RHR: Is it Possible to Get Off Thyroid Medication
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Is it Possible to Get Off Thyroid Medication?

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Revolution Health Radio podcast, Chris Kresser

As is often the case, when we look at a question like this, it becomes a lot more complex and it may seem initially, on the surface.  Let’s tackle issues number two through four first, because they’re actually going to inform the answer to the first question, which is, is it possible to get off thyroid medication?  In terms of diagnosing Hashimoto’s, it’s actually not quite as straightforward as just doing an antibody test and seeing what the results are.  I wish it were.  It would make my life a lot easier, for sure.  But the first-line test you do, typically what I do, is for antibodies. By antibodies, I mean thyroperoxidase and thyroglobulin antibodies, these are the two antibodies that tend to be elevated in Hashimoto’s.  Thyroperoxidase is elevated a lot more often than thyroglobulin.  It’s more sensitive to Hashimoto’s.  It’s not more specific.  So you’ll tend to see it elevated more frequently.

In this episode, we cover:

3:15  What Chris ate for breakfast
6:36  Are antibodies reliable in diagnosing Hashimoto’s?
14:50  Can you reverse autoimmunity?
19:13  3 issues that cause T4 to T3 conversion problems
30:46  Is it possible to get off thyroid medication?

Links We Discuss

Steve Wright:  Hey, everyone.  Welcome to another episode of the Revolution Health Radio show.  This show is brought to you by ChrisKresser.com.  I’m your host, Steve Wright from SCDlifestyle.com.  With me is integrative medical practitioner, New York Times bestseller, and healthy skeptic, Chris Kresser.  How are you doing, man?

Chris Kresser:  I’m great, Steve.  How are you?

Steve Wright:  I’m doing good.  I’m reintegrating back into life.

Chris Kresser:  I want you to tell everyone a little bit about what you’ve been up to these last couple weeks.

Steve Wright:  Okay.  Well, it depends on how the sound comes out.  I apologize, everyone.  They’re doing massive construction outside of my new apartment.  I’m in the kitchen right now, trying to find the best acoustics.  So I went on a 10-day Vipassana meditation retreat.  That form of meditation retreat means absolutely no self-expressionno talking, no writing, no exercising.  You just meditate for approximately 12 hours a day.  The only people you can talk to are the teachers or the management staff.  That wrapped up about five days ago.  It was transformational.  It was one of the hardest things I’ve ever done, no doubt, but it was so worth it and so amazing.  I don’t think words can really express what I’ve gotten from it.

Chris Kresser:  I know what you mean.  It’s such a powerful, like you said, transformational experience.  It’s a big commitment to make.  But as you shared with us, I know from my own experience that there’s really nothing else like it.  There’s no other.  It’s such a precious gift to give to yourself.  I’m so glad that you did that.

Steve Wright:  Thank you.  I knew I didn’t know myself, but just getting to spend some time with yourself I think was so amazing.  I know that there are lots of different forms of meditation.  We’ve talked about it on the show a lot.  I can’t thank you enough Chris for pushing me in this direction towards meditation. It’s something I probably wouldn’t have done, had we not been friends for the last couple of years. So thank you for contributing to that.

Chris Kresser:  Oh, my pleasure.  You’re the one that made the commitment and did it.  It’s really amazing to see what comes out when you’re just sitting there on a cushion, you have no distractions, and none of our typical things that we do to distract ourselves from what we’re feeling or thinking.  It’s quite a valuable experience, isn’t it? Maybe we’ll put up a link to the Vipassana website that has a list of all the centers, in case people want to give it a shot.

Steve Wright:  Awesome.  Well, I think the Vipassana Association would love us sending some traffic their way.  Enough about meditation, Chris.  What did you have for breakfast?

What Chris Ate for Breakfast

Chris Kresser:  Today, I had cold-brewed coffee with some cream.  It was an intermittent fast day.  I just didn’t feel particularly hungry when I woke up.  I had kind of a late dinner.  I knew I was going to be recording.  So that was it.

Steve Wright:  Awesome.

Chris Kresser:  So we have a great question today.  I think it’s going to be relevant for a lot of people.  We’ll give it a second to play, and then we’ll answer it for the rest of the show.

