5 Thyroid Patterns That Won't Show up on Standard Lab Tests | Chris Kresser
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5 Thyroid Patterns That Won’t Show up on Standard Lab Tests

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In medicine, the key to choosing the best treatment is an accurate diagnosis. If the diagnosis isn’t correct, the treatment will be ineffective – or even cause harm.

Unfortunately misdiagnosis is common in the management of hypothyroidism and other thyroid disorders. If you go to a doctor with hypothyroid symptoms, you’ll simply be given replacement hormones without any further inquiry into the cause of your condition.

Even worse, if you have hypothyroid symptoms but your lab tests are normal, you’ll be told you’re “fine.” If you insist you’re not, you might be sent home with an antidepressant, but no further clue about the cause of your symptoms.

The problem with this approach is that thyroid physiology is complex.

The production, conversion and uptake of thyroid hormone in the body involves several steps. A malfunction in any of these steps can cause hypothyroid symptoms, but may not show up on standard lab tests.

It’s incorrect and even negligent to assume that all cases of hypothyroidism share the same cause and require the same treatment. Yet that’s exactly what the standard of care for hypothyroidism delivers.

In this article I’ll present five patterns of thyroid dysfunction that won’t show up on standard lab tests. If you have one of these patterns, your thyroid isn’t functioning properly and you will have symptoms. But if you go to your conventional doctor, you’ll be told there’s nothing wrong with your thyroid.

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A standard thyroid panel usually includes TSH and T4 only. The ranges for these markers vary from lab to lab, which is one of two main problems with standard lab ranges. The other problem is that lab ranges are not based on research that tells us what a healthy range might be, but on a bell curve of values obtained from people who come to the labs for testing.

Now, follow me on this. Who goes to labs to get tested? Sick people. If a lab creates its “normal” range based on test results from sick people, is that really a normal range? Does that tell us anything about what the range should be for health? (For more on the problems with standard lab ranges, watch this great presentation by Dr. Bryan Walsh)

The Five Thyroid Patterns

1. Hypothyroidism caused by pituitary dysfunction

This pattern is caused by elevated cortisol, which is in turn caused by active infection, blood sugar imbalances, chronic stress, pregnancy, hypoglycemia or insulin resistance. These stressors fatigue the pituitary gland at the base of the brain so that it can no longer signal the thyroid to release enough thyroid hormone. There may be nothing wrong with the thyroid gland itself. The pituitary isn’t sending it the right messages.

With this pattern, you’ll have hypothyroid symptoms and a TSH below the functional range (1.8 – 3.0) but within the standard range (0.5 – 5.0). The T4 will be low in the functional range (and possibly the lab range too).

2. Under-conversion of T4 to T3

T4 is the inactive form of thyroid hormone. It must be converted to T3 before the body can use it. More than 90% of thyroid hormone produced is T4.

This common pattern is caused by inflammation and elevated cortisol levels. T4 to T3 conversion happens in cell membranes. Inflammatory cytokines damage cell membranes and impair the body’s ability to convert T4 to T3. High cortisol also suppresses the conversion of T4 to T3.

With this pattern you’ll have hypothyroid symptoms, but your TSH and T4 will be normal. If you have your T3 tested, which it rarely is in conventional settings, it will be low.

3. Hypothyroidism caused by elevated TBG

Thyroid binding globulin (TBG) is the protein that transports thyroid hormone through the blood. When thyroid hormone is bound to TBG, it is inactive and unavailable to the tissues. When TBG levels are high, levels of unbound (free) thyroid hormone will be low, leading to hypothyroid symptoms.

With this pattern, TSH and T4 will be normal. If tested, T3 will be low, and T3 uptake and TBG will be high.

Elevated TBG is caused by high estrogen levels, which are often often associated with birth control pills or estrogen replacement (i.e. Premarin or estrogen creams). To treat this pattern, excess estrogen must be cleared from the body.

4. Hypothyroidism caused by decreased TBG

This is the mirror image of the pattern above. When TBG levels are low, levels of free thyroid hormone will be high. You might think this would cause hyperthyroid symptoms. But too much free thyroid hormone in the bloodstream causes the cells to develop resistance to it. So, even though there’s more than enough thyroid hormone, the cells can’t use it and you’ll have hypothyroid – not hyperthyroid – symptoms.

With this pattern, TSH and T4 will be normal. If tested, T3 will be high, and T3 uptake and TBG will be low.

Decreased TBG is caused by high testosterone levels. In women, it is commonly associated with PCOS and insulin resistance. Reversing insulin resistance and restoring blood sugar balance is the key to treating this pattern.

5. Thyroid resistance

In this pattern, both the thyroid and pituitary glands are functioning normally, but the hormones aren’t getting into the cells where they’re needed. This causes hypothyroid symptoms.

Note that all lab test markers will be normal in this pattern, because we don’t have a way to test the function of cellular receptors directly.

Thyroid resistance is usually caused by chronic stress and high cortisol levels. It can also be caused by high homocysteine and genetic factors.

Conclusion

The five patterns above are only a partial list. Several others also cause hypothyroid symptoms and don’t show up on standard lab tests. If you have hypothyroid symptoms, but your lab tests are normal, it’s likely you have one of them.

Not only do these patterns fail to show up on standard lab work, they don’t respond well to conventional thyroid hormone replacement. If your body can’t convert T4 to T3, or you have too much thyroid binding protein, or your cells are resistant, it doesn’t matter how much T4 you take; you won’t be able to use it.

Unfortunately, if you have one of these patterns and tell your doctor your medication isn’t working, all too often the doctor’s response is to simply increase the dose. When that doesn’t work, the doctor increases it yet again.

As I said at the beginning of this article, the key to a successful treatment is an accurate diagnosis. The reason the conventional approach fails is that it skips this step and gives the same treatment to everyone, regardless of the cause of their problem.

The good news is that, once the correct diagnosis is made, patients respond very well to treatment.

841 Comments

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  1. But that’s exactly my point, Carina: that “normal” thyroid labs don’t necessarily equate “normal” thyroid function. This is the argument I’m making in the article.
    These 5 mechanisms I listed here can suppress thyroid function, but they won’t necessarily show up on lab tests and they won’t necessarily respond to replacement. The value of those trials is that they confirm that replacement won’t work for patients when their underlying mechanisms haven’t been addressed.

  2. Chris,
    I guess I digressed there from your article, but these questions always pop into my head when I hear of trials like the one mentioned.

    I really thought it was normal to raise the dose quite a bit. But even so, if some of the test persons had one of the underlying dysfunctions, then that would skew the results, so I would still say that there are problems with trials trying to determine whether or not patients with “normal” labs would benefit from thyroid meds.

  3. I assume Carina meant that when you first start treatment you increase the dose every 6-8 weeks until optimised. Not that you change the dose every six weeks for the rest of one’s life. This is very common when the above mechanisms are not addressed or a person is on T4 only though.

  4. Carina,

    The point of this article is that there are physiological mechanisms which depress thyroid function that won’t respond to standard thyroid hormone replacement.

    For example, if your cells are resistant to thyroid hormone, supplemental thyroid hormone will have a limited effect. If you underconvert T4 to T3, taking Levothyroxine or another T4 replacement won’t help much.

    The reason thyroid patients have to continually increase their dose is that these underlying mechanisms aren’t being addressed. It’s not “normal” to have to raise the dose every 6-8 weeks. It might be common, but it’s not normal.

    • I’m not sure I agree with what you are saying here Chris. You place a lot on thyroid resistance when it is more likely hypothyroid symptoms whilst taking thyroid meds is due to other matters such as low/high Iron and low/high cortisol, poor functioning adrenals etc. These are easy things to test and sort out and should be so. There are also other things such as high flouride/bromide levels, high toxic metals such as mercury or lead etc. These too are things which must e addressed but may cause someone to eed higher doses of thyroid hormone meds.
      Of course for most people who are put on levothyroxine they may suffer the problem of poor conversion and rT3 conversion and so their meds must be changed otherwise they will always be hypothyroid and no matte how much Levothyroxine they receive their symptoms will not abate.
      It is normal to raise your thyroid hormone meds every 6-8 weeks but only until the best dose is attained and that is the dose which relieves your symptoms – and not lowers your TSH to whatever level.
      So I agree with Carina that study is not a study to base any treatment on, since the hypothyroid issue is too complex and should not be affected by that one study; I’m not sure what the point of the study was to be honest, if you need thyroid hormone then a placebo will not do -simples!

  5. “In trials where people with normal blood tests but symptoms of low thyroid are given thyroid hormone or placebo (inactive pill, e.g. sugar pill) (e.g. BMJ 2001;323:891-895) there was no benefit in giving thyroid hormone over placebo.”

    I´m curios how these trials can possibly work, since you have to raise your thyroid hormone until symptoms are relieved and the sufficient amount is so individual. For me it took 100 mcg of tyroxin to get any real benefits, but even that wasn´t enough. I did feel a little better on 50 mcg than on nothing but I was still sick as a dog. I would have probably been written off as one that didn´t respond better than placebo. How high a dose do test patients get in such studies? And do they raise the dose every 6-8 weeks as a normal thyroid patient would?

  6. Can you please state which tests to order for a full thyroid evaluation  —name them in order in a way the lab will understand and/or I can take to my doctor.
    thanks for the great information.

    • The problem is not what tests to order, but finding a doctor that knows how to do a proper thyroid evaluation. You can order the right tests, but if your doctor doesn’t know how to interpret them, it’s not much use. The standard tests I order for each patient are TSH, TT4, TT3 and T3 Uptake. If I suspect autoimmune involvement (almost always the case if TSH is elevated), then I’ll order thyroid antibodies as well.

