you say you take 2.5ug liothyronine every two hours?

      I presumer these are waking hours! Good thing for phone alarms!

      How did you hit on this dosing regimen and are you doing anything else.

      Thanks much.

      CJ

      1. Hi CJ,

        The 1/2 tablet of 5mcg Cytomel came about because my T3 was way below normal and my doctor added 5mcg Cytomel two times a day. I would take a tablet, and my temperature would jump from the 96.8°F , up to 99.6 for two hours then drop down again to 97.2°F.

        It was obvious to me I was getting too much at once, and then after two hours my body was not getting enough, do I tried cutting it in 1/4 sizes to take spread out.

        That was better, my temperature would get up to 97.4 and stay there longer by taking every two hours, but my T3 was still below normal. So he increased it to 5mcg of Cytomel four times a day.

        So now by taking 1/2 tablet Cytomel 5mcg every two hours my body temperature, while I am awake, stays at 98.2 to 98.8°F. Two hours after the last dose, you body temperature drops to 98.1, and continues dropping. In the morning when I wake up, NY temperature will be 97.2°F, and sometimes it is down to 96.8°F or less.

        I just added taking 150mcg of iodine, since I realized I was not getting any iodine, and that I developed hypothyroidism after moving from the coast inland where the water and soil has practically no iodine.

        On the coast you get iodine from the water and soil, and even the air if you are close enough to the beach.

        By taking the iodine my T4 raised up into normal range and I was able to stop taking Synthroid, and my TSH is in normal range, but my T3 is still not changed. If my T3 changed then it should be in high normal instead of the mid-range it has been on the two hour regimen, but my body is still not converting T4 into T3 much.

        TSH effects the making of the enzymes to convert T4 into T3, and there is enough TSH to push that process, but it may be that after 20+ years the body has “forgotten” how to do this. I am hopeful it may pickup over time.

        Some people can use a time release form of T3 medication, but they do not work well on me, I get too much or too little. So taking the Cytomel every two hours is the only way for me to have a stable temperature and not be running too hot or too cold.

        My body runs through the T3 in two hours, they say Cytomel has a two hour half-life, which I just found out a week ago, so after two hours my body just starts to think it is bedtime. Temperature drops, I get very sleepy and tired, etc. With this regimen I can go without napping 2-3 times a day, my body hair is coming back, and I can finally exercise without feeling like I am runninemptyan empty gastank with only fumes left.

        1. Dear Aelxa,

          What a story! It takes a lot of dedication to get your health back.

          The resources which have been of greatest benefit to my understanding are here (thanks HD!), RT3-Adrenals Group (one has to sign up), and Recovering with T3. All can be Googled (not sure if URLs are permitted here).

          As you’re on this path, Paul Robinson’s three books: Recovering with T3, The CT3M Handbook, and Thyroid Patient’s Manual, were what fixed me.

          I was getting to the point where I, too, was ready to try iodine. I did enough research to determine one needs preparation and a supplement protocol before even considering taking iodine. The iodine folks are the fringiest of alt-med so don’t believe everything you read! Nevertheless, we are mostly deficient and iodine can boost one’s immune system IF taken properly. Search Curezone Iodine Group, look up “Recommended Co-supplements”. I also suggest ND Stephanie Buist’s The Guide to Supplementing with Lugol’s Iodine.

          Good health to you…

  89. Separating endocrinology from quackery is highly desirable. Endocrinologists, ‘alternative physicians’ and some patients appear to be in competition to see who can espouse the most nonsense. This article is no exception.

    Firstly, and most important, there is an assumption that all hypothyroidism can be treated by restoring thyroid hormones to the patient’s normal levels. Certainly, if we were to take a healthy person and chop out a chunk of their thyroid, we can expect that restoration of their original serum hormone levels will make them well again. For this group of patients with primary hypothyroidism this therapy should be effective. Many patients do very well on levothyroxine monotherapy, maybe not quite perfect, but they do not notice any minor imperfections. We can hope this therapy is not associated with subtle long-term adverse consequences. However, a substantial minority of patients with primary hypothyroidism do not do well on levothyroxine monotherapy https://onlinelibrary.wiley.com/doi/full/10.1046/j.1365-2265.2002.01654.x .

