A streamlined stack of supplements designed to meet your most critical needs - Adapt Naturals is now live. Learn more

3 Steps to Choosing the Right Thyroid Hormone


Last updated on


This article is part of a special report on Thyroid Disorders. To see the other articles in this series, click here.

I often get comments and emails from people asking me which thyroid hormone I think is best. My answer is always the same: “It depends.” As much as some practitioners would like to make us believe, there is simply no “one size fits all” approach to thyroid hormone replacement.

Statements like “Synthroid is best” or “I prefer to use synthetic T4 with my patients” or “I only use bio-identical hormones” demonstrate a lack of understanding of thyroid pathology. Why? Because, as I’ve explained in this series, the underlying causes of thyroid dysfunction are diverse.

Giving all patients the same thyroid medication without understanding the mechanisms involved is analogous to not checking a patient’s blood type before doing a transfusion. Granted, the consequences may not be as severe, but the underlying principle is the same.

Before we continue, let me remind you that I’m not a doctor and I’m not offering you medical advice. My intent is to educate you about the various considerations that should be made when choosing a thyroid medication, so you can discuss them with your doctor. Understood? Great. Let’s move on.

Choosing the right thyroid medication requires answering the following three questions:

  1. What’s the mechanism that led to the need for medication in the first place?
  2. Are there any mechanisms that may interfere with the actions of the medication?
  3. Does the patient have sensitivities to the fillers used in the medications?

Let’s look at each of these in turn.

What’s the Mechanism That Led to the Need for Medication in the First Place?

If you’ve been following this series, you know that there’s no single cause for low thyroid function. Do you have an autoimmune disease (Hashimoto’s) causing destruction of your thyroid gland? Do you have high levels of estrogen causing an increase in thyroid binding proteins and a decrease in free thyroid hormone? Do you have a systemic inflammatory condition affecting your ability to convert T4 to T3, or decreasing the sensitivity of the cells in your body to thyroid hormone?

In order to choose the right hormone, you have to know what the underlying mechanism causing the dysfunction is. Let’s look at an example.

Say you have a problem converting T4 to T3. In this situation, your TSH may or may not be slightly elevated, but let’s say it is, and your doctor prescribes Synthroid. Synthroid is a synthetic T4 hormone. Will this help you?

No. It won’t help because your problem in this example isn’t a lack of T4, it’s an inability to convert T4 to the active T3 form. You could take T4 all day long, and it won’t do a thing unless your body can convert it.

The first step in this case would be to address the causes of the conversion problem (i.e. inflammation), in the hopes that you may not need replacement hormone. If that doesn’t work, though, what you’d need in this situation is either a so-called bio-identical hormone that has a combination of T4 and T3, or a synthetic T3 hormone (like Cytomel). These will deliver the T3 you need directly, bypassing the conversion problem.

Are There Any Mechanisms That May Interfere with the Actions of the Medication?

The vast majority of long-term hypothyroid patients that haven’t been properly managed find that they constantly need to increase the dose of their medication, or switch to new medications, to get the same effect.

There are several reasons for this. First, inflammation (which is characteristic of all autoimmune diseases, and Hashimoto’s is no exception) causes a decrease in thyroid receptor site sensitivity. This means that even though you may be taking a substantial dose of replacement hormone, your cells aren’t able to utilize it properly.

Second, elevations in either testosterone or estrogen (extremely common in hypothyroid patients) affect the levels of circulating free thyroid hormone. For example, high levels of estrogen will increase levels of thyroid binding protein. Thyroid hormone is inactive as long as it’s bound to this protein. If you take thyroid replacement, but you have too much binding protein, there won’t be enough of the active form to produce the desired effect.

Third, there are several medications that alter the absorption or activity of T4. These include commonly prescribed drugs like antibiotics & antifungals (i.e. sulfonamides, rifampin, keoconazole), anti-diabetics (Orinase, Diabinese), diuretics (Lasix), stimulants (amphetamines), cholesterol lowering medications (Colestid, Atromid, LoCholest, Questran, etc.), anti-arrhythmia medications (Cordarone, Inderal, Propanolol, Regitine, etc.), hormone replacement (Premarin, anabolic steroids, growth hormone, etc.), pain medication (morphine, Kadian, MS Contin, etc.), antacids (aluminum hydroxides like Mylanta, etc.) and psychoactive medications (Lithium, Thorazine, etc.).

All of these factors must be considered if a particular medication isn’t having the desired effect.

Like what you’re reading? Get my free newsletter, recipes, eBooks, product recommendations, and more!

Does the Patient Have Sensitivities to the Fillers Used in the Medications?

Another important consideration in choosing the right hormone is the fillers contained in each medication. Many popular thyroid medications contain common allergens such as cornstarch, lactose and even gluten. As I explained in a previous post, most hypothyroid patients have sensitivities to gluten, and many of them also react to corn and dairy (which contains lactose).

Synthroid, which is one of the most popular medications prescribed for hypothyroidism, has both cornstarch and lactose as a filler. Cytomel, which is a popular synthetic T3 hormone, has modified food starch – which contains gluten – as a filler.

Even the natural porcine products like Armour suffer from issues with fillers. In 2008, the manufacturers of Armour reformulated the product, reducing the amount of dextrose & increasing the amount of methylcellulose in the filler. This may explain the explosion of reports by patients on internet forums and in doctor’s offices that the new form of Armour was either “miraculous” or “horrible”. Those that had sensitivities to dextrose were reacting less to the new form, and experiencing better results, while those that had sensitivities to methylcellulose were reacting more, and experiencing worse results.

The best choice in these situations is to ask your doctor to have a compounding pharmacy fill the prescription using fillers you aren’t sensitive to. Unfortunately, insurance companies sometimes refuse to cover this.

Other Considerations

Another common question that is hotly debated is whether bio-identical or synthetic hormones are best. Once again, the answer is: “It depends.” In general I think bio-identical hormones are the best choice. A frequently perpetuated myth (in Synthroid marketing, for example) is that the dosages and ratio of T4:T3 in Armour aren’t consistent. Studies have shown this to be false. Armour contains a consistent dose of 38 mcg T4 and 9 mcg T3 in a ratio of 4.22:1.

However, in some cases patients do feel better with synthetic hormones. One reason for this is that a small subset of people with Hashimoto’s produce antibodies not only to their thyroid tissue (TPO and TG), but also to their own thyroid hormones (T4 and T3). These patients do worse with bio-identical sources because they increased the source of the autoimmune attack.