      • So, even if I order the TSH, TT4, TT3, and T3 Update as well as the Thyroid Antibodies… the doctor may not realize if something is wrong looking at the tests? So far they only order the T3 and TSH (I believe)… But since my cholesterol is high and my Vitamin D is low and I have other symptoms of what could be Thyroid issues (sure, they are symptoms of other things as well)… I’d like to truly rule out the Thyroid. I do also have recurrent Iritis (an autoimmune disease), so I am relatively sure that my other non-eye symptoms are autoimmune in nature… just can’t pin them down.

      • i have had underactive thryoid for a year now, i am on 125mg levothyroxine. Recent blood test shows my t3 and t4 are ok but TSH is high. My doctor has advised me to go to 100mg and then re-test in a month. My joints ache at the moment and feeling very tired. Do you think I have thryoid resistance? What is the best way to treat this. I have never felt 100% since being diagnosed and long to feel like the old me 🙁

      • So T4 Free (1.1), T3 Uptake (31), & T3 Total (86), will not paint the complete picture? What else should I take? Is TSH necessary?

      • I am starting to feel like there is a link between my son’s mental health and his Thyroid.

        My son has been diagnosed ADHD and we tried every type of stimulant. They did not even touch the problem. In fact they made things worse (very out of control mood swings).

        My son is 8 years old. Off the medicine he is incredibly active can literally run all day (I have 5 children and my wife is a school teacher… his activity level stands out). He also has emotional outbursts when he is off the medicine, getting very upset, and then eventually crying and coming back down to normal. During his outbursts he says things like, “I wish I was never born.” and other very sad/ low self-esteem things (This is odd for someone so young).

        All the ADHD stimulants made his outbursts worse. At some point he was prescribed a small dose of risperidol and it seemed to help, but he started to gain a lot of weight, so we took him off of it. His weight normalized and then we tried Abilify, that definitely helped, but again weight has started to creep up.

        One of his doctors actually did a thorough blood work on him. I noticed that his TSH level was 7.34. (I have other blood info if useful)

        Do you have any recommendations? What type of a Doctor should I see to get to the bottom of this. Psychiatrists are not the right answer…

        Thanks
        Mark

        • Mark, I would strongly consider getting your son evaluated for Bipolar disorder. That sounds like a better description of his symptoms than ADHD and explains quite well why stimulants make things worse and why Abilify helped. Abilify is a mood-stabilizer and is used with people who are bipolar.

          Note: I am not a doctor nor a therapist. I do, however, have a masters in exp. psychology and used to own and run a counseling office with my then-husband who was a clinical psychologist. I am not diagnosing your son as bipolar. Just suggesting that it is a possibility and if that is what he has, then treatment might be able to be better geared toward that than adhd. It is not unusual for kids to be diagnosed adhd when they are really bipolar. Here’s a quick link about the two: http://www.webmd.com/bipolar-disorder/guide/bipolar_disorder_or_adhd.

          Good luck!

          • If I were you Mark, I would have your son taken to a endoctrin specialist..your sun has obvious hypothyroidism. Insanity…above 7????? He needs treatment. Psychologists or psychiatrists do sometimes more harm than good…as they do not understand the hormonal connection and your body’s needs. A friend of mine had tsh 4.90 and used to be deeply depressed with severe anxiety. When they found out here levels, she received treatment and feels much better now.

        • The brain must have adequate supplies of T3 to function well. Certainly the TSH levels appear high but interpretation of TSH levels is so variable. I would persue the thyroid issue since it is well known that hypothyroidism causes mental health issues amongst a myriad of other symptoms.
          Whether he has Bi-polar or ADHD it is likely whatever he has is due to low thyroid hormone.

        • Mark, my kindergarten son would have emotional outbursts like yours everyday after school. In 1st grade diagnosed ADHD combined. For him the meds seemed to help but I was never comfortable putting such a young and underweight child on Ritalin. I researched and went to different Drs. Finally when he was in 4th grade found a naturopath to do neurotransmitter tests (way off!) and food allergy tests. Once child had his food allergies removed which for him were gluten, dairy, eggs, bananas and 3 different types of beans, he was like a totally different child. He was able to totally come off the meds and do even better in school. When originally diagnosed I was concerned about him getting through the 1st grade and now he’s shooting for the honor society in middle school. Also remove any known GMO (genetically modified ) foods from the diet as there is concern that the BT toxin engineered into the plant, along with the pesticide residues can lead to leaky gut, causing the food allergies in the 1st place.

          • I am headed to the Dr. with my son tomorrow. This Dr. specializes in Pandas (which I don’t think my son has), but I think this Dr. may lead me down the right path.

            I have heard from several different sources that food allergies/inflamation may be to blame. I want to make sure I suggest the right tests… Is there a food allergy test that is more accurate/revealing than another?

            Also, I had his neurotransmitter levels tested (urine test), and they were all over the map. Almost none of them fell into the “normal” range… I have some Drs. say that the test is not a useful indicator of anything.

            I am trying to avoid quackery while not just settling for the easy answer. Either way nothing has really worked yet.

            Thanks for the help.

            • Mark, in response to your original post, there’s a great book “Healing ADD: The Breakthrough Program That Allows You to See and Heal the 6 Types of ADD” by Daniel Amen and one of the 6 types does not respond well to stimulant meds. Not sure where you live. Here’s naturopath web site for neurotransmitter testing http://stevenenninger.com/ I would no longer go to the Drs who say that neurotransmitters do not mean anything because they most certainly do especially to a Dr skilled in analyzing them and knowegable in correcting any inbalances by removing food allergies and using corrective supplements. Unfortunately such a Dr will most likely be a nathropath and may not participate in your ins. plan. There’s various food allergy tests IGG, IGA testing across 96 foods. Its impossible to have normal neurotransmitters when there’s hidden inflammation because the body is reacting to unknown food allergens. My 10 YO on ritalin for 3 yrs, was so allergic to gluten,dairy, eggs that whole digestive tract and neurological system was inflamed causing ADHD sym. and stunted growth. Diet + supplements- ritalin and w/in 1 month child became new person. Was able to avoid ritalin with younger son, using these techniques.

  7. I don’t see the connection between thyroid hormones and cholesterol. I have hypothyroidism, have had for 55 years, and normal cholesterol. Ben, I’m really sorry you have to use statins. The only time I would recommend statins is in a case like yours becaue they can have deleterious effects.

    • There is indeed a connection between hypothyroidism and high cholesterol. Thyroid hormone is needed to activate the LDL receptors. So when thyroid hormone is low, there will be a larger amount of LDL floating around in the bloodstream.

      • My blood work came back with that very thing (elevated/high cholesterol and low t3 uptake). My TSH was at the low end of normal (well below functional levels) and my T4 was mid range, I think. (I’m going off memory for the latter stuff). Haven’t been able to speak with my Dr yet (phone tag) but with the results coupled with the symptoms (cold hands/feet, fatigue, aching joints, mood swings, etc) I’m hoping the Dr will be amenable to exploring if medication might be beneficial. What do you think?
        And are there any books that are recommended for further education about thyroid?
        Thank you!!

      • My last lipid panel (a few years ago) also showed crazy high LDL. My doctor recommended medication (statins, I assume.) I insisted on an LDL particle test and a CRP test. The LDL particle test came back normal and the CRP test was lower than they could measure. I would never take statins based on an LDL number alone. From a standard lipid panel, the Triglyceride to HDL ratio is the best indicator of heart disease risk. My ratio was excellent, which accurately predicted that the particle count and CRP would be fine too.

  8. Low thyroid hormone supposedly can cause high cholesterol…
     
    Unfortunately, my doctor says all my thyroid numbers (t3, t4, etc) are normal.. so i’m on statins to keep my cholesterol on check (otherwise it shoots up to above 400!!))
     
    There’s a book by David Brownstein, that I’ve heard covers how to step by step diagnose thyroid issues!   In the meantime I’m minimizing my pufa intake, and increasing the number of antioxidants!

    • Please, anyone using Statin drugs to control cholesterol, PLEASE also be taking SIGNIFICANT amounts of CoQ10!
      In Japan, as far back as the early 1990’s, Docs understood clearly, Statins strip critically necessary CoQ10 from muscles–especially from heart muscles where it’s so greatly needed.
      They’ve been dosing Statin takers with -several hundred milligrams- CoQ10 daily.

    • Statins can be very dangerous – I won’t use them. I am using niacin at 500mg at night(you must use the flushing kind and it is a bit like hives so I take it at night). Brought my cholesterol down from 280 to 220. You can also try fish oil – 3g per day or policosanol. All these work to lower cholesterol altho like a statin the policosanol should be used with CoQ10. Niacin was what was used before stains came on the market – very cheap.

    • Rising cholesterol used to be the diagnostic test for hypothyroidism due to the fact that hypothyroidism causes rising blood cholesterol levels. Why? Low thyroid hormone affects the liver as much as it affects other aspects/organs of our body. The Liver is unable to process cholesterol; you will also find it cannot process Vitamin A either, etc., etc.
      Statins will cause more problems and are contraindicated in hypothyroidism; further are you taking CoQ10 at the same time?
      Have a 24hour urine thyroid profile test done this measures how much thyroid hormone your body has actually used. Do some basal temperature tests over several days too. Write a list of your symptoms and any other signs of hypothyroidism and also write a detailed history including family/medical history; these should take precidence over TSH testing; oh and get some studies which demonstrate TSH testing is rubbish, read them and understand them so you can argue your point.