    A consideration much overlooked is that the thyroid has deiodinase activity. Peripheral deiodinase is in part regulated by TSH. In patients with little or no thyroidal function there is a loss of thyroidal deiodinase, levothyroxine monotherapy leads to lower T3 levels. This is compensated with a higher dose of levothyroxine resulting in a TSH that is lower than in the healthy population. This reduces peripheral deiodinase, specifically type-2 deiodinase which regulates local T3 levels in tissues such as the brain and skeletal muscles. This is a relatively small effect and prescribing an appropriate dose of T3 would restore normal thyroid hormone function. This might be of greater benefit to patients with deiodinase polymorphisms.

    Many patients have substantial signs and symptoms that are not resolved by combined T3, T4 therapy that restores physiologic levels. These patients improve substantially when given higher doses of T3 in the form of liothyronine or NDT. This is an observed effect, the experimental data. However, the endocrine community decree that patients who need T3 must get better by restoring normal free T3 levels, they are not permitted to get better on higher doses. Studies show that this strategy is ineffective, but the same flawed study protocol is repeated multiple times. ‘Doing the same thing over and over again and expecting different results.’ Or are they? Is this a convenient means of avoiding good research and addressing the consequent need to reject the established dogma?

    There are forms of hypothyroidism that require abnormal serum T3 levels. (Allow me to define hypothyroidism as insufficient thyroid hormone action).

    For example, endocrine disrupting chemicals (EDCs) have the capability to cause a form of acquired resistance to thyroid hormone (ARTH) that affects peripheral tissues but not the hypothalamic pituitary thyroid axis. This is a consequence of the way toxicology testing of new substances is carried out. Since the axis is minimally affected serum thyroid hormone levels may be normal but peripheral hormone action severely affected. This group of patients need supra-physiological levels of thyroid hormones with a high proportion of T3 in order to bypass the protective role of the deiodinases. Endocrine disruption is universally ignored by the endocrine community – with the notable exception of the Endocrine Society https://www.endocrine.org/topics/edc .

    A second example. A long period of hyperthyroidism can down-regulate the hypothalamic pituitary thyroid axis, lowering TSH, reducing thyroidal secretion and peripheral deiodinase. When TSH fails to elevate in respond to subnormal T3 and T4 patients are told they are not hypothyroid. Reduced deiodinase, particularly type-2 deiodinase in the brain is not compensated by restoring serum fT3 levels. Supra-physiological fT3 levels are required to mitigate local hypothyroidism. In both these examples hormone status will vary somewhat between tissues, compromised therapy may be required.

    Ignoring these considerations is quackery which causes immense harm to patients.

    I’d like to comment on specific quackery in this blog.

    ‘Guess what the ratio of T4:T3 is in the human body – about 15:1!’

    Correct, but it’s wrong to imply that hormone therapy should be given in a 15:1 ratio. The thyroid secretes about 90 mcg T4 and 8 mcg T3. In addition, a healthy thyroid converts T4 to T3. The serum T4 : T3 ratio should not be used to guide a therapeutic dose ratio, levothyroxine and liothyronine have different pharmacokinetics, different absorption rates and half-lives. Nor should the relative potency of T3 and T4 in tablets assumed to be the same as in the blood. It is not https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2888764/ . Half the combined therapy studies are invalid, they assume a 4:1 or 5:1 dose substitution ratio. The ratio you put in your gob is not the ratio you get in your blood!

    ‘And then we have pig thyroid, which gives you both T4 and T3 (two for the price of one!), but in a ratio that is way out of proportion for the human body.’

    True, but if you honestly believe in restoring serum ratios you will advocate combined levothyroxine / NDT therapy. Levothyroxine monotherapy gives a ratio that is infinitely out.