Another issue is the use of T3 hormones. As we’ve discussed, T3 is the active form and has the greatest metabolic effects. The flip side of this, however, is that it’s far easier to “overdose” on T3 than on T4. Patients with trouble converting T4 to T3 do well on synthetic T3 or bio-identical combination T4:T3 products. But for many patients with Hashimoto’s, which is can present with alternating hypo- and hyperthyroid symptoms, T3 can push them over the edge. They are generally better off with T4 based drugs.

As you can see, the best thyroid hormone for each patient can only be determined by a full thyroid work-up and exam, followed by trial and error of different types of replacement medications. Such a work-up would include not just an isolated TSH test, but also a more complete thyroid panel (including antibodies), other important blood markers (glucose, lipids, CBC with diff, urinary DPD, etc.) and possibly a hormone panel.

A history must be taken with particular attention paid to the patient’s subjective response to replacement hormones they may have tried in the past.

Unfortunately, this rarely happens in the conventional model, where the standard of care is to test only for TSH. If it’s elevated, the patient will get whatever hormone that particular practitioner is fond of using without any further investigation. And all too often, as many of you can attest, this simplified and incomplete approach is doomed to failure.

ADAPT Naturals logo

Better supplementation. Fewer supplements.

Close the nutrient gap to feel and perform your best. 

A daily stack of supplements designed to meet your most critical needs.

Chris Kresser in kitchen


Join the conversation

  1. I was on Armor thyroid for a year but then switched back to levoxyl because my t3 was high and my t4 was low. TSH was also high.

    Labs were

    TSH 9 (range .27-4.20)
    Total T3 1.60 (range .59-1.63)
    Total T4 4.59 (range 4.20-10.40
    Free Thyroxine Index 4.9 (range 4.2-9.5)
    TPO 6.6 (range 0.0-34.0)
    TG 22.6 (range 0.0-115.0)

    During this time I was experiencing palpitations. etc.

    My doctor switched me back to levoxyl

    First recheck

    TSH .62 (range .27-4.20)
    Total T3 .62 (range .59-1.63)
    Total T4 8.46 (range 4.20-10.40)
    Free Thyroxine Index 8.9 (range 4.2-9.5)

    She wanted to increase the does of levoxyl, but I was having issues with the new formula so I had the new does .88 mcgs compounded.

    Recent labs were

    TSH 16.38 (range .27-4.20)
    Total T3 .57 (range .59-1.63)
    Total T4 7.56 (range 4.20-10.40)
    Free Thyroxine index 8.1 (range 4.2-9.5)

    I don’t know where to go from here. I feel horrible. Plan is to once again increase compounded T4 but I don’t believe this will help.

    Any insight would be greatly appreciated!

      • The T3 in the Armour elevates your Total T3 lab test result, because it is measuring what you last ingested before your blood draw. Total T3 and Total T4 are the wrong tests anyway; you need FREE T3 and FREE T4 tests, which will tell you how much T3 is “free” to be absorbed and used by your cells (probably a very low result , especially if you’re thyroidLESS) and how much T4 is “free” to be converted into Free T3, which every individual cell in the body and the brain NEEDS, and/ how much T4 is “free” to be converted into Reverse T3, which your cells can’t use. Supposedly, 60% of T4 gets converted (into Free T3 and/or Reverse T3) in the liver; 20% gets converted in your gut (where your immune system is located) and the other 20% gets processed out as waste, because it is “bound”. Two issues your doc is ignoring: ingested hormones aren’t as easily absorbed or used by cells, so you need to ingest more than a healthy thyroid would secrete, which will, necessarily, increase your Free Te and Free T4 lab tests’ results. Second, the labs are using reference ranges based on sick and suffering people who have thyroid problems to tell your doc you’re “normal”, just like all the sick and suffering people your lab is testing (healthy people with healthy thyroids aren’t getting tested). Doctors can “control” your TSH and Free T4 lab tests’ results with a T4-only med, but neither lab result tells them or you anything about the T3 you need at the CELLULAR level. Healthy volunteers with healthy thyroids tested .4-2.5 for TSH, .7-1.8 for Free T4, 4.25-6.19 for Free T3 for WOMEN, 2.3-5.0 for Free T3 for MEN. You can “order” your own tests from an online lab, go to an “approved” blood draw station and your results are provided to YOU if your doc won’t order these tests (Free T4, Reverse T3 and Free T3), but it’s out of pocket (not covered by any insurance). I wish you and your doc more education. Read other comments here, because Chris clearly isn’t going to answer any questions unless he can profit financially by providing the answers. We’re all so very individual! We all DESERVE to be treated as individuals, rather than as a set of lab tests’ results compared to other sick and suffering people with thyroid problems….

  2. I am somewhat disappointed. I nearly took this article to my conventional endo as a reference to try NDT. Upon further research I discovered that the starch in Cytomel is not a gluten containing starch — cytomel is gluten free. — Synthroid is gluten free but not made in a gluten free factory therefore legally can not claim the status.———— Had I made this argument against cytomel to my endo I would have been made to look like a fool and loose all credibility as my own health advocate. — please look into it an correct the article.

  3. Hello,
    My endocrine issues started 16 years ago. I had elevated prolactin level >135 ng/dl, but no adenoma detected. Diagnosed Hypo in 2000 and managed on Synthroid 75mg? I never felt well, but normal ranges so diagnosed with depression and adult ADD. In 2008, I had my tubes tied / uteral ablation and with in 6 months bed ridden. Went to wellness dr who switched me to armour. Improvement, however I had several other issues to address; lyme, mold exposure, etc.
    My pcp is an endocrinologist and has me on Armour 1
    My labs for the past year are as follows:

    FT4 0.7 (0.7-1.7 ng/dl)
    FT3 2.5-3.6 (2.3-4.2 pg/ml) swings, but mostly low on Armour 1 gr
    TSH 0.3-1.3 (.35-4.5)

    My symptoms are mostly psychiatric in nature. The brain fog is crippling. I have no executive function of my brain. Thoughts do not come automatically to me and I am very easily overwhelmed when I have to make the effort to think something through. I have internal angst that paralyzes me. It is very irrational and because of it I do not leave the house much. I am always irritable and agitated. I have complete apathy and depersonalization that feels like I am always homesick. Around 3pm I can feel the anxiety starting to rise. Most of the time it escalates to a pressure in my brain that feels like it is on fire. I feel like I lose touch with reality. What is odd is that it passes within a few hours. Often I take Ativan to abate the symptoms quicker.