  9. Hi Chris, I noticed in this article about thyroid testing you didn’t mention Free T4 or Free T3.
    My MD has always ordered TSH, FT4, FT3, TPO & TgAb when checking my thyroid, stressing the importance of measuring the Free’s.
     
     

    • T3 uptake gives a rough idea of free thyroid hormone status, is included on most standard lab panels, and is cheaper than running FT3 and FT4. But yes, if I am particularly concerned about the free hormones I’d probably run them too.

        • My thyroid goes up and down. I have autoimmun problems from rheumatoid arthritis. I gained weight, got alopecia in my eye lashes, splitting nails and fall asleep all the time. My doctor has been checking my blood for three years. He can’t give me any medicine because it’s turning out my lab tests are normal.

          • Your Doc should not be treating the lab tests he should be treating you and your history and your symptoms and your signs that includes basal temperature test. Don’t be put off – change your Dr if necessary.

      • You mentioned for one scenario with high estrogen to clear some out of the body. How is that done?
        Love this article! Most helpful I have found!

  10. Sorry it took so long to approve that comment, againstthegrain.  It got caught in my spam filter.

    I like directlabs.com for ordering labs w/o a prescription.

  11. Something tells me Angus is from the BTA or the BTF, with his talk of good doctors being struck off. He seems obsessed with the TSH, which is a pituitary hormone for a start!

    • I don’t have time to answer in the detail I’d like to right now because of my upcoming exam. So I’m going to wait until I do.

      • I have a nodule on my thyroid, persistence of both hypo and hyperthyroidism, and yet every doctor I have been to trying to resolve this has given me a blood test and told me my levels are fine. I have hairloss, brittle nails, anxiety and depression, and huge fluctuations in my weight for seemingly no reason. Not to mention lots of family history. Could you reccomend a doctor that would properly diagnose me? I would be more than willing to travel to get proper care. Help!

        • Hi Kate,

          I also have nodules on my thyroid. However, I do not have symptoms thus my doctor said I’m fine because my TSH is normal. I insisted that I get my T3 and T4 tested and they both were well within the normal range. I’m wondering what I should do next?

  12. FYi, it isn’t always necessary to go through a doc to get the tests you need (though it is great to have a good doc to help with test result interpretation – so I’m not knocking consulting with a good doctor).  In many, if not most cases, patients CAN order the tests themselves, without having to hurdle a gate-keeper doctor, pay unnecessarily for an office visit, or share the results (except in NYS where the legislature seems to think the residents are too feeble-minded to mind their own health).
    If you are willing to pay out-of-pocket instead of billing your insurance co, have a good PPO plan which will reimburse fees for any accredited lab, or if you already are paying out-of-pocket for lab tests, consider using a service that will allow patients to order their own tests.
    There are numerous labs that will take a lab order direct from patients, such as MyMedLab.com (no affiliation other than as a customer).  The test fees are often discounted, especially when “bundled” with other tests typically ordered for common conditions, and include the doctor’s order necessary to run the tests (except NYS, where this arrangement is specifically prohibited by law).  Test samples are collected at many convenient locations, including the widespread Lab Corp network.  Results are usually speedy and communicated directly to the patient, though can be also copied to a physician if desired.
    I couldn’t get my endo to run thyroid tests for thyroid antibodies (he said it wouldn’t make any difference in my treatment) so I ordered the test my self from MyMedlab.com and had the blood draw done at LabCorp.  I received an email the next day that my results were in (avail via secure log-in at the website).  The fee was very reasonable.
    I also have ordered my own tests at Enterolab.com to check for gluten sensitivity.

    • I totally agree with this! I think its so so important to get the advice of medical professionals, but when you know you need some tests, its ok (and sometimes cheaper) to just order them yourself. I went way way too long without knowing this, so I am glad that someone has already posted about it here. I found a helpful site for me to find info about ordering my own blood work at http://PrivateHealthNetwork.net

      I really hope that Chris does/did well on any exams he has- This is one of THE BEST sites that I have seen for Thyroid information. It really has helped me- I have been scouring the web trying to find info about my condition, and this is one of the few sites that has helped!
      Thank you!

    • I’m one of those in NYS. What can we do about getting the same rights as other states to order our own tests? Why do New Yorkers pay so much in taxes and have so few medical rights? This alone makes me want to move!

    • But how do you fund someone to help you when you have the results and don’t know what to do now??

  13. This article displays  lack of understanding of basic thoiroid function. Taking the points above in order:
    1. T4 will be low in hypothyroidism secondary to pituitary dysfunction
    2. Control of TSH is dependant on feedback from T4 and T3 levels acting on the hypothalamus and pituitary. The action of T4 and T3 on inhibiting TSH production is proportional to peripheral activity (ie T3 has more peripheral activity  and more feedback (for a given concentration). Therefore if you are poor at converting T3 to T4 you will secrete excess TSH until the combined action of T4 and T3 is at a physiological level (T4 may be above ‘normal’ and T3 lower but overall activity will be unchanged.
    3. Assays which measured total thyroid hormone went out in the 1980’s. All assays used now measure free hormones therefore changes in TBG are irrelevent.
    4. Now I’m completely lost. Tempting to say you couldn’t make this stuff up but of course you have. High levels cause thyroid underactivity? Well obvoiusly thats why all those people with thyroid overactivity have symptoms of underactivity. Except they don’t they have symptoms of overactivity (sweats/palpitations/weight loss etc). Can you produce any evidence for this? Thought not.
    Also, for your information I expect the testosterone levels seen in female to male transexuals are rather (about 10 times) than the slight increases seen in PCOS.
    5. Untrue. Usually Thyroid hormone resistance (which is mainly inherited) affects the receptors in the pituitary and hypothalamus in a similar way to to those in the rest of the body. The end result is elevated TSH levels and T4/T3 but the peron with the condition has no symptoms.
    Sadly the symptoms seen with underactive thyroid are very non specific, really common, usually not caused by thyroid problems and often caused by complex factors with no simple cure. In trials where people with normal blood tests but symptoms of low thyroid are given thyroid hormone or placebo (inactive pill, e.g. sugar pill) (e.g. BMJ 2001;323:891-895) there was no benefit in giving thryoid hormone over placebo. Unnecessary thyroid hormone treatment carries a risk of side effects including osteoporosis and changes in heart rythm. There are good reasons why UK doctors who prescribe thyroid hormones to people without any evidence of deficiency are struck off and national guidelines are explicit in advising against (http://www.british-thyroid-association.org/news/Docs/hypothyroidism_statement.pdf).


    • Sorry it has taken me so long to respond to this. As some of you know, I was preparing for the acupuncture licensing exam in early August, and then on vacation until last Sunday night.

      1. T4 will be low in hypothyroidism secondary to pituitary dysfunction

      That depends what you mean by low. It’s possible in this pattern for T4 to appear within the normal lab range, but below the functional range. Lab ranges are not based on scientific studies, but instead on bell curve analyses of patients who get tested in labs. Who gets tested in labs? Sick people. Therefore standard lab ranges represent what is “normal” for sick people, not what is normal for healthy people.

      What’s more, many people who have their TSH & T4 tested are taking supplemental hormones, which further skews the lab ranges.

      Finally, as much a we’d like to think that these feedback loops work in a textbook manner, they don’t. For example, I have a patient with confirmed Graves’ disease. According to the textbook, she should have low TSH (she does) and elevated T4 and/or T3 (which she never has). In fact, it’s not at all uncommon to have patients that don’t fit the expected patterns.

      2. Control of TSH is dependent on feedback from T4 and T3 levels acting on the hypothalamus and pituitary. The action of T4 and T3 on inhibiting TSH production is proportional to peripheral activity (ie T3 has more peripheral activity and more feedback (for a given concentration). Therefore if you are poor at converting T3 to T4 you will secrete excess TSH until the combined action of T4 and T3 is at a physiological level (T4 may be above ‘normal’ and T3 lower but overall activity will be unchanged.

      There is some controversy on this issue. But I can tell you that I’ve seen lab work on patients with normal TSH, normal T4 and low T3. If it were always true that low T3 would increase TSH, then such a result shouldn’t be possible. But as I mentioned above, patients very often don’t present with the textbook pattern.

      I’ve also seen and heard of patients improving when treated for T4 to T3 conversion problems even when their TSH is normal.

      3. Assays which measured total thyroid hormone went out in the 1980′s. All assays used now measure free hormones therefore changes in TBG are irrelevent.

      I don’t know what it’s like in the UK, but here in the US the standard measurement is total thyroid hormone (which includes free and protein bound). Few doctors order free T4 or free T3 routinely. Therefore TBG is not at all irrelevant. This is why T3 uptake is still included on standard thyroid lab panels.

      4. Now I’m completely lost. Tempting to say you couldn’t make this stuff up but of course you have. High levels cause thyroid underactivity? Well obviously thats why all those people with thyroid overactivity have symptoms of underactivity. Except they don’t they have symptoms of overactivity (sweats/palpitations/weight loss etc). Can you produce any evidence for this? Thought not.

      It is well-known that receptor site expression and sensitivity are both down-regulated in the presence of excess hormones – whether thyroid, insulin, leptin or other.