    ‘All the different tissues in the body (liver, kidneys, muscles, brain, etc) are going to make however much T3 they need.’

    This is wrong. Deiodinase expression and activity varies across tissues. The liver and kidneys express type-1 deiodinase (D1) which provides circulating T3. The brain expresses D2, preferentially admits T4 using D2 to provide most of its T3. Many tissues have little or no deiodinase, they are reliant on circulating T3. In general tissues do not make however much T3 they need.

    ‘Are there instances in which various tissues don’t make as much T3 as they need? Yes, but this is nowhere near as common as some of the non-evidence-based information out there would have you believe.’

    Endocrine disruption is common, confirmed by epidemiological studies, such patients may have supra-physiological T3 requirements. Subnormal TSH secretion is common, evidenced by the number of patients with low normal TSH, fT3 and fT4 exhibiting severe hypothyroid signs and symptoms that respond to therapy that includes T3.

    ‘Hypothyroid patients with depression may benefit from the addition of T3 to their levothyroxine.’

    Adjunct T3 therapy (at quite high doses) has been demonstrated to be effective in relieving depression which is refractory to anti-depressant therapy. It is not know if this is due to an undiscovered form of hypothyroidism.

    ‘Anyone particularly susceptible to the placebo effect will like T3’. ‘T3 is a short-acting hormone that – especially when given in supra-physiologic doses (like pig thyroid!) – tends to act as a stimulant.’

    Any placebo effect would also apply to T4, patients are told by doctors and learned bodies that levothyroxine works perfectly.

    T3 is not a short-acting hormone. It has a short elimination half-life (24 hour) but its action time is considerably longer. Thyroid hormone receptors require several hours T3 saturation before expression is activated. The end-point effects of thyroid hormone can take considerable time to manifest. For many years I was on 40 mcg liothyronine twice daily, I monitored my overnight heart rate, although my serum T3 levels fluctuated there was no corresponding variation in heart rate. T3 is not a short-acting hormone. Twice or thrice daily dosing will mitigate any effects https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3205882/#!po=32.1429 .

    It’s often suggested that T3 is a drug that it makes patients ‘feel better’, this is contrary to the experience of patients who complain when given too much T3. Patients suffering from hyperthyroidism do not visit the doctor because they feel good. This assertion is subsequently contradicted in the blog ‘Symptoms like heart palpitations, tremors, sweating, anxiety, and insomnia may occur even if the TSH is within the normal range’.

    ‘Remember, each organ is making its own T3 based on its needs at that moment.’

    Not true, not all tissues express deiodinase and certainly not D2 which regulates local T3.

    ‘I realize that my TSH is optimized, which should mean that the treatment of my hypothyroidism is optimized.’

    TSH is distorted by levothyroxine monotherapy with consequent effects on deiodinase regulation of local T3 levels. This assumes the axis is functioning perfectly and there is no peripheral resistance to thyroid hormone.

    ‘I’m getting at least 7-8 hours of sleep every night’

    Hypothyroidism can have profound effects on sleep duration and quality. Catch 22.

    ‘I exercise several times per week [this better be true]’

    Patients with severe hypothyroidism can have myalgias that make it almost impossible to exercise. Catch 22.

    ‘It was written by an endocrinologist, so I hope it’s more trustworthy than the majority of the nonsense out there on the internet. It seems like there is a small subset of hypothyroid patients who will benefit from adding in a small dose of liothyronine to their levothyroxine. I understand that, when used, the levothyroxine dose should remain somewhere around 10-20 times as much as the liothyronine dose, to keep the ratio close to normal for human physiology.’

    It’s not more trustworthy than other nonsense on the internet. The number of patients who would benefit from liothyronine has not been established by clinical trial, nor has the size of the dose. In many cases it is necessary to deviate from the normal physiologic serum T3 : T4 ratio.