Raven:  Hi Chris, this is Raven. Love your show. I wanted to know if you think it’s possible to get off thyroid medication? I do not have Hashimoto’s, I’ve always tested very, very low in antibodies, but have had a conversion problem for at least the past 10 years. Originally, when I was put on medication, my T4 levels were good, but my T3 was very low. Now that I’ve been on medication—I’m currently using Nature Thoid and some Cytomel—and I’m trying to lower the dose. My TSH does not kick back in, so it stays at a very, very low level (.07) even when my T4 drops way below the normal. Is there any way to gradually get off medication or should I just resign to my fate? I have felt some improvement, some ability to use less thyroid medication as I’ve been working to heal my gut, which of course, is not very surprising.  Still, I’d love some words of wisdom and insight. Thank you very much.

Chris Kresser:  Thanks for your question, Raven.  There are actually several different issues to address here in this question, probably at least four.  Hopefully, we can get through those in this episode.  If not, we’ll circle back and finish it off another time.

Steve Wright:  I’ve been doing a deep dive into this, Chris.  So I’m ready, man.  I’m ready to throw some curveballs your way.

Chris Kresser:  Great.  The first question was her main one, which is, is it possible to get off thyroid medication?  Another question or issue to talk about is, are antibodies reliable in diagnosing Hashimoto’s in the first place?  If they’re not, what is?  A third issue would be, what causes the problems that we see with conversion of T4 to T3?  So what causes T4 to T3 conversion problems in the first place?  The secondary question there would be, is medication the best way to treat those problems or causes?  Number four would be, what does a TSH of essentially zero, 0.07, and low T4 indicate when you’re taking thyroid medication?  As is often the case, when we look at a question like this, it becomes a lot more complex and it may seem initially, on the surface.

Are Antibodies Reliable in Diagnosing Hashimoto’s?

Let’s tackle issues number two through four first, because they’re actually going to inform the answer to the first question, which is, is it possible to get off thyroid medication?  In terms of diagnosing Hashimoto’s, it’s actually not quite as straightforward as just doing an antibody test and seeing what the results are.  I wish it were.  It would make my life a lot easier, for sure.  But the first-line test you do, typically what I do, is for antibodies. By antibodies, I mean thyroperoxidase and thyroglobulin antibodies, these are the two antibodies that tend to be elevated in Hashimoto’s.  Thyroperoxidase is elevated a lot more often than thyroglobulin.  It’s more sensitive to Hashimoto’s.  It’s not more specific.  So you’ll tend to see it elevated more frequently.

Steve Wright:  And elevated means anything above zero or lab range elevated?

Chris Kresser:  Yeah, I do use the lab range.  I know some practitioners will say anything above zero is abnormal, but I don’t actually think that’s true.  When you look at any kind of antibody test—even Cyrex Labs for their Array #5 multiple antibody screen or any of their gluten intolerance panels—you’ll see that a small amount of antibody production is actually not pathological or abnormal.  I don’t know what the scientific basis is for claiming that thyroid antibodies being anywhere above zero is abnormal or indicative of pathology, because I’ve never seen any research to back that up.  So I use the lab range.  If it’s getting close to the top of the lab range, I will definitely be paying attention, because the cutoffs are always somewhat arbitrary.  You know, they’re based on research and prospective studies, and I’ve seen some prospective studies that suggest to me that the lab range should be, perhaps, a little bit lower than it is.  Like with thyroperoxidase, usually 34 is the upper end of the limit or somewhere around there.  I’ve seen studies suggesting that if you have TPO antibodies above 30, you’re much more likely to develop hypothyroidism in the future.  So it’s possible that the lab range should be a little bit lower, but I don’t think it should be zero.  The problem with thyroid antibodies is, like almost any lab test that you can mention, they’re not 100% reliable as a way of diagnosing Hashimoto’s.  For example, in a study of 100 South Asian Indian people that had Hashimoto’s confirmed by histological analysis—meaning actually looking at the tissue and seeing for sure that they have Hashimoto’s—about 89% had TPO antibodies and 65% had thyroglobulin antibodies.  That means that 11% of people with Hashimoto’s would have been missed if you were only looking at TPO antibodies, and a full 35% of patients with Hashimoto’s would have been missed if you were only looking at thyroglobulin antibodies.  There are other studies that have actually even shown lower numbers.  It’s more like 75% to 80% have TPO antibodies, and as low