      It’s true that a large excess of thyroid hormone will produce hyperthyroid symptoms. But it’s a question of scale. To illustrate this, let’s look at a similar pattern that occurs with another hormone: insulin resistance. Chronic elevations of insulin cause insulin resistance. The cells are less sensitive to circulating insulin and hyperglycemia results. However, what happens if you give a hyperglycemic an insulin shot? They become hypoglycemic. Even though their cells are insulin resistant, they still have some receptor site activity, and the flood of insulin from the shot is enough to activate the receptors – whereas the smaller amounts of insulin produced from eating food is not.

      Thyroid hormone resistance with decreased TBG is similar to what I described above. The elevations in free thyroid hormone are enough to down-regulate receptor site activity, resulting in decreased proteonomic response. However, in hyperthyroidism, the level of circulating free hormones is more analogous to the levels of insulin after a shot. These much higher levels are still able to activate the receptors and increase proteonomic response.

      5. Untrue. Usually Thyroid hormone resistance (which is mainly inherited) affects the receptors in the pituitary and hypothalamus in a similar way to to those in the rest of the body. The end result is elevated TSH levels and T4/T3 but the person with the condition has no symptoms.

      Sadly the symptoms seen with under-active thyroid are very non specific, really common, usually not caused by thyroid problems and often caused by complex factors with no simple cure. In trials where people with normal blood tests but symptoms of low thyroid are given thyroid hormone or placebo (inactive pill, e.g. sugar pill) (e.g. BMJ 2001;323:891-895) there was no benefit in giving thyroid hormone over placebo.

      My answer to #4 above addresses this. Of course there would be no benefit to giving thyroid hormone to people with resistance. Their cells can’t use it. The factors causing resistance in the first place must be addressed for these people to improve.

      This is one reason why people on supplemental thyroid hormone continue to need larger and larger doses.

      • “But I can tell you that I’ve seen lab work on patients with normal TSH, normal T4 and low T3.”
        Well, such lab work is the reason I am here. Haven’t been officially diagnosed with anything, but I had my tests last week, saw the results and now I am educating myself.
        Thank you, Chris.

        • I am suffering from almost all of the symptoms of Hashimoto’s Thyroiditis and my THS & T4 levels are normal. I asked to take the TPO & TG tests!

        • You can have ‘normal’ TSH levels and ‘normal’ T4 levels and low T3 levels and be hypothyroid. How? The pituitary gland soaks up huge amounts of thyroid hormone and may be adequately supplied with thyroid hormone even though the rest of your body’s tissues, cells and organs are depleted of thyroid hormone….probably due to poor conversion of T4 to T3 – at this point normal levels to high normal levels of T4 can circulate whilst T3 levels may be low. The individual will display signs and symptoms of hypothyroidism and this must not be ignored.
          There may also be something such as oestrogens or high/low Cortisol or High/Low Iron levels which block thyroid hormone gaining access into the cells.
          Further no one has mentioned reverse T3 (rT3). If there is an abundance of T4 circulating and in some other circumstances T4 and only T4 is converted to rT3 and not T3; hence low T3 serum blood levels, normal/normal high levels of T4 and ‘normal’ levels of TSH. If the rT3 levels are measured it is possible to work out whether the body is (and not the pituitary) is low in thyroid hormone or not by working out the ratio of T3 to rT3.
          Further, if you are all confused it is easy to measure exactly how much thyroid hormone the body has been able to use – or not as the case may be. There is a 24hr urine thyroid hormone profile test; which measures T4 and T3 metabolites; that is what exactly the body has used and the remains of which (metabolite) is expelled by the kidneys.

      • Hi Chris, I have had hyperthyroid a few times in my life. It came after childbirth and a few more times after that. I take medication for a few months till the thyroid becomes hypothyroid and I ween off the medication and I go back to normal. I am 45 and had a partial hysterectomy which now has put me in menopause . What has been happening now is that I have had major heart pounding that went straight through a week long period and now I have palpitations and tremors . My muscles are very fatigued and I have no energy and my blood pressure gets high at times( I never have high blood pressure) . It feel very much like how I felt with hyperthyroidism but the blood work is showing up fine. I have went for 3 tests and there is nothing. They checked the tsh and the free t3 and t4. I feel horrible and I am so frustrated because I am a very healthy active person. Can you let me know what you think. Thank you

        • I would say check your adrenal gland function and iron profile too…also ask for rT3 and T3 ratio lood test.
          If you are hypothyroidi it is very unusual for someone to remain euthyroid once they stop their thyroid meds….there are transient cases but they are not too common. If you have to take thyroid meds of and on and off and on then one might suspect you should stay on the meds and stop coming off them to stay well.

      • Bc,
        I have a Downs daughter, she is now 32, and even though her blood tests show her thyroid only a little low, her doctor has upped her strength of meds on two occasions.
        From what I observe from watching her day to day, I believe she does not metabolize her food properly and in turn has upset stomach more than should be, she has gained weight more than should be, she sleeps to much, and is content to set to much. In short to tire, to much weight gain, always tired, and sleeps as soon as se exerts any energy over active work. Just shopping for an hour or two will send he off for a long a long nap.
        Does this sound like a thyroid that needs a more in depth testing? Or should I look into another area?
        Thank you for any help.b

        • It sounds as though she is on the wrong meds; likely she needs some T3 such as Armour or ERFA Thyroid or she may need T3 only meds. This might be necessary on a temporary basis to get rid of any rT3; but you need someone who has an understanding of the issues around low thyroid hormone.
          If she converts T4 to rT3 then it is of no use giving her more T4 meds since she will convert her meds to rT3 and remain hypothyroid. The symptoms you describe are hypothyroid symptoms; find a Dr who knows more than you; and in the mean time educate yourself to get the best deal.

    • I have FDH as do 3 other female members of my family, we all have normal thyroid function tests but symotoms of both elevated and low thyroid. We have been told by doctors that cant see past black and white that FDH does not cause symptoms. Well i would like them and you, who is adament that people couldnt possibly have symptoms, live with this thing!!

    • I agree with much of what you said in your post but the last bit is incorrect; Before a study can be considered valid it must be repeated and the same outcomes must also be repeated….so the test with placebo vs thyroid hormones has not been replicated…one also has to consider how the test was carried out and on whom; as we know low thyroid hormone/hypothyroidism is a complex subject.
      A trial of thyroid hormone is a valid thing to do and is not dangerous; your statement is scaremongering. I am based in Europe and the European Union Guidelines support the use of thyroid hormone trials when diagnosis is uncertain. The use of a trial of hormones has been carried out safely through many decades and should still be a valid option when doubt exists.
      Firstly, patients should be tested for Adrenal function and iron profile testings and also in my experience fungal infections, and treated accordingly, prior to a trial commencing. If the patient complains of symptoms associated with hyperthyroidism then the trial can be stopped and no harm is done; only if thyroid hormone is continued whilst the fpatient experiences these hyperthyroid symptoms and this has to continue for a very long time, before any damage is done.
      Osteoporosis is associated with long-term untreated hysiological hyperthyroidism and not with thyroid hormone treatment; this is another scare tactic Drs use against patients receiving adequate thyroid hormone treatment.
      Drs who prescribe thyroid hormone treatments do not prescribe them with no good reason; and I am unaware of any UK Dr being struck off as a result of treating hypothyroidism. I am however, of Drs being persecuted by the GMC as a result of prescribing thyroid hormone which has made their patient ‘better’ relieving their hypothyroid symptoms – that is due to ignorance on the part of the GMC and the BTA and nothing more; they have not though been struck off.
      If you have read the Guidelines and you have any knowledge of studies and evidence relating to hypothyroidism you will note that it is possible to blow Bonny and Clyde bullet holes right through the guidelines. The are not scientific they are prejudicial in favour of pharmaceutical companies and most definately not the patients. It is due to these pathetic and entirely wrong guidelines that patients remain hypothyroid, with and without treatment.
      Please stop scaremongering; hypothyroid patients have enough to contend with as it is.

    • The british thyroid association no damn all,clowns all of them.

      I have checked the stop the thyroid madness website ,the information they provide makes much more sense to me.

  14. Wow, just wow. 55 years of Synthroid, several doctors including endocrinologists, and not one tested me for anything except TSH and free T4 and T3. I went through misery after misery, fought with those doctors, changed doctors. NOT ONE mentioned a possibility of any other problem with my endocrine system. I’m floored.

    This is depressing me since I don’t think I can find the kind of doctor I need in my area, At age 80, perhaps I will just have to do the best I can with my present situation. Outside of my hypothyroidism, and skin itching the dermatologists can’t find a reason for, I’m very healthy.

    Perhaps when I started Synthroid in 1955, there were no tests? I was just trying to get pregnant, at age 26, and my doctor tried the low dosage of Synthroid. It worked.

    Thank you, Chris, for your enlightenment. I’m sure that if I take this article to my endocrinologist, he will just pooh pooh it and tell me to stop reading junk science on the internet. 🙁

    • Yes there were tests in ’55 but they have changed over the years; indeed rising serum cholesterol levels were probably the test of choice in those days; (and more reliable than TSH, T4 in my opnion)
      Itching skin is likely due to a fungal infection. Look on the net for antifungal diets/foods etc. Further I have used a product called Lufenuron – I am not associated with this proudct in any way but found it very effective in treating my life long fungal infection AND without side effects unlike the drugs given to you by the medics..

    • Find another Dr. that will take you seriously. At 80 you don’t have much time. My dad just passed at 85 and he went to the same type of idiot Dr.s that just prescribed useless drugs causing more side effects than his original symptoms. Your kids would rather see you healthy and happy. You don’t need to leave a large inheritance to anybody and you certainly can’t take it with you.