    The average endocrinologist has a dismal understanding of thyroid hormone action which leaves a vacuum for other quacks to fill. There is a need for good science in thyroidology, to ditch the dogma and carry out proper trials. Hypothyroidism can only be defined by the response of signs and symptoms to thyroid hormone therapy. Normalising serum hormone levels does not always restore clinical euthyroidism in all tissues.

    1. I am just a normal person, not super educacted on these issues, but to me, you bring up something that I’ve thought all along.

      Even IF blood levels are perfect, symptoms remain. Maybe you have the right amount of thyroid hormones in your blood, but it’s not getting where it needs to go in the cells to relieve symptoms. Similar to Type 2 diabetes- your body releases insulin, but it doesn’t get into the cell to lower blood glucose.

      So maybe the author is right, maybe ISN’T your thyroid. Maybe thyroid levels are ok. Maybe T3 just can’t get where it needs to go to prevent symptoms. The question is WHY so many people have symptoms when levels are normal. Maybe there’s an environmental factor blocking T3 from entering cells or something else.

      Like I said, I’m just a patient. You all know more about this than me…

      1. You are right on both counts.

        First it isn’t the thyroid, but it is hypothyroidism – provided you let me define hypothyroidism as insufficient thyroid hormone activity. The literal meaning is too little secretion by the thyroid but I find that definition of little use. Ultimately, hypothyroidism can only be diagnosed by signs and symptoms and their response to thyroid hormone treatment. When given thyroid hormone does the patient get better or do they exhibit signs and symptoms of hyperthyroidism? A patient may have a failing thyroid but when given sufficient hormone (perhaps L-T4 + a little L-T3) to restore their blood levels they improve but still have substantial signs and symptoms. Many of these patients get better when given more L-T3, more than is normal leading to abnormally high fT3. Perhaps this involves risk, I suspect it gives a small risk of atrial fibrillation but I also suspect there are other (greater) cardiac risks from leaving the patient clinically hypothyroid. This concept is uncomfortable for endocrinologists, it removes the comfort blanket of going by TSH and makes their job more challenging.

        Your analogy with type-2 diabetes is also valid. A confounding issue is that unlike diabetes thyroid hormone action is reflected in TSH. It’s reasonable to ask “if thyroid hormone isn’t working then why is TSH normal? TSH is regulated by feedback from thyroid hormone acting on the thyrotope in the pituitary, so TSH reflects thyroid hormone activity levels”. This concept generates a high degree of confidence in TSH. TSH is often an excellent marker for thyroid hormone status, it rises if fT3 or fT4 levels fall. TSH rises before fT3 or fT4 falls below their reference interval lower limits.

        The problem is that the pituitary is the most atypical organ from a thyroid hormone aspect. TSH is regulated by TRH from the hypothalamus and various influences such as starvaton, severe illness or depression can lower TRH and TSH. The pituitary converts T4 to T3 relentlessly whereas peripheral tissues have their deiodinase (conversion) regulated by various factors including TSH. Secretion of TSH can be down-regulated by a period of hyperthyroidism, which can occur in Hashimoto’s. In this case abnormally low TSH will reduce deiodinase activity in peripheral tissues such as the brain. The pituitary has different thyroid hormone receptors (TRB2) to peripheral tissues (TRA1, TRB1). Endocrine disrupting chemicals – environmental chemicals that mimic hormone – can disrupt peripheral thyroid hormone action with neglible effect on thyroid hormone action in the pituitary, producing severe hypothyroidism with normal blood hormone levels.

        The problem is that apart from rare cases of central hypothyroidism (pituitary or hypothalamus failure) the only cause of hypothyroidism considered is a failing thyroid gland. Patients are then obligated to have hormone levels that comply with primary hypothyroidism – elevated TSH and low fT4. “If your blood hormone levels don’t behave according to our theory you can’t be hypothyroid”. This is bad science. It is not true evidence based medicine. We must diagnose and treat patients according to signs and symptoms, observe their parameters (blood hormone levels) and then develop theory that fits in the experimental data. We cannot demand the data fits our theory, that ain’t how it works. This is illustrated in this brief commentary from Richard Feynman that I have on my website http://ibshypo.com/index.php/good-science/ .