    I decided to get second opinion.

    The new dr. suspected hypo and ordered panel on 11/01/14:
    FT4 0.7
    FT3 2.7
    TSH 0.3
    RT3 21.3 (8-25 ng/dl)

    She suggested that I not take any T4 and use cytomel. She also supported low adrenals with HC.

    The last three weeks have physically been hell. But some of
    the mental symptoms have greatly improved..so we are hitting on something.

    current regimen:
    6am t3 5mcg
    HC 5 mg
    armour .5 grain
    10am HC 5
    12pm T3 5mcg always feel revved
    2pm HC 10 Start to feel fluish, achey, tingly, anxious
    4pm Armour 1/2 gr.

    I’m NOT feeling well on this regimen. The question is if I am on too much or not enough T3. I am hoping to have new labs on Monday.
    Sorry for such long post. Any input would be appreciated. Thanks!

    • YaY! For YOU getting any T3 at all!!! Yes, I’d agree that you’re not getting enough T3. eaware.org describes how to increase T3, and how to ingest it once you’re up to treatment level doses. They suggest starting with 12.5 mcg and increasing by 12.5 mcg every several days. I know one person who increased every eight days; I increased every three days. I’m taking a total of 150 mcg/day in six doses (I’m thyroidless and ingest no T4).

      The Armour is 80% T4, and it’s still converting to RT3 because of everything else going on.

      Rigorously screened, healthy WOMEN test between 4.25-6.19 for FT3. Because you are ingesting instead of secreting, you need more than their healthy thyroid secretes, so your FT3 lab test result “should” be higher than 6.19 (unless you stop ingesting your T3 for 24 hours before your blood draw, in which case it should be really low, like it is now).

      Dissolve the T3 in your mouth; eating immediately before will decrease it’s effectiveness, because a healthy thyroid interprets food as stress and secretes extra T3 to help digest the food. Eating immediately after dissolving in your mouth has no effect, because the T3 doesn’t “kick in” for 30-45 minutes afterward. It WEARS OFF 3-6 hours later, when you need to dissolve another dose in your mouth! “Most people” need 3-4 doses of T3 per day; I ingest six smaller doses, trying to mimic what a healthy thyroid secretes. You need more T3 in colder temps as well. Dose sizes that work in the spring and early summer won’t be enough in the winter, depending on where you live.

      You ARE getting better, but you’re not ingesting enough T3, because the T3 you ARE ingesting is teaching your thyroid to shut down altogether–you need and DESERVE replacement instead of supplemental doses. Your PITUITARY is responding EXACTLY as it’s supposed to respond to ingested T3: it’s getting suppressed, as revealed by your TSH result.

      It’s still a process that takes time, but it takes less time with T3 than it does with T4. Hang in there!!!

      • Thanks TBarb!!
        I will read how to titrate. Since my post, I went up to 10mcg T3 in am and noon. And this morning went up 5mcg more….15mcg total this am and don’t feel so great.
        My dr. called in compounded T3…NOT SR. So I won’t be able to dissolve it.
        My labs came back and levels are the same. RT3 was 12. Can it drop that much in three weeks? However, my FT4 has consistently been low as far back as I can remember. My FT3 levels are never usually at the mid mark.

        I’m just confused why it seems so difficult to titrate dose.
        Thanks so much for your input!!

        • You’re welcome!

          The point in having T3 separately, in known doses, instead of compounded is so YOU can decide how much you need and when you need it. Eventually you learn to anticipate by 30-45 minutes before you need it, so it can “kick in” by the time you need it. Compounded may have different fillers, better for you than the brand or the generic. I’d chew it if it’s not sustained release!!!

          Usually, compounded means sustained release, or a T4/T3 combo, so be clear about what your doc ordered….

          The more T3 you ingest, the quicker you’re clearing the RT3 (so long as you continue to address the causes of your RT3). RT3 can only be converted from T4, so if you’re not ingesting T4, your RT3 will clear.

          If FT4 continues to register after you’re not ingesting any T4, then that FT4 result indicates your thyroid is still working! But, the T3 you’re ingesting will suppress your TSH, which, over time, teaches your thyroid to shut down and stop secreting whatever FT4 shows up in your lab tests.

          Makes sense? Hang in there!!!

  4. HELP!!!! I’m in desperate need of answers. I came upon this site and you all seem to know what you’re talking about, so PLEASE help me.

    In March 2010 (3 months after having a baby) I was diagnosed with hypothyroidism. The doctor said my numbers were significantly low immediately put me on Levo 175. I must’ve taken it only a few weeks then I stopped because I moved away and I lost the medicine (I ended up being homeless and didn’t make trying to replace my Rx a priority….

    Fast forward to March 2014 – I was experiencing the same symptoms which I had back in 2010, so I went to the doctor to get a Rx for Levo, but when my labs returned, the doctor told me she could not put me back on Levo because my numbers were normal and I DON’T have thyroid problem…. I asked for a copy of my labs. I don’t understand the numbers but they were as follows:

    TSH (3rd gener.) 5.359 Ref. Range 0.340-5.600
    FREE T4 1.3

    Now, today 8 months later, I am not feeling any better so I went back to the doctor and I explained to him 1 dr saying I have hypo and the other saying I don’t. You’re probably subclinical. had more blood work a week ago. I got the results for my thyroid and according to this new doctor I do NOT have hypothyroidism. My results are as follows:

    TSH 4.11
    T4, FREE 1.1
    T3, TOTAL 106
    T3, UPTAKE 25

    I left his office feeling relieved that I don’t have a thyroid problem after all……. OR do I ???????

    Because I’m still waiting for the results of the cortisol test (taken on a different day) and I’m looking for answers, I came upon a book, “The Hormone Cure”, and I read it all today- according to this book, it appears that not only do I have Hypothyroidism, but may also have both High AND Low cortisol in the same day….

    If I understand right from what I’ve read, some doctors wont treat subclinical hypothyroidism, and apparently my doctor is one who doesn’t… I have mixed feelings about that!! Part of me is OK with that because I would like to treat it with herbal therapies instead (which I know NOTHING about)…

    I should mention that I’m 47 yrs old. Don’t try to do the math, yep, I was 43 when I had my little girl. So I have a soon to be 4 yr old. I’m perimenopausal. I was just told I have arthritis on both shoulders (losing movility on my left shoulder) and I have a 1 inch fibroid on my uterus….