  15. Great post thanks Chris!  It’s great to know there are reasons thyroid tests come back ‘normal’ when they don’t feel normal at all.  Do you know much about using basal body temperature as a means of testing thyroid function?

    • It’s not a reliable indicator. Too many different factors affect BBT for it to be conclusive.

      • If you have signs and symptoms of hypothyroidism and you also have repeatedly low basal temperatures then Dr Barnes (who used/’invented’ the test) thought it was reliable. Barnes compared the basal temperature with the basal metabolic test outcomes and they compared favourably; however, if a detailed history is taken and a clinical examination is also carried out and the basal test and all of these other indicators agree the liklihood of hypothyroidism then it is as good a test/reliable as any other and better in the case of TSH.
        When making a diagnosis for any disorder/disease all factors should be taken into acccount and history, and aclinical examination must be given a great deal of credence. Basal Temperature test is part of the clinical picture.
        A Trial of thyroid hormone is acceptable and can be the final piece of the jigsaw if there is any doubt. A trial of hormone can rule out hypothyroidism for some patients if done properly. A trial of thyroid hormone is not dangerous and has been carried out for around 100years without being problematic.

  16. “These stressors fatigue the pituitary gland at the base of the brain so that it can no longer signal the thyroid to release enough TSH”

    I think you need to edit this misleading wording  – the thyroid doesn’t release TSH, the pituitary gland releases TSH to stimulate the thyroid to release thyroid hormones (not TSH).  I’m pretty sure you know this, but some might not.

    • Thanks for catching that. I changed it to what it should have been in the first place (“thyroid hormone”, instead of TSH) I think my brain is melting down from too much studying. 4 weeks until the licensing exam, and I’m feeling it.

      I need a proofreader.

      • Just to let you know, I have been studying anatomy and patterns of disease around adrenals and thyroid for about 4 year. You BY FAR are the most knowledgeable, articulate, and thorough source I have come across. Thank God for your brain. I wish all doctors were like you.

        • I just come across your article and am very impressed by it I have had fatigue weight gain small amounts of weight loss neck pain shoulder pain that comes and goes and periodic pain right where my thyroid is just had blood work all normal did not see t3 checked just tsh and t4 like u spoke about my dad had thyroid issues as well as my oldest boy if my ct scan comes back normal I know where to go from here hoping for the best and thanks for sharing your info

          • What do you do if your doctor what listen to you? He only goes by the levels as you spoke of?

            • What you do is fire the doctor and go find one that will listen to you. YOU are the customer. The doctor should take orders from you. Unfortunately that is the way it goes and people don’t realize the power they have.

              • Foolish Rebecca. People die waiting to be seen by Endocrinologists and you callously give advice to fire a doctor and wait even longer for treatment and another appointment. In some areas “firing” a doctor may not be an option. For many socioeconomic classes either. The best advice is to work with your physician. Take in your research. Doctors want to help their patients. Be prepared. Be informed. Be persistent. Be in charge of your health but don’t give orders to a physician. You did not go to med school. Rebecca advice is very bad.

                • Naive Christy. Not only do many doctors have 0 interest in truly helping their patients, even the ones who do want to help are annoyed by what they call WebMD MD’s. When you go in with a lot of web research to try to make them listen, they tune you out even more. The original question was about a doctor who won’t listen. The correct answer is: fire the doctor. Many times, you can do this simply by requesting a referral to specialist. This solution makes everyone happy. You get to leave the doc who won’t help in favor of someone more likely to have the knowledge to help, and s/he gets “the problem patient” out of the office so the the next $$ – er, I mean, patient can have the room. This may sound cynical, but it’s absolutely true. After 15 years in the healthcare industry, I can tell you with certainty that capitalism and healthcare go together as well as water and electricity.

                • LMAO at “fire the doctor” and “YOU are the customer”.

                  If you want people to take your opinion seriously, don’t make it ignorantly. I believe the correct terms are “leave” instead of “fire” (because really, only their employer can fire them, and you are NOT their employer, as much as you wish to believe you are), and “patient” instead of “customer”. Oh the customer one freaking hilarious! Hahaha…just. ..come on! Hahahaha!

                  And if you honestly believe doctors are there to take orders from uneducated, unintelligent people who know nothing about what is happening themselves (which is why they are at the doctor), I’m afraid your medical life is going to be full of struggle and unnecessary stress if you honestly believe that.

                  I’m not saying be a slave to any doctor you meet because you have no choice, but don’t kid yourselves about “the power you have” over your doctors.

                • I agree with “firing” the Dr just because you didn’t choose to be a Dr doesn’t mean you are uneducated or don’t know what type of care you need. There may be things in your medical history that your Dr is unaware of and they need to take the time to listen. Also they may be annoyed by Web MD or people doing their own research but science is constantly changing and evolving not to mention that they have been out of school for some time and have numerous amounts patients they can make mistakes it’s your life not there’s you are already stressed enough your relationship with your Dr matters you need to feel comfortable talking to them about everything. Why do you think they go over sensitivity and how to relate in medical school? I “fired” an Endocrinologist and within a week found one that was better. No one knows your body better then you and you are not a generic make up where they can just come in and slap the “normal” diagnostic on you and collect their Co pay and never give you a second thought If you feel you are rushed or unheard by your Dr feel free to find someone better even if you have to drive a little distance the inconvenience is worth your time. You have more power then you think you can take you money else where and write reviews on the medical board. Don’t use slander but give other people insight about your experience and let them decide if they want that type of care

      • My name is pauline long i have had Thyriod resistance disorder problems for 10yrs now, and still feel very tired lerthergick sorry but im also dyslexic so my spelling wont be upto date,i am at present on 125mgs per day of Levothyroxine, and feel worse every day, with no energy what so ever im also depressed and cant think properly, the thyriod problems run through my dad who is no longer with us, not only that but ive found out theres thyriod problems on my mothers side but have never youfound out if she had any cos she was never tested please could you help me sort this medical problem out once and for all so i can get on with the rest of my feeling much better in myself thank .

        • Maybe your doc should try a different medication if you aren’t responding to the Levothyroxine. Perhaps Armour or Nature-Throid will work better for you.

          • I have been suffering for years. One Dr finally put my on Armour and it worked but then one day the pharmacy said they could no longer get it. I also have recently found out I have a cyst on my adrenal gland. I just saw another Dr. and she said they dont do Armour only synthroid. She gave me some tests. One is anti-throglobutin which was high at 1046. The lab normal here is <40 She also did an anti-tpoab which came in at 868,0 She has also done an utltrasound of my thyroid results are pending. My blood sugars get elevated at times as well. i had a cortisol test done which was negative .How can i find a dr that prescribs Armour?

            • Nature-throid is what you want. Armour has corn fillers in it and some folks don’t tolerate corn well. Be persistent with your physicians. I don’t know what part of the country you are in, but here in Indiana, Walgreens and CVS will get Nature-throid. It is not what the Doc usually prescribe, so I had to check with the pharmacies myself and then tell my physician that was what I wanted. It took a 45 minute conversation but we got it done and it is working well for my daughter who has Down syndrome.

              • Armour stopped working for me and many other people couple of years ago; I think the technology was changed. Nature-Throid is working well, and regular Walgreens can order it for you, even if they do not have it in stock. Mail-order pharmacies also carry it, and it is usually covered by insurance. The thing is to find a doctor who is willing to prescribe it. Normally, endocrinologists prescribe synthetic T4, expecting it to convert to T3 (according to their theory) which does not work for many patients. So go to naturopathic doctor instead. Insurance usually does not cover the visit but on a long run, it will be a very wise investment, because your health is precious.

            • I was recently on Armour. I was getting it from CVS. I live in Northern California. I just got diagnosed with Hashimoto. So right now I got off of Armour.

            • You have got to find yourself a Holistic doctor. Any regular doctor will HATE and refuse to give you the less filler more natural Thyroid medicines.

        • I felt the same way. I did not respond to the synthetic thyroid medication. I need to take armour instead. Also there may be other issues that resemble thyroidal symptoms. On my own, I figured out that I can not eat Rye bread…. So no longer may I have a Ruben sandwich. my tongue immediately thickens and I feel lethargic. You need to see a good general physician. and Endocrinologist will only look at what they are knowledgeable, and not the overall big picture. Armour may also be needed as it is the only one I am aware of that inherently converts T 3 – T 4. Because it is natural. It made all the difference. Best of luck.

        • I don’t know anything about Thyroid but I have an 11 year old with dyslexia…. never apologize for that … you are a very special person and have a very special gift from God… you posses skills that others can never have… do some research and don’t think of Dyslexia as a bad thing … consider it a gift A wise man once said ” if you judged a fish by how well he could climb a tree…he will spend his whole life thinking he is stupid”

          • Hi!

            My husband thought he was dyslexic for years until a behavioural optometrist diagnosed our daughter with a convergence dysfunction. She got multifocals and went from the bottom of the class to the top with reading. My husband then was diagnosed with it. Behavioural optometrists diagnose plenty of things normal optometrists don’t.

            • my daughter was dyslexic until I took her out of school and retaught phonics. She shows no signs of dyslexia now.
              Don Potter has an excellent page with information and a test to give the student to see if they were taught whole language or phonics.

        • Need to also test adrenals (cortisol) if in some state of adrenal fatigue, the thyroid will not improve. Also see 23andme for genetic tests and doesn’t hurt to do heavy metal test as toxicity can negatively affect many things. If Dr will not do these tests, go to another one who does, even if you have to go out of network and pay out of pocket. This is an investment in your health and more important than other expenses.