        Now let me be pedantic. Your concept is right but I dislike the phrase ‘thyroid hormone is not getting into the cells’. The idea is right but there is a lot of evidence that the literal statement is wrong. Almost always thyroid hormone is getting into the cells (except in very rare cases). However, I’m sure in many cases there is insufficient thyroid hormone activity for various reasons, e.g impaired T4 to T3 conversion in cells (type-2 deiodinase) and impaired T3 binding to receptors in peripheral tissues, a form of peripheral resistance to thyroid hormone. Thyroid hormone is getting into the cells but is not able to do what it should do within the cells. A pernickety point but it will help with understanding what is happening.

        The thrust of my aguement is that we need more evidence based medicine and this requires better science, ditching dogma and using more rigorous logic. Doctors have incredible skills, able to absorb masses of information, have great interpersonal skills but they can be lacking in the sort of science skills exhibited by physicists and other scientists. Until these priciples are applied to thyroidology there will be a large body of poorly treated thyroid patients at the mercy of alternative quacks. (There are some excellent doctors who challenge the status quo).

        1. Very interesting. I do have depression and a strong family history (my mother is bed-bound at age 60 with severe depression and has hypothyroid also with normal labs and no symptom improvement) .

          And although no starvation or severe illness, I do work night shift 2 days a week so stay up for 24 hours 1-2 times a week.

          Agree more research needs to be done with this piece of the puzzle!

          1. Watch out for low normal fT3 and fT4 with TSH not elevated. This is not normal. Although each hormone may be within its reference interval TSH should not be if fT3 AND fT4 are bouncing along the bottom of their intervals. I call this ‘subnormal TSH secretion’, it has effects on deiodinase, in particular type-2 deiodinase which regulates local T3 tissue levels. Possible solutions are to resolve the depression, preferably without drugs (I know you probably tried this) or to try more T3 in the form of liothyronine. T3 therapy may help with depression. If you fT3 is average and fT4 not high (when not on T3 therapy) then the above comments probably do not apply to you.

          2. ND…all bets are off if your circadian rhythm is off. Night Shift work is notorious for disrupting all metabolic procedures. HD has pointed out that he believes people are having “symptoms reminiscent of hypothyroidism” but we need to look at our life in its entirety. We need to get the basics correct first. Diet, exercise, sleep, stress reduction, etc.. Check out two experts in the field. Dr. Matthew Walker and Dr. Satchin Panda. A search on youtube will supply great video. Rhonda Patrick interviews them both and you will be surprised at what body systems will not work when your sleep and circadian rhythm are disrupted.

  90. Have you seen someone needing weird doses like 150mcg Levothyroxine M-Sat and 200mcg on Sundays. Wouldn’t that just make you feel differently on Sunday when the higher dose is taken?

    1. The half-life of levothyroxine is very long (about a week I think) so no you don’t notice any difference at all. Basically you can just make it an “average” for the week.

  91. My endocrinologist said to me over the phone that he thinks it’s interesting that my TSH is 2.5, my FT4 is high (though not outside the normal range), and I’m having hypo symptoms.

    I went in about a week ago to tell him that I’ve been having many of the symptoms I recognize in a hypothyroid state. I told him that two years ago, I began taking 50 mcg of Synthroid and felt fantastic, then over many months I began to have many of my previous symptoms again. I was boosted to 75 mcg. I felt great. Over many many months, much of the cognitive symptoms came back with intermittent severe bloating and water retention…88 mcg of Synthroid was prescribed. My FT4 became very high. I had some symptoms of hyperthyroidism, yet my TSH didn’t change much, and I still felt hypo in some areas. Ultimately Synthroid was backed down to 75 mcg…I went into see a new endocrinologist. Bloating, water retention, brain fog, apathy, etc. are key areas I addressed to my endocrinologist. His guess is that my body is not very sensitive to the Synthroid given the labs I mentioned above. He wants to bring Synthroid down to 50 mcg and add Cytomel 5 mcg.