    I know this is long, but I don’t know where to go from here or where to start because from what I’ve read (so far) if I eat “this” it helps with my thyroid, but screws up my cortisol, and if I eat “that” instead, it wont affect my cortisol, but it’s not good for my fibroid, and eating something else altogether is not good for my arthritis / severe inflammation. It’s all so overwhelming 🙁

    I welcome ANY and ALL responses and/or suggestions. Please if you can recommend any herbs, supplements, vitamins, links, websites, etc….

    Thank you in advance,

    • You are PROBABLY “hypothyroid”. Taking the Levo taught your thyroid to shut down; labs indicate you MIGHT be able to “heal” it. See hypothyroidmom.com. She had a guest doc talk about this. You’ll need other tests FIRST, to find out if you have antibodies, and I’d suggest Reverse T3 and Free T3 tests from the same blood draw, with the blood being drawn about 3-4 Pm (not first thing in the am). Levo is a T4-only med; every individual cell in the body and the brain NEEDS T3, not T4. T4 is converted to T3 in the liver, but it also converts to Reverse T3 instead of Free T3, and 21st century medical science has PROVEN that the T3 converted from T4 is NOT enough (you DESERVE to replace your T3 IF you need replacement at all).

      A healthy thyroid makes T4, T3, T2, T1 and Calcitonin. T4 gets converted to Reverse T3 when someone is sick. At that point, a HEALTHY thyroid is exquisitely self-regulating. It stops makes T4, dramatically increases secreting T3 (not the converted kind) and that continues until you are well again. “Most people” who ingest a T4-only med end up with adrenal problems, especially women.

      As our ovaries shut down (perimenopause), our adrenals pick up the slack. Testosterone decreases quickest, then progesterone, then estrogen. Estrogen unopposed by progesterone generates, first, excess stress. Stress depletes the supply of Free T3 quicker than any other drain! Then, estrogen “deactivates” whatever T3 is available. So, I’d suggest some USP progesterone cream. Progesterone is a KNOWN component of converting T4 into Free T3 as well. Remember, menopause is more about fluctuations in hormones’ levels than it is about dramatic drops. Menopause can last up to ten years or more. Most women ovulate for an average of 40 years, so take the age at which you started, add 40 years and know you may have been “pushed into” menopause (as opposed to being perimenopausal).

      Next, know that uterine fibroids go away all by themselves; you don’t HAVE to have surgery; and I don’t suggest ablation. They MAY go away with the use of progesterone cream (balancing out the excess estrogen because your adrenals aren’t working up to par).

      Next, know that adrenal fatigue, or insufficiency, or whatever the doctors call it, generally, doesn’t get treated, just like “subclinical” hypothyroidism. They wait until it’s a disease called Addision’s….

      Rigorously screened, healthy volunteers tested as follows:
      TSH: .4-2.5 (so your 4.whatever IS too high)
      Free T4: .7-1.8
      Free T3 for WOMEN: 4.25-6.19
      Reverse T3: Zero
      “Thyroid” Antibodies (listed elsewhere in other replies here): ZERO, Undetectable!

      TPO is the most common antibody. I have TPO antibodies AND I have NO thyroid, so they are not “thyroid” antibodies. When you have them AND you still have your thyroid, they take “bites” out of your thyroid gland, dump massive amounts of T4 and T3 into your system (causing the T4 to convert to Reverse T3 eventually), and you will fluctuate between hypo and hyper. For a list of systemic symptoms, go to 21centurymed.com, Hypothyroidism tab and scroll down. hypothyroidmom.com also has a list of more specific symptoms–300 of them.

      eaware.org explains a lot, in “lay peoples'” language you can understand.

  5. Hi, I had thyroidectomy in June 2014 due to Graves’ disease. Dr put me on t4 replacement (levo)

    July 16 2014 –
    T4 free results 18.9 (réf range 7.2-21)
    Tsh results <0.03 ( réf range 0.3-5.6)
    Sgpt results 11 (réf range 4-43)

    October 21 2014
    Tsh 0.07 (réf range 0.5- 5)
    Thyroxine free results 19 (réf range 10 – 22)

    I have been trying to conceive with no success…. From blood results any reason I should not be able to conceive? I have conceived twice before being diagnozed and fairly easily. Do you think their would be a benefit in taking t3 replacement as well?

    • Yes! If you don’t have antibodies, you may be better able to conceive with a Natural Desiccated Thyroid (NDT) med. Otherwise, I’d suggest some Cytomel to go with your Levo, because 21st Century medical SCIENCE proves that the T3 converted from T4 is NOT enough. You DESERVE to replace the direct T3 that your otherwise healthy thyroid would have made for you.

  6. Hi All…Recently diagnosed with Hashimoto. Diagnosed 10 years ago with hypo.
    Most current lab results:
    TPO <35 2070
    Thyroglobulin Antibody <40 364
    TSH .350-4.5 13.935 (Down form 52.889)
    FT4 0.80-1.80 1.09
    FT3 2.3-4.2 2.7
    Had 1st appointment with Endo…he changed me from Levo 125 to Synthroid 137 and Vit D and B12. Joint aches are much better but still feeling exhausted and worn out. Irritability is not as bad but not so good either.
    Would I benefit from a T3 or an NDT rather than just Synthroid alone?

    • Yes. Hashis CAUSES hypo. Antibodies, literally, “eat” away at your thyroid gland. Four digits of TPO ab is waaaaayyyy too many! My guess, at this point, you may not have any gland left, and yes, you need to replace both T4 (your Levo), assuming you can convert it into Free T3, AND T3 (brand name Cytomel). Lots of references listed in other comments.

      Rigorously screened, healthy volunteers, WITH healthy thyroids, tested as follows:
      TSH: .4-2.5
      Free T4: .7-1.8
      Free T3 for WOMEN: 4.25-6.19
      Free T3 for men: 2.0-5.0
      Reverse T3: Zero
      Antibodies (there are four of them): Zero, UNdetectable.

      A healthy thyroid secretes about 94-110 T4 and 10-22 T3. You must ingest more than a healthy thyroid secretes to get the same effect at the cellular level, so your lab test results will not be within the above ranges (TSH gets suppressed, FT4 and FT3 will be “too high”).