          • Maria – you hit it spot on. I have been tested in the past by my PCP and everything comes back “normal”. My younger sister had thyroid cancer in both lobes; my father had goiter and removal of one lobe; I have several nieces and nephews with thyroid issues as well. Do you suggest I see an endocrinologist? or just another PCP? What specific tests should I have done?

            • Neither, I had cortisol saliva test through naturopath. Allopathic Drs are generally not good at these tests. You can do a mail away test unless you live in NY state where mail away laboratory tests are not allowed. Have you read Dr. David Brownstein’s books or seen his youtube on thyroid and iodine?

              • I want to talk about the comment on Dr. Brownstein and iodine. I discovered thyroid cysts in 2006. I had several ultrasounds and the doctors said to leave the cysts at that time. I was deemed to be euthyroid even though I WAS indeed hypothyroid, but with a TSH of .4 and sometimes lower (notice I said POINT 4). I suffered for years with hypo symptoms, and finally made my way to an endocrinologist. Good thing there are practitioners like Chris out there because I was told I needed to get my thyroid removed!!! The cysts are not that big nor do they cause any issues for me other than I was coughing a little as they were growing slightly. SO, instead of telling me to take iodine, the endocrinologist warned me over and over NOT to take iodine as it would make matters worse as she said. So, I found this wonderful ENT at the university of MN. She is not holistic by name but by practice she is an inquiring mind and is alternative. She told me to find ‘an old fashioned’ doctor and have her/him guide me with iodine. I told her that I had finally found a functional doctor but that I still needed guidance. She then told me to take 550 mcg of Iodine daily and guess what? My cysts have GONE DOWN in size. And they have stayed down. If Iodine has competition from other halides, i.e. bromide, chloride, fluoride, then it cannot do its job with the thyroid. So, DO watch that youtube video and educate yourself. My doctors have told me not to take as much as he advocates. I had a reaction to 6 mg that I took, a very bad one. So, I just stick with 550 mcg and I think the upper tolerable limit is 1100 per day, but not positive. I hope this helps. I feel wonderful now and interestingly to note, that when I started taking T-3 which was FINALLY prescribed to me my TSH went UP not DOWN as all other practitioners said it would. I was low and the T-3 (liothyronine compounded) did not make me hyperthyroid as they all (but one) said it would. And when I began using Iodine concurrently with the T-3 RX I then found that the energy was better and the RX worked better. I still have thyroid issues and weight gain and testosterone levels that are either really high or really immeasurably low. I am going to contact Chris about this and hope that he can help me work on this and see why that happens. Jan

                • I realize this is an old story but I am seeing it just now. I have been told for years I was just fat and lazy. I would work out like crazy on a daily basis and my weight wouldn’t budge. My sizes would sometimes go up or down but my weight always went up. I was able to work out a system of eating 800-1300 calories a day. It makes you super tired and hungry and probably sounds crazy but it was the only way I could lose weight. I finally went to the doctor this year and HE made the suggestion to test my thyroid and pituitary hormones. I told him I had been tested before when I was pregnant and they told me I was just morbidly obese. I also have had horrible side pains around my liver area. I thought it was my gall bladder and the doctors I saw during my pregnancy told me I was stupid and it was probably gas. Turns out I have an enlarged fatty liver and the pain was from it stretching its casing. So I have been wondering if the two are related somehow other than me being overweight….

                  And to Jan, my close friend has PCOS and that causes her hormones to be wonky. She grows facial hair really bad almost like a man would and has heavy weight in her midsection. There’s different treatments for it including surgery and hormone therapies. Maybe get tested for that?

                • Jan, Could you tell me the name of the functional doc in MN that you see for your thyroid/iodine?
                  Thanks

            • A good Dr. would treat the symptoms and not necessarily the test results. A full thyroid panel is a great start. If Dr. refuses then you know they are not the right Dr. for you.

              • I started on thyroid medication about 10 years ago. At the time I did not want to start medication because I had no symptoms other than the blood test that said my tsh level was low. I felt good, had energy, hair was healthy, skin good. My Dr. just kept after me until I finally gave in. After about 2 years on medication, I had symptoms. Hair falling out and dry, low energy, dry skin. My hair has stopped falling out, but still have dry skin and do not have the energy I should have. I feel like I should not have started taking meds. Is there anything I should do now to maybe get off medication or change what I am taking?

                • Joan, I feel that I am in the same boat as you! I started on synthroid at age 40 (19 years ago) after the birth of my second child – he was 1 year old. A blood test showed that my thyroid level was low, but I had no symptoms except being tired from 2 toddlers and working and weight still to lose. I felt great the first 5 years, but have gradually developed symptoms of low thyroid. My present doctor has been adjusting my levothyroxine according to TSH and T4 levels. I recently got my free T4 and T3 uptake included and they all “look normal” on blood tests (in range) but symptoms persist. I went to an endo about 8 years ago when my Dr. couldn’t understand some of my numbers (like high calcium) to have my parathyroid checked but it was normal. I also went to a Bioidentical Hormone Doctor to have hormone levels tested but costs were getting prohibitive (not covered by insurance of course) so I quit. I would like be able to afford a doctor that will test my hormones for the “big picture” but being retired, I cannot afford it. My doctor and I’m sure my insurance will not cover Armore or Nature-throid – not made by Big Pharma.

              • Joan, what type of labs is your Dr. running? Need to do full thyroid panel including free T3 &T4 & reverse T3 (RT3) several times a year and explain results to you at a minimum. If you’re over 40-45 then other hormones may have started to change. What does your Dr. say when you tell him about numerous low Thyroid symptoms? If he does not address them, go to another Dr. even if you have to pay out of pocket. Your well being is worth it. Without good health, you can’t really enjoy much of anything else.

                • I just got my blood tests back:

                  July 2014:
                  TSH: 3.530
                  T4: 0.88
                  Reverse T3: 13.6
                  T3: 70
                  TPO: negative 6
                  Thyroglobulin Antibodies: Negative 1.0

                  Can someone help me interpret them? Teresa
                  my email is [email protected]

          • I have a thyriod problem and I take 88mg of Levothyroxin a day. I also havae adreanal insufficiency and addisons disease. I take Hydroquartisone everyday just to stay alive. I also have to eat salt because the Addisons disease make my kidneys spew salt.
            I feel like a walking hypocondriack, but I am not. Now I just discovered I have diverticulos and colitis. I take no medication for the colitis and the diverticulosis. I know how you people feel. Sometime I get so weak and tired but I cant sleep. Outside of that I feel great. Its very hard to find a Dr. who doesn t think just in main stream medicine terms. Its a catch 22, if you find a natural health dr your insurance won t cover it and they are to expensive to pay out of pocket. I try to eat clean food and do not eat fried food or fats. Its not perfect. Oh well.

      • hi ive been having hypo symptoms for at least 3 yrs now all the tests the dr’s have ran says im in the normal range what kind of dr do you think i should see besides a thyroid dr for much deeper tests . they said i have fibromyalgia after diagnosing me with mixed connective tissue desease and polyarthritis i think it was im frustrated help please

        • If you are on a PPO, you should go see an endocrinologist. If you are on an HMO, you will need a referral which may be a pain in the butt to get from your GP. If you cannot get a referral, you can always try a holistic (natural) medicine doctor in your area too, although it will be an out of pocket expense and you can expect to pay upwards of $100 just for the appointment, plus whatever they charge for the blood tests on top of that.

          • hi laura i went to get a second oppinion on the fibromyalgia and he ran a vitamin d test and ultra sound for pcos the ultra sound came back ok but the vit d came back low they put me on 1000 iu dose of vit d theres been some inprovement on the pain but still feel theres a thyroid issue as the weight just wont budge im going to ask to be sent to a endocrinologist

            • Funny, I have 13 symptoms of hypothyroidism but my doc tells me I’m just vitamin d deficient. I feel like crap every day and it is really starting to affect my lifestyle. So depressed that he won’t even TRY to consider anything else. Looking for a new doc as we speak as I am tired of feeling this way, but being brushed off if I complain.

              • I also have the fatigue chronic pain Vitamin D deficiency migraines for years now The depression is overwhelming most days I hurt so bad everywhere I don’t get out of bed I have had two primary Dr’s that ran blood tests The first one was totally uneducated saying my vitamin d was so low that I had Ricketts I’m 50 years old I thought that was for kids So I switched Dr’s the second told me my thyroid levels were fine so it’s not a thyroid issue I don’t believe trust that because it was my gastrointestinal and my respiratory therapist and my pain mgmt dr that said they think it’s fibromayalgia What kind of Dr will confirm this?? My primary is no help but I will demand a referral if you tell me for what kind of Dr Please help I’m going insane Thank you

                • Do an online searchfor “MARY SHOMON DOCTOR LIST”. You will find doctors listed by state. Also, read her site and Gina Nolin site to get list of labs to run.

          • I had a nuclear scan and a biopsy I was diagnosed with cold nodules of the thyroid .iwas told that it cold be cancerous and should be operated on,and that they would have a pathologist in the theatre
            To check and see if they have got it all out.but I have been delaying
            Can one advise

            • Misdiagnosed and untreated thyroid disease can cause nodules on thyroid. I had small one and when properly treated with Armor or Naturethroid & iodine they went away. Did you get full 6 panel (hormone) thyroid test? This is essential for proper diagnosis. If Dr. is not willing to run proper tests complain to medical board and go to another one who can properly diagnose you. Only have surgery as last resort when other proper protocols have failed and its clear (get 2nd 3rd opinion) that surgery is needed and would benefit your condition.