    Have you had patients like myself? What do you think about the situation I’m in? Yes, my expectations are low, but do you think a patient like me would see some benefit from adding Cytomel?

    Thank you in advance for you reply…

    1. Hi Hinke,

      The hypothalamus senses T3 in the brain, if T3 in the brain is low then the hypothalamus sends the chemical signal TRH (thyroid regulating hormone) to the Pituitary Gland, so the Pituitary will send the chemical signal TSH (thyroid stimulating hormone) to the thyroid gland to release thyroid hormones. The thyroid will then excrete mostly T4 and a small amount of the active form of thyroid hormone, T3, in the morning.

      You body will then over the day use the T4 to make active form T3. The brain uses T3 to make serotonin and other neurotransmitters it needs to function properly.

      If you have enzyme problems in the body, the T4 will not get converted into active T3, and the T4 is doing nothing for you. You need the active thyroid form, T3.

      It is likely that you have two copies of the MTHFR gene C667T and/or A1298C.

      Two copies will reduce the methylation system down to 20% efficiency. The methylation does many functions, but in the case of the thyroid and thyroid hormes, the methylation system regulates enzymes and hormone conversions.

      So you have lots of T4 in your blood stream and it is getting converted at such a low rate, that you are still hypothyroid with a high T4 bloodlevel.

      I am not a physician but you doctor should be seeing your blood tests results and saying to themself, “Hmmm, the patient has lots of T4 , yet both the TSH level and the T3 level are saying the patuent has a problem converting the T4 into T3. I better lower the amount of T4 the patient is getting, and start adding lots of T3.”

      The comment the endocrinologist said that it was” interesting” is what I call a stupid comment.

      Your bloating and water retention is from the high T4 level in your body, too much T4 so the medication needs to be lowered.

      Your apathy and brain fog are from the lack of neurotransmitters, due to too little T3 in your brains tissues. Your brain needs a constant supply of T3 in order to make those neurotransmitters, in the mid-range blood level at least, and something is preventing the conversion process. In this case you need T3, and much more that one 5 mcg pill of T3 daily. One 5mcg pill will not help you much at all.

      I have this condition, and I need four of those 5mcg Cytomel pills, taking 1/2 of a tablet every two hours during the day, and stopping four hours before I sleep.
      This regime keeps my brain T3 level good, where the brain has enough to make the neurotransmitters it needs to function correctly

      I used to have CFIDS and Fibromyalgia, now I have almost no pain, plus I can go to the gym and workout for 1&1/2 hours and walk out feeling great. But to be healthy I need to take T3 every two hours, after two hours it stops too low.

      Show what I have written to your physician, perhaps then you will get the T3 you need. No one should suffer needlessly.

      Plus the still high TSH level would make it ok with the official endocrinology group to treat your hypothyroidism, since they are fixated on treating the patient via the pituitary gland’s TSH leveil only, and T4 is obviously not being converted.

      1. Aelxa, I get the feeling that too many cases are being blamed on genes. It’s quite possible Emery needs some T3 because their thyroid is progressively failing and they are missing out on the T3 and the deiodinase activity it provides. It’s also possible, although less likely, that they are selenium deficient. My issue with genetic polymorphisms is ‘how come you were fine with this polymorphism for 50 years and now it’s a problem?’, that sort of question. We are conceived with these genetic variations and apart from conferring varying risks for diseases they don’t cause us problems. We may miss the T3 secreted from the thyroid and the deiodinase activity of the thyroid but when that is compensated for by a little T3 all the polymorphisms are irrelevant. I’m concerned patients are wasting brain cycles on studying genetics and money on unnecessary genetic testing.

        1. Hi Jim,

          How could people be fine with a polymorphism for generations then suddenly it is a problem?

          Simple answer to that is before 1940 the environment was still fairly clean, so running around with a methylation system that only worked at 20% of normal was tolerable.