      I have NO thyroid and yet I have TPO ab. Therefore, my conclusion is that ab are evidence of autoimmune disease, not “thyroid” disease. Left unchecked, by YOU (not your doctor), they go on to “attack” other systems/organs (MS, diabetes, etc.). I try to stay away from processed and GMO foods, eat only grass-fed meat and dairy. My ab fluctuate between 0-17, depending on how successful I am at not eating what is, in reality, NOT real food.

      Hang in there, but I’d suggest yes, get some T3 to go with your T4. 🙂

  7. Does an elevated TSH level of 7.2 with normal levels of T4 Free and T3 require thyroid hormone? The doc is suggesting desiccated thyroid at 30mg for a month just to see if it brings the TSH down. The TSH has been slowly rising over the last five years from 3.74 to 7.2 even though the T4 and T3 continue to be normal. The normal TSH range where I live is between 0.35 and 5.00 mIU/L but I know the range is different in other countries. All other lab results are good except for ALT which is slightly elevated at 40 U/L.

    • FT4 and FT3 are “normal”? According to reference ranges generated by testing rigorously screened healthy volunteers (see my response to other comments), or according to the lab where your tests are run, based solely on the sick and suffering people being tested, precisely because their doctors believe they have a thyroid problem!??

      Ingesting any form of T3 will bring your TSH down, because the TSH is a PITUITARY test, not a thyroid test. It’s based on the thyroid hormones IN the pituitary, and thyroid hormones’ concentration is highest IN the pituitary. It tells nothing about thyroid hormone levels in any other part of your body OR your brain. Every individual cell needs T3, not T4.

      If you’re not having any symptoms, why a trial? If you are having symptoms, my guess is you’ll need 30 mg for two weeks, then 60 mg for two weeks (two doses a day), and continue to increase from there. Research shows most people need 3-5 grains to feel well. 60 mg = 1 grain. But you can’t just start taking a grain 3-4 times a day, you have to build up to it. Some people only need 3 grains; others need 5. We’re all very individual.

      Know that just that little amount of medicine will teach your thyroid to shut down, to depend on what you are ingesting instead, because the slightest extra T3 ingested suppresses the TSH. When the TSH is suppressed, the pituitary isn’t telling the thyroid to secrete anything.

      When the TSH is 7.2, it’s screaming at the thyroid to make more T4 and more T3. For you, it appears your pituitary is screaming at your thyroid to make more T4 and more T3, because your pituitary KNOWS whatever T4 and T3 is being secreted is not enough (not “normal”), for YOU, regardless of the lab saying it is “normal” for all the sick and suffering people your lab is testing. In the USA, those healthy volunteers tested between .4-2.5, most of them under 2.0, so even your 3.74 was too high years ago. Ask your doctor to NOT depend upon the lab to tell him what is “normal”; acknowledge he only got one week’s training about dysfunctional thyroids in med school; and then tell him that 21st century medical science trumps 20th century medical myth. There has been progress in the “treatment” of “thyroid problems” since the 1960’s. Today, “treatment” depends on the CAUSE of your thyroid problem, not your TSH lab test result.

      YaY! for desiccated thyroid rather than a T4-only med!!! That’s worthy of paying for that doc’s “care”! From my perspective, you still need to know WHY you need to ingest anything at all. For instance, pituitary tumors are rare, but they do exist=it’s not always a “thyroid” problem, but ingesting supplemental doses of thyroid hormones can cause a thyroid problem if you don’t need them.

      Treat symptoms (or lack thereof), not lab test results (plural).

  8. Hello. I just saw a new doc who gave me Thyroid. He said it was natural, not synthetic. It was given/sold to me by his office staff in a plain medicine bottle with a label printed on the spot. Dosage was 1 grain however the pills were 2 grains so I was told to break them in half. There was no pamphlet or information about the medication, its manufacturer or where it was made. I tried to find information about it online but with such generic name “Thyroid”, I did not have much success. Imprinted on the pill is “TCL 023”. Can someone please help me figure out what I am taking or point me to a manufacturer’s site? My next appointment is not for another month and the office staff doesn’t seem to know much about the medication when I asked beyond the standard “doc always prescribes it for low thyroid and it’s all natural so you’re safe.” Thank you!

    • Natural thyroid usually means thyroid hormones from a cow or a pig (over the counter versions) or from a pig (prescription versions in the USA). IF your doc makes his own concoction, it’s usually made from cows, pigs OR synthetic (chemically equivalent) hormones. I, personally, wouldn’t ingest anything that doesn’t come with a package insert. If his staff doesn’t know what’s in it, or how to ingest it, or how to interpret your lab results differently once you are ingesting it, the doctor may not know either(!), and I’d find another doctor who DOES know.

    • I searched on line for the numbers on your medication and came up with a site “Drugs.com” that says it is 120 mg descicated thyroid. Rugby is the manufacturer.

  9. Chris, I’ve been getting your emails for a while now and really appreciate your work, especially on behalf of hypothyroid patients 🙂

    You made this comment and it caught my eye: …”elevations in either testosterone or estrogen (extremely common in hypothyroid patients) affect the levels of circulating free thyroid hormone. For example, high levels of estrogen will increase levels of thyroid binding protein. Thyroid hormone is inactive as long as it’s bound to this protein. If you take thyroid replacement, but you have too much binding protein, there won’t be enough of the active form to produce the desired effect.”

    As of Feb. 2014 I am under the care of a bioidentical hormone practitioner and she is managing my thyroid. I have Hashi’s, too. My tests showed low everything – flat lined adrenals, low estrogen and low testosterone among other things. My thyroid panel was acceptable but not optimized. Symptoms are somewhat under control and afternoon fatigue and sleeping habits are improving but not great or normal, IMO.

    Now, I’ve suspected for about a year now that the testosterone was making me gain weight in the middle & butt (I’m fighting slow metabolism due to years of low carbing and yo-yo dieting – trying now to heal and following some of Matt Stone’s and Ari Whitten’s guidelines – but the weight gain with refeeding is getting too much, IMO). I’m on 90 mg of Armour thyroid and progesterone compounded cream also. I eat very well with occasional minor slips. Organic whenever possible, green smoothies, raw veggies, salads, mostly fish and chicken and occasional beef.