              • I just had a 2nd visit with new doc…I was told to go off medication so doc can see thyroid panel clean..I went off for 5 weeks and felt like crap..all symptoms came back as soon as got back on after new blood work within 4 days I began to feel better and goiter began to shrink. when I kept asking questions about why with the medication my hypothyroid symptoms go away plus my large thyroid goiter begins to shrink I was told there is no possible way that the medicine could be making me feel better or have an effect on goiter since my tsh t4 and t3 are all normal. When I challenged this I was told by doc I’m not going to argue with you about this. This is my 5th endo who is unwilling to be cooperative!

                • I am so sorry you are having such a hard time finding a doctor who can help you. All of my blood tests always come back in the “normal” range but I have severe symptoms and a huge goiter. My endocrinologist has been great and by treating my goiter and symptoms with thyroid medicine, my symptoms have improved and my goiter has gotten smaller. I had three nodules and they all disappeared within 6 months of being on the medicine. It’s been nearly 4 years now, I still have a goiter but it’s much smaller. Symptoms are very mild but I have had to have my medication increased 5 times in the past 4 years. My endocrinologist says that my thyroid doesn’t work well unless my TSH is at a 1 (or a little lower). The blood tests and the “normal” range are not accurate for my thyroid. It has changed my life in the past 4 years and I am so sorry to hear that no doctors are willing to look past the numbers to help you.

        • I had fibromyalgia in the 90s when diagnosed with CFS. I got relief from B-12 injections (methylcobalamin only) and eating an anti-inflammatory diet. It is so so so important to eat foods that won’t inflame us and especially if we have fibro. Check out http://www.nutritiondata.com and see which foods are appropriate. Try to balance the Omega 3’s with the Omega 6’s to help with inflammation. That is what my husband and I have been doing. He had an extremely high Ferritin test results, high CRP, both markers of inflammation. We cleaned up the diet and he no longer uses insulin (which is also very inflammatory). I had fibro so bad that I could hardly move. I now job and walk every day, work from 6:00 to 10:00 and am a senior. I hope this helps you.

      • So I have glassy eyes severe weight loss fast heart rythm symptoms started after pregnancy. What do I do to find a doc to treat this and listen to my symptoms not just bloodwork? In nj area

        • check out lists of functional doctors, holistic doctors, and alternative. There is Institute for Functional Medicine and I have been told there is a list of names on there, state by state.

          Good luck!!!

        • You could have pregnancy induced Graves’ disease. Gives same symptoms you listed.

          I had it 25+ years ago after a pregnancy.

      • Hi there, very interesting article and almost sounds like there’s hope for me somewhere in there. I did have a very high-profile, high-stress job and slowly but surely found my hair falling out, my nails became very brittle, irrespective of how many supplements i was taking. I also started gaining weight, initially not because of overeating, just gaining around my belly. And my weight had been stable and between 68 and 72kgs all my life. i could no longer sleep without a sleeping tablet and became depressed, could not concentrate and lost confidence in myself completely. This was 6years ago. Since then, i have gained 30kgs! i have tried 4 dietitians, to no success. They put me on extremely low calorie diets and the weight-loss was truly minimal. I could see they thought i was just cheating and that made me feel so bad i stopped seeing them. I cycle every second day for 30minutes minimum, do my own housework, ie vacuum, mop, sweep, dust, polish, dishes, washing and ironing for the sole reason to stay supple. I have seen an endocrinologist who did plenty blood tests (unfortunately i do not have the results, he has) and he claimed my thyroid, pituitary functions etc were normal. The only abnormalities that i can recall was a slightly elevated liver count and my pancreas was checked twice, if that means anything to you?? I do not drink alcohol at all and i don’t smoke at all. The only chronic medication im on is degranol 2 pd and nexiam 20mg 1x pd. i do not take anti-depressants, however i realize and recognize that i still suffer from depression and have become a bit of a recluse. I have tried several appetite suppressants, no success there either. The doctors talk about insulin resistance, i tried antagolin, no luck. i am desperate, so desperate, im ready to slit my wrists. Please tell me what treatments you would suggest for these 5 Thyroid patterns you’ve identified so i can discuss it with my doctor. Lastly, i live in South Africa,am 51years old, height – 1m 71cm and now weigh 97kgs. Please help me! Thanks and regards. I hope to hear from you soon!

        • This is for Annie:
          You have a right to ask for a copy of all your blood work and x rays and any otheer test The labs due. Go to your Dr. and tell him you want a copy of your blood results. Just ask the girl at the window in your Drs office and she should give them to you.

      • Chris,

        Can your column be shortened to the most current comments? Also, is there a thryoid treatment for “Dummies” available?
        Just asking.

        Lisa

      • Chris, I am a 47 yr old female who had routine blood work done in Feb 2013 whereby my TSH was 2.47..I was having chronic yeast infections. I felt horrible six months later and my primary ordered more blood work and my TSH was 10.2. Went to endo and more blood work showing no antibodies. Also, thyroid not enlarged. She diagnosed me with Hashi’s gave me synthroid 112 mcg and said see you in 6 mo’s. Medicine worked the first two weeks then nothing. How can I have Hashi’s without antibodies? Why has the medicine stopped working? I am very confused.

      • Hi,
        I loved your article.
        My question is, where can I go to get an accurate diagnosis. My primary care would only do a TSH.
        I live in Boston. Can you advise on reputable resources.
        Thank you

        • I had bloodwork for this done by my chiropractor, who ordered a full thyroid panel. I came back as TSH 2.86 with slightly low T3, but my ob/gyn had ordered a simple TSH and told me I was normal. Good luck.

      • What happens when your TSH level is 1.78 and protein level is 8.1 and you’ve gained 20 pounds in five months and the doctor basically tells you it’s your fault? What then? I can’t afford to go to multiple doctors to find one that’s willing to listen to me and help me.

        • Hi Lynsey, through the help of a naturopath and the right tests and meds, we have found that my perfect TSH is more in the range of 0.05, which is pretty low for most people. Perhaps the 1.78 is just still too high for you.

        • I AM THE SAME. except I have 4 nodules but since my bloodwork is “normal” I am FINE. I’m not fine. I am fat and tired among about 15 other bad things. This isn’t my normal. I have been to endo and pcp. I’m out about $1,000 and have no help yet.

      • You say conventional doctors won’t go into detail or maybe misdiagnose/mistreat or not help you fix whats really wrong with your thyroid. What type of doctor do you recommend me going to if I’m having some trouble?

        • Lindsey,

          Not sure who you are replying to. I wish these articles had comment set up similar to mercola.com articles where its much easier to read, and respond to comments. 3 generations of my family have repeatedly been medically mistreated, misdiagnosed for many ailments. It was not until I went to nathropath who can look at the entire body, vs. many Drs. looking at one little part and not seeing the big picture, that I was properly diagnosed and we began healing. It is well worth it even if insurance doesn’t cover appointments. Its a totally different way of health care and the process of healing takes time vs. just medicating one symptom. What price do you put on good health. I know many people who practically live in Drs. offices not only not getting better, but actually sicker as they experience negative side effects of their prescriptions.

      • Can you elaborate on what treatment would look like for these? And what tests do I ask my doctor for? I have every single symptom of hypothyroidism but always test *normal*.

      • Mr. Kessar, I’m 35 years old and I had a nodule in my thyroid that caused for a right lobe ectomy when I was 25 years old. I’m a mother of five and I struggle with low energy level which I never had issues before as I was very active and push hard to remain. l have weight gain, joint pain and constant skin rashes and hair loss…The list goes on. I had two endocrinologist test my T3, Tsh , T4, and prescribe me 125 mg of synthroid they say that my numbers are two to three points higher than what is “normal” and technically I’m hyper. I’m exhausted constantly not feeling well, can you please give me advice as to what I can do to get back on a healthy level please!!!

        • I want to add this piece of information for Angelina, May 6:
          Thyroid/TSH, Free T4, Free T3, Thyroid Peroxidase Antibody/TPO,Thyroid Antibody/Anti-thyroid AB

          and want to say that youtube searches:
          ” dr. kent holtorf hypothyroidism ”
          will lead you to brief explanations, info and insight. best, Nona

          • I will also comment that Dr. Kent Holtorf has clinics in the east and west of the U.S. and there is a book named “Stop The Thyroid Madness” that he is connected with and his premises are quoted through the book. I have found more thyroid information in this book than anywhere else on the internet or in a doctor’s office.

      • Watching women in my geographic area living but not thriving; one of these is my daughter. I want to take part in this conversation because maybe I have come across resources that can help here.