          Now everything, water, air, and food are filled with chemicals the human body never had to deal with until the last 40 years.

          Just the bromine messes up the thyroid gland as bromine competes with iodine, and the bromines were not around in the environment until Du Pont started producing the stuff. Bromine in the bread, in the mattresses and clothing for fire-proofing, etc.

          And if your methylation system only worked at 20%, then you are the one person who will get sick first, as the stuff hangs out in your body much longer or never even gets expelled at all.

          Yes, her thyroid gland could be failing, it could be a lack of selenium due to not eating grains ( the midwest soil is high in Selenium, the restbof the country’s soil is fairly poor in the mineral), or lack of retinoic acid form of Vitamin A due to not having enough iron in the body for the body to convert beta-carotene ( a vitamin A precuser) into retenoic acid (true Vitamin A).

          But whatever the cause, she needs T3, and much less T4. If her conversion processes in the body were functioning well, they should be converting the T4 she does have into T3, as her TSH is well high enough that the enzymes should be there to do the converting.

          Methylation is involved with making enzymes, converting hormones, converting vitamins, etc. If that system is impaired beta-carotene is not going to get converted into Vitamin A, the T4 will not be converted to T3, and other processes are malfunctioning .

          I found by taking methylfolate, my body works better, as my body can not turn folic acid into the folate my brain and nervous system needs. And folic acid is being put into everything, it is added to all flour since the 1990s.

          If you know you have the MTHFR gene variants which impair this process, then you know to avoid eating anything that has folic acid in it. You need a balance of B6 , B12 and folate for the nervous system to function. Throw in folic acid and the nervous system misfunctions, and you have big problems develop. The physician sits there wondering why the patient has neurological problems. Well, with two of those MTHFR gene variants the physician would know the patient needs to avoid folic acid and take methylfolate instead to fix the problem.

          Other gene variants like a CBS gene variant can even make the methylation problems worse, but how many physicians are aware of this? Not many. More is learned every year about genes affects on health, to keep up with the new knowledge takes constant learning, once a physician leaves medical school, most of them do not keep up.

          I learned about the MTHFR because I was exhausted and getting sicker every year. My physician had me taking 1,500mcg of folic acid every day, trying to reduce my homocysteine level.

          Well, no wonder I was getting sicker every year, my body is almost completely unable to convert any of the huge amounts of folic acid I was taking daily, and the folic acid was blocking the functioning of the little folate I was getting from the vegetables I ate.

          Once I stopped the folic acid and switched to methylfolate, my homocysteine went down and I started to get better each year. So learning about genes saved my life, and has enabled me to improve my health and physical condition. It helps that I had worked for decades in the medical field and can read and comprehend medical studies and journal papers, making research using PubMed easy for me.

          1. I take your point about genetic makeup making some people susceptible to endocrine disrupting chemicials (EDCs). I had in mind patients who are well and then develop primary hypothyroidism, they should recover when their serum hormones are restored back to where they were.

            Looking at genes in patients who seem to be affected by EDCs makes sense as a formal study, if we can identify these groups it shows that particular EDCs have harmful effects and will support efforts to get rid of them. As a fellow patient I see very few cases of patients with a highish fT4 and mid-interval TSH which would suggest a general deiodinase problem that could be explained by genes. Far more common is low TSH with high fT4 which would not be caused by a factor that affects deiodinase in general. We don’t know Emery’s TSH, fT3 and fT4 so it’s difficult to comment on their case.

    2. I had some similar situations and I believe it was Iron Deficiency that contributed to this issue. [HD: reader-to-reader advice redacted]. In my case my Iron was still “in range”, however, it was not very good. My Iron Transferrin saturation was 21% , now it’s 38%. My MCH and MCV in my CBC was below range. I’m doing much better now that my Iron levels have come around. I don’t know how I fixed things, but I have been focusing on nutrition and making sure I get enough food everyday. Something to check out. B12 should be considered also, but my B12 seemed fine.

Comments are closed.