    Everyone I ask about the possible connection between testosterone replacement and weight think it’s impossible – the general consensus is T makes women and men both tend to lose weight and build muscle. (I can’t really work out much due to some unrepaired orthopedic issues right now).

    Any wisdom would be appreciated. I love the way the T replacement makes me feel, but I HAVE to figure out what all the elements are of my recent huge weight gain (over 20 lbs in 5 months). Doesn’t seem like refeeding could account for it all because of the foods I eat and I know better than to pig out after all those years of paleo and low to zero carbing. Thanks in advance!

    • Testosterone is like most meds: it’s made by men for men, based on studies of men by men. My testosterone is non-existent, but I refuse to ingest any, because doctors don’t really know what it’s doing to men!

      Flat-lined adrenals means you’re probably converting any T4 you’re ingesting into RT3.

      GMO plants and GE animals are not the only source of endocrine disruptors (autoimmune disease). Check all your household cleaners, soaps, shampoos, etc.

      In my experiences since 1998, the weight gain has been 100% related to insufficient FT3 at the cellular level, for which there is no blood test. Estrogens are stored in fat in both men and women; maybe your estrogens’ levels have increased with the 20 pounds?

      Maybe a break from the T?

      Maybe more T3?

      It’s all related, and we’re all very individual. Hope your new doc can help!

  10. help! hashi’s patient. taking 65mgs Nature Throid. now losing hair. test results last wk :
    TSH .728
    FREE T4 71
    T3 202.60

    I have asked the doctor if there could be something up w/ my hormones. She didn’t answer and offered to lower my Nature Throid and put me on T4 med.

    I’m going to be bald soon! HELP!

  11. Hi I don’t have a thyroid because its been removed which is the best meds you recommend synthroid or naturthroid. I’ve been taking so many different meds going higher & lower that I just stopped taking everything & now starting from scratch again so now I’m taking 75 MCG synthroid. Its only been about a week 1/2 I started with 1/4 every 3 days then 1/2 & so on to work up to now 75 MCG but I’m not losing much weight & lots of hair is falling even m,y eyebrows is this from synthroid or just being hypo from being off all meds for 2 months. However as soon as I got on syhthroid I noticed the hair loss. Should I just go back to naturthroid?

  12. Dear Barb,

    My mom is having Hypothyroidism and her latest reports read as : T3 – 62.35, T4 – 9.40, TSH – 2.50 & Anti Thyroglobulin Anti bodies – 369. She has been on Elctrocxin 75 for past 6 months. Pls advice

    • Sounds like you live in another country, where lab results are very different. However, even one antibody is TOO MANY, because rigorously screened, healthy volunteers with healthy thyroids had ZERO antibodies–they were undetectable. “Thyroid” antibodies aren’t evidence of “thyroid” disease; they are evidence of autoimmune disease that attacks the thyroid FIRST. They prevent whatever T3 your Mom has available (regardless if ingesting or secreted) from getting INto the cells. There is NO lab test result that reveals how much T3 is actually getting INto the cells.

      Left unchecked, antibodies go on to attack other organs/systems. I suggest your Mom read and re-read the above article and all the comments by everyone until she understands. I’ve suggested other resources in other comments as well. I’m not a doctor or a nurse; but most doctors and nurses aren’t living without a thyroid, and the ones I’ve met who have “hypothyroidism” are settling for abuse and neglect from their doctors with a T4-only med that shortens their lifespan. I wish you education and a medical professional who is willing to be educated so your Mom can feel better, regardless of what her lab results might be.

  13. deration.

    I have a question, i take synthroid since i have 12 years old ( im now 26), but i forget sometimes to take it.
    do you know if there is another form to take the hormones? like for birthcontrol, now we can use implanon – a chip full of birthconrols hormones that stays in your arm 3 years, until u change it.
    does anyone know if such thing already exists for thyroid hormones?

    • Not to my knowledge, but it sounds nice.

      Sunthroid is T4-only; in general, for most people, it takes seven to ten days to get to your liver, get converted into Free T3 and get back out to your cells, so missing one dose, one day, probably won’t hurt you. If it does, you probably won’t notice until a week later.

      You deserve to replace the T3 not converted from T4 as well. Clinical outcomes prove that the T3 converted from T4 is not enough to restore and maintain health. If you have no antibodies, you might do well on an NDT.

  14. I have a question, i take synthroid since i have 12 years old ( im now 26), but i forget sometimes to take it.
    do you know if there is another form to take the hormones? like for birthcontrol, now we can use implanon – a chip full of birthconrols hormones that stays in your arm 3 years, until u change it.
    does anyone know if such thing already exists for thyroid hormones?

  15. Try an ob/gyn first, then a holistic or integrative doc, then a functional medicine doc?

    • Hello, Thyroidless Barb, are you still receiving replies from this site? I am at my witts end and you seem so much more knowledgeable than anyone I have found yet. If you can help me too I would be so grateful, I am so close to giving up this fight, no matter what I try NOTHING works…

      If you don’t mind, my issue is I had half of my thyroid removed by UNEDUCATED Endocrinologists and then was put on 30 mcg/mg? of Synthroid, then MONTHS of getting worse and worse. I found another doctor who allowed me to try Synthroid + cytomel….still no change. She then let me try Armour…..I felt much better (scale of 0 to 10, “10” being how I felt BEFORE Hashimotos problems, so with Armour 180 I felt like I had gone from 0 to 6.) However I still had/have MAJOR memory problems, anxiety, and inflammation NO MATTER the dose or T4 T4/t3 combo..This “better feeling” was short lived, and then we looked at my low adrenals (24 hr saliva tests), she put me on 400mg of Spironolactone and I started to feel better for a few months then I began to feel HYPER, so we lowered the 180 Armour to 120, which right away made me VERY HYPO, so 4 months later I had to go back on the 180 dose!!! I have done all of the allergens test, for 18 months I took out ALL of the foods that “could cause problems”, and that make life worth living, did the gut and candida tests, all negative….A few months into taking the Spironolactone I began having NON STOP UTI’s, I knew it was the Spiro DESPITE the UNEDUCATED KNOW IT ALL DOC’s online who claim Spironolactone DOES NOT cause UTI’s as a side effect, but weeks of research prove that using Spironolactone causes UTI’s IN MANY WOMEN, NOT JUST ME !!! I decided to wean off of the Spironolactone because NON-stop UTI’s is simply unbearable, BUT weeks later I had the HORRIBLE acne again and all over weakness and body pain. I then started back taking 200 MG of Spirono but 200 had little affect on the acne and NO effect on the inflammation/pain. I am now feeling the HYPER again, and my doc told me to start back on 400 mg of Spirono, but it DOES NOT help with the inflammation, it DOES cause non-stop uti’s, it ONLY helps with my chronic pain and acne…..