      • Wow I think this is one of the best articles I have read. You should get a knighthood for the amount of people you have probably helped as a result of this page… My only wish is that you were in Scotland. I have been displaying signs of hypothyroid and similarities to hashimotos for years (I’m only 34 now but been back and forward to doctors for over 10 years). I also have PCOS and hormone stuff which doesn’t help but I have been feeling like a hypochondriac even though I know there is something wrong. Blood tests are always in “normal” range but I have had a goiter since I was 13. My grandma and mum had hypothyroid. The doctor keeps asking if I’m depressed and I say no, although moods all over the place but I have a fantastic 2 year old son who is my world and a great job etc. I had a thyroid ultrasound scan last week and they said there’s chronic inflammation of thyroid. I spoke to doctors again and he said That my thyroid is fine as bloods are fine…. Argghhh so frustrating. He said there’s probably a autoimmune thingy there but won’t treat it as don’t know what it is. I am worried, I get back leg cramps now too and my veins are bad on my legs. I have also been getting pains in my chest but doctor thinks it’s gallstones. It just all seems connected but until I find out the cause and doctors believe me I won’t get treatment. Symptoms, weight, hair growth, freezing feet and hands, purple legs, varicose veins, swollen ankles, acne, sleep problems, moods, no sex drive, dry hair, itchy legs, cramps, skin tags, goiter, weak nails, bits of eyebrows missing, facial hair, indecisive, chest pains, occasional abscesses when run down, strange stretch marks on shoulders, high blood pressure, a pulsing feeling in belly, constipation followed by bouts of the other, constant aches and pains which I don’t even think about now as I just live with it. Feet always hurt, no energy… My get up and go has got up and gone. Feel like I’m always so moany like this post (sorry!) but I used to be carefree and happy. My nickname was smiler. My mum committee suicide a few years ago so I guess that doesn’t help. What else can I do to get doctor to listen or who can I speak to ? Thank you and sorry x

      • Chris~ I wish there was a thyroid expert who lives in Richmond VA. For the past 16 years I have been taking synthroid in gradually increasing doses and I feel awful.
        I am a nurse and have just enough info to get me in trouble. I have read your book and kept up w/ other experts…but what do you do about joint pain-specifically shoulder and knee pain-weakness? I am unable to play tennis and am feeling like an 80 year old. I am 55. YIKES!!!

        • Ann. I am in Richmond and just recently diagnosed with enlarged thyroid lobes. Can’t believe how hard to get an appt with an endo.

          I have terrible burning mouth syndrome as well. Ruining my life.

      • I am suspicious that I have some sort of thyroid disorder but currently am not on health insurance. Where should I go to get accurately tested if I don’t have a primary care physician? Thank you!

      • My life changed 1 1/2 ago….I have been constantly fighting a cold, alergies or infections…gained 35 pounds…can sleep at night..or wake up every other hour…my day are a marathon were I have to convince my self I ll make it to the end ( I have three kids…3,5.10)….sometimes I even feel my heartgoes to fast…or way to slow..I am always tires…no energy…I push my self to go to the gym…have not lose a pound and no matter how much I stop wating or doing healty diets…I do not loose weight…recently talk to my obg..she said I was been dramatic..and my carsiologiest..test me just yesterday and toldme I was fine…this are the results…can you help me to understand…can you please help me?
        This are my test results…
        T3 uptake 30
        T4(thyroxine), total 7.3
        free T4 index(T7) 2.2
        Globulina 3.0
        TSH .91

    • Hi Chris
      I read your article and it was very interesting. I have a son with special needs who I am taking him in to be tested. Can you please tell me exactly what tests need to be done. He is 18 years old and has Down Syndrome.

      Thank you!

    • Hello Chris,What do you do when your thyroid is not functioning because of elevated cortisol?I have has adrenal fatigue for decades..cut out all problem foods, do chi gong, meditate, only eat real organic and grassfed food..but am tired and cold all the time. My doctor put me on armour thyroid 30, but it made my loose stool worse, so stopped.I felt tired again right away..really not sure where to turn to get my leaky gut healed, my adrenals back and my thyroid working again! Help!

      • kate – leaky gut, follow a SCD/GAPS diet for a few months, lots of bone broth/stock and fermented foods, won’t take too long. If it does take a while, supplement with raw camel milk. Google this stuff and check it out, you’ll be fine!

      • Here is an idea for all but you mentioned leaky gut and it made me think about the “virgin diet” by J.J. Virgin and she uses that term “Leaky Gut” to explain about food sensitivities that can cause symptoms that look like many diseases I have a lot of the same problems as many of you I take generic Synthriod but I have no energy etc. I would suggest having your vitamin levels checked low D3 can make you depressed low B12 can make you tired I am still learning about other vitamins. Many of our health problems will have multiple origins and all need to be looked at because they are usually a combination and for those with Fybromyalgia you can do all of these steps and still be tired all of the time believe me I know as I have that as well. I would suggest having a sense of humor about your health problems. Not ignore them or make fun of them but to not let them get you down and to realize that

        • Hypothyroidism is associated with low Vitamin D levels but most people in the first world these days have low Vitamin D levels. Further Hypothyroidism causes low B12 levels due to the low levels of Stomach Hydrochloric acid and Intrinsic Factor being produced. Injections of Vitamin B12 are appropriate.
          These are problems have one origin and that is Hypothyroidism.
          In the 1970’s when there was a swing to using levothyroxine and testing for TSH became the vogue, as predicted by the fab Drs around at the time, many Hypothyroid patients were left undiagnosed. Over a number of years there have been different ‘new’ disorders which all describe Hypothyroidism by another name; fibromyalgia, M.E., C.F.S. and so on. Dr Gordon Skinner (UK) demonstrated that those people who present with these so called ‘new’ disorders will be relieved of symptoms if given thyroid hormone treatment.
          Check out the history of Hypothyroidism – its fascinating and will open up another world.

      • Low Adrenals must be treated before your thyroid med will work well enough. Check adrenal gland function with salivary test – Cortisol and DHEA. Also check with temperature at 3hourly intervals through the day; if they are labile then its adrenals; if they are simply persistently low then thyroid; if low and labile then likely adrenals and thyroid and often the two go hand in hand.
        Hair analysis may help identify if you are low in certain elements. You may need to supplement either DHEA or Cortisol (at physiological doses) BUT there are a number of vitamins and minerals which also support the adrenals:
        Magnesium taken at night don’t take calcium too.
        You may need Phosphorus too but you will need a multimineral tablet or powder too.
        Vitamin B complex plus additional Vitamin B3, B5 and B6. Its likely you’re low in B12 too(due to hypothyroidism)
        Vitamin C dose to Bowel tolerance.
        Vitamin E 400iu daily.
        Adaptogenic herbs such as Ashwagandha support low adrenal function. Take these regardless…..then check DHEA and Cortisol too.
        Always support adrenals before taking thyroid medication.

    • I’ve had hypothyroid symptoms for years….Im angry I’ve been getting just tsh tests but I found out that can come back normal and drs say I’m ok….told my Dr to do the full t3 and t4 I feel I’m not bipolar I have bladder problems high liver enzymes high cholesterol weight gain and loads of other symptoms….my t4 was 0.8 and t3 4.1 my tsh was 1.75. Can this still be possible?

      • Yes it can still be possible: All tissues, organs and cells require thyroid hormone mainly T3.
        It appears that many hypothyroid sufferers cannot easily convert T4 to T3; this is not revealed by the TSH, T4 tests. Further the Pituitary gland which secretes
        TSH is a special tissue compared to those others around the body; it will be saturated with thyroid hormone when all other tissues, organs and cells around the body have very little. So we can be hypothyroid at the cellular level and yet the pituitary gland will be oblivious to this fact since it soakes up thyroid hormone like a sponge; so pituitary gland is soaked with thyroid hormone = no TSH gets released.
        If conversion is also a problem the thyroid may be producing its hormone mainly T4 with a little T3 some bound by proteins which make it unaccessible to the cells tissues and organs. Further, if it is not converted it remains in circulation; HAHA – yes the levels of T4 circulating in the serum may be at NORMAL levels!
        So we have low TSH levels (‘normal’ or within range) and T4 levels within range too. However, you ARE hypothyroid and your body is displaying all the symptoms of the disorder – infact often it is screaming out.

    • How do I figure out why I am having all of the hypothyroid symptoms: brittle nails/hair, tired all of the time, light headed, freezing cold hands and feet, short of breath.
      Labs are as follows:
      T3 uptake 27.6
      T4 total 6.7
      Tsh 1.75
      Drs keep saying I’m borderline? I’m not understanding!
      Any help would be appreciated. Please and thank you

      • Ask for a 3 month trial of thyroid hormones: if you feel better and some symptoms resolve then the trial should continue as permanent treatment. If however, whilst taking the hormones you may experience some palpitations and signs of HYPERthyroidism it may be one of two things: (1) you are not HYPOthyroid and the additional hormones are tipping you over into hyperthyroidism. (2) You need to treat your adrenal glands and have a second trial or better still treat your adrenal glands prior to the thyroid hormone trial.

    • I have fibromyalgia but believe I may also have hypothyroidism. I have severely swollen glands under my chin. I am cold all the time. I the last six months I have developed a chronic vomiting problem. Whatever I eat it seems to come back up. I cough incessantly and choke while drink eating or jist swallowing saliva. My cough is continual. Of course I am always tired but can’t sleep at night without sleeping pills. The nausea seems constant. My GP seems to think I am a hypochondriac and my rheumatologist was annoyed when I brought in a list of 19 symptoms to be addressed. I know my body better than they do and I KNOW something is wrong other than the fibromyalgia. Can anyone help me? Give me suggestions? Thank you

      • Go to different Dr. I did not start to get properly tested and feel better until I tried naturopathic Dr. They are trained to look at the whole complete person not just specialize in a little part of the body, so they save you time and money that way. Unfortunately many do not participate in ins. plans but what price and priority do you put on your health?

      • Debi, perhaps its something to do with the vagus nerve or the autonomic nervous system (the vomiting). Have you tried seeing an osteopath? If there is something pinching a nerve or compressing something it can affect all sorts of bodily processes. My family doc told me I had “fibromyalgia” too (I think that’s just code for “I have no idea what’s wrong with you”! But I’m lucky he actually believed I had a true condition, not like those stone-age docs who tell you it’s all in the head!) I suffered for years with severe tachycardia and POTS – I’ve been seeing a great osteopath and things have improved so much, I can’t believe how much better I feel.

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