      I have read SO MUCH for SO long, most things are contradictory to other things, I know about the rt3 etc but I can’t find CUT AND DRY information to print off for my doc…..seriously, if we have Hashimotos we MOST likely can’t concentrate, focus, remember the info from 40 different “thyroid” sites…….I have just become TOO overwhelmed, my doctor will try anything to help me, BUT she is VERY over worked due to being the ONLY doctor who will listen to patients, so I NEED to be able to get the CLEAR info on what to try next from someone like you who really knows her stuff!!

      I am so sorry to bother you with this, I just don’t know where else to turn, the information is all so spread out and contradictory from one of these sites to another and my going , SEEMINGLY, ALL the way back to square one….I don’t want to keep living like this if there is some other thing to help me…Thank you so so so very much, I hope to hear from you, and I hope you have a wonderful week.

      • Oop’s Sorry I forgot to add my current syptoms and dosages:

        I take 400 mg Spironolactone (was on 200 until yesterday) (been taking Spironolactone for 9 months now)

        180 mg of Armour

        I have been “Hypo” for 4 years now as far as always having all over inflammation, edema, unable to lose weight, brain fog (more like brain dead), weakness, all over pain, headaches almost daily, sore neck, dry eyes, constant white goop in my eyes often making my vision blurry, acne on face, neck, under chin, upper back (but only if im taking less than 400 mg Spironolactone), MAJOR anxiety, easily winded just walking from one side of house to the other, and HOT, I am ALWAYS SO HOT, I sweat almost non stop and stay HOT no matter what,(since May, before May it just was night sweats and almost daily HOT FLASHES, I have been dealing with the EASILY STARTLED issues for YEARS now (7 years), and it has NOT improved AT ALL taking nothing more than sudden movement to send me to the ceiling, and noise is worse and the “freight” makes me MAD angry at the one who caused me to startle, I am SAD, but not depressed, I feel helpless and hopeless, I feel like crying but have NO tears, and NO saliva anymore (Spirono side effect) I STILL have TMJ and recently my plantar fasciitis returned so walking HURTS in the mornings especially, dry hair dry skin, and weird individual bumps that are skin colored, sometimes itch for a day but can go weeks without itching, they sart as an itch I MUST scratch and slowly grow to a 2/3cm bump kind of like a skin colored pimple…In the past year I have gotten 7 of these, one on my breast, 3 on thighs, and 2 on legs, one on my knuckle on right hand middle finger and I can’t find info on what they are? I am SURE there are more symptoms but I can’t remember right now. My skin is still sagging more and more especially on my thighs and chin/face, It started in late 2010 I was 32 yr old 117 lbs 5’4″ tall…..NOW I am 36 yrs old BUT I LOOK 56 yrs old, I weigh 136 and CAN’T LOSE NO MATTER WHAT I TRY….

        I would like to try LDN for the inflammation because I cant wear shoes AT ALL, and I haven’t been able to wear a wedding ring for 3 years….but with NOTHING else getting better, I am at a wall….I just don’t know what to do? Again, thank you so much!

        • Yes, I’m still here, periodically. I still can’t afford the internet at home.

          Most people I know who ingest an NDT also ingest synthetic T3 as a supplement, as needed or daily with extra as needed. The T3 in one grain (60 mg) of your NDT acts the same way as synthetic T3–it gets to work in about 30-45 minutes after dissolving it in your mouth and wears off 3-6 hours later. I ingest my T3 doses about every three hours. I DO have “thyroid” antibodies (autoimmune disease) even though i have no thyroid.

          There’s an LDN facebook page; they “treat” themselves based on lab results, comparing their lab results to the reference ranges provided by their lab (which are based on sick and suffering people who have dysfunctional thyroids). I haven’t tried it, so I can’t help with that.

          IF you’re converting the T4 in the NDT (and it’s about 80% T4) into RT3 instead of FT3, that means the T3 in the NDT (about 15%) isn’t enough for all your cells.

          IF autoimmune disease caused your “hypothyroidism” in the first place, that needs to be treated as well as replacing the thyroid hormones your thyroid can no longer produce since you had it removed. Same with calcium since your paras were removed.

          A healthy thyroid makes about 94-110 T4 and 10-22 T3, so, ingesting an NDT, you’ll need 3-5 grains (180 mg is 3 grains) for replacement. Congrats on getting a doc to prescribe 3 grains! Dissolve them in your mouth at 3 different times per day (not all at once)!

          It takes 7-10 days for the T4 to get to your liver, get converted and back out to your cells, so changing dosing times and amounts, usually, takes about two weeks for you to notice any difference.

          I think ALL of your symptoms are related to under-replacement of thyroid hormones, even if you are converting the T4 to FT3 instead of RT3. The imbalance really screws with our reproductive hormones. When I have an estrogen spike, a separate dose my of OTC progesterone cream helps. Women even have estrogen spikes AFTER menopause.

          As the ovaries shut down (during the sometimes ten-plus years of menopause), progesterone levels decrease quicker than estrogens’ levels, so supplementing or replacing progesterone becomes that much more important. Usually, adrenals pick up the slack as the ovaries shut down, but with thyroid problems comes adrenal problems. Women ovulate for an AVERAGE of 40 years, so take your age when you started and don’t let any doctor bully you into removing your parts! Menopause is more about FLUCTUATING levels of reproductive hormones than it is in dramatically dropping levels. Intense fluctuations, as the adrenals learn to compensate for the ovaries, cause symptoms. Those symptoms can be less intense IF your cells are getting the T3 they need.

          Here’s a blog written by someone else named Barb (I’m not writing blogs yet). If I had written it, it’d be a lot longer!


          Bottom line, for me: a healthy thyroid is EXQUISITELY self regulating. Providing this exquisite self regulation from the OUTside IN is NOT easy! You have to know how a healthy thyroid works so you can replicate that health for your individual body. The only site I know that summarizes all this information is http://www.eaware.org.

          Hope this helps!!!

          There are multiple articles on my timeline on facebook set to “Public” view so you don’t have to be my friend to read them. Most of those articles appear in January for “Thyroid Awareness Month”. Barb Shultz (Barb Boston), my profile pic is a white tiger cub.

  16. How do you find a dr to test your labs and treat hashimotos? I’m desperate to find a dr that can help me. I feel like I’m dying…

  17. Hi Barb,

    Great insight you have there. It is difficult to find information for those who no longer have a thyroid. Can I ask what you take now that your RT3 problem is at bay? Do you take T4/T3 or just T3?


  18. I am a 66 year old female. I am tired; sleep great at night; can’t lose any weight; walk everyday 2 plus miles. Last TSH in October 2013 5.75. I have been on the high side for several years. Do I need thyroid replacement therapy?

    • Only YOU can make that decision. If I were you, I’d get more tests FIRST, to figure out WHY your TSH is so high. Maybe you have thyroid antibodies, which is evidence of autoimmune disease, not thyroid disease? Maybe you’re no longer converting your own T4 into the Free T3 your cells need, in which case, you need a T3-only med instead of a T4-only med. TSH results, just like Free T3 results, fluctuate during the day, so what TIME of day is your blood drawn (both results are highest in the morning, lowest at 3-4 pm for “most people”)? Mr. Kresser won’t answer your questions; I suggest you make an appointment with a functional medicine doctor who also happens to be an integrative medical doctor, it will probably be cheaper to order your own tests from an on-line laboratory, and get more results, get more info on how a healthy thyroid works and THEN decide if and which thyroid hormone you might need to supplement or replace. 🙂

      Rigorously screened, healthy volunteers tested as follows, so ignore any labs’ reference ranges:

      TSH .4-2.5 (yes, 5.+ anything is too high!)
      Free T4 .7-1.8
      Free T3 for women 4.25-6.19
      Free T3 for men 2.0-5.0
      Reverse T3 ZERO
      Antibodies ZERO! UNdetectable!!!
      (There are four antibody tests.)

      Good luck!!!

      • Barb,

        I have appreciated reading your comments. My father had thyroid cancer many years ago and it is now becomming clear to me that his medication for NO THYROID has been terrible mis-managed for a long time. I am trying to educate myself so I can hopefully steer him in the right direction to get the help he needs. The internet seems to be focused primarily on treating hypothyroidism rather than treatment for no thyroid. Would you be willing to give me your perspective if I ask you some questions?
        If so, my email is [email protected].

        First question: Is the reason you are unable to convert T4 to T3 because you have no thyroid or a different unrelated issue?

        • Mark:

          I sent you an email.

          We think I was only converting T4 into Reverse T3, but there’s no way to tell since we just started me on T3-only and never looked back. eaware.org, under Thyroid on the left, under RT3, says that ingesting T4 for a long period of time causes Reverse T3, so that’s probably also a part of my previous problem. Since RT3 can only be made from T4, I won’t ever have that problem again.

          On the other hand, ingesting T4-only when I needed the T3 not converted from T4 also caused “other issues”.

        • First, you need to know the test measurement. (Get a copy of ALL your lab reports; they show your result, the test measurement and the reference range your lab is using.)
          Second, you need to realize that Free T3 only measures the Free T3 IN your bloodstream, NOT how much is actually getting INTO your cells.
          Third, in the USA, healthy women with healthy thyroids test between 4.25-6.19 pg/mL, so, if that’s your test measurement, someone is misreading the result as high, OR, everyone being tested by your particular lab is really, really sick and suffering. (I’d be nearing my deathbed if my FT3 result was 2.anything!)
          Fourth: RT3 and antibodies can prevent the Free T3 in your bloodstream from getting INto your cells, but there is NO blood test to measure how much FT3 your cells are actually receiving.
          Fifth, the time of day your blood is drawn affects your result (it’s highest in the morning and lowest in the afternoon for “most people”).

          Doctors will say it means you are “hyperthyroid” or you have Graves Disease. Graves is autoimmune disease, not thyroid disease, so destroying your thyroid won’t address the underlying cause. I’ve listed elsewhere the antibody tests.

          You can order your own tests from an online lab if you can’t get anyone to re-order (or order more) tests.

          If they want you to swallow radioisotopes or ingest an anti-thyroid med, get a second opinion first!!!

  19. Hi!! so glad i came across this board, Thyroidless Barb, I have sooo many questions for you…. I have no thyoird, had rt3, 8 weeks at t3 only, plus low cortisol, at cross road, should i have antibodies checked before I make a switch??

    • I would get my antibodies checked, remembering that one is too many regardless of which reference range the lab provides. There are four antibody tests:

      Hashimoto’s Disease:
      Thyroid Peroxidase Antibody (TPOab)
      Anti-Thyroglobulin (TgAb)

      Grave’s Disease:
      Thyroid Stimulating Immunoglobulin (TSI)
      Thyroid Receptor Antibody (TrAb)

      This might help:

      LOW thyroid (short version):

      We get what appear to be hyPER symptoms when labs prove we are hyPO. What occurs is that when the body senses the metabolism slowing due to low thyroid hormones, in it’s effort to maintain homeostasis, the adrenals are given the signal to increase catecholamine output (adrenalin) which revs up the heart rate and BP, causing anxiety, heart racing and palps.

      NO thyroid:

      We get what appear to be hyPER symptoms AND lab results when we are hyPO. What occurs is that when the body senses the metabolism slowing due to low thyroid hormones, at the CELLULAR level (not in the bloodstream), in it’s effort to maintain homeostasis, the adrenals are given the signal to increase catecholamine output (adrenalin) which revs up the heart rate and BP, causing anxiety, heart racing and palps. Low T3 at the cellular level also stops production of progesterone (elevating estrogen unopposed by progesterone) and increases cortisol. Progesterone is a KNOWN component of converting T4 into FT3, and I notice my T3 works better when I use my OTC progesterone cream.

      Labs will always be higher and the TSH lower when ingesting thyroid hormones, especially when ingesting T3, because you must ingest more than a healthy thyroid secretes to get the same effect at the cellular level….

      My TSH and FT4 are completely suppressed; my FT3 is too high; my RT3 is non-existent, since it can only be made from T4; and my antibody levels/results vary/fluctuate, depending on what, when and how much I eat. I trying to do all organic, no GMOs, but it’s not cheap!

      I’m also not a doctor or nurse. We’re all VERY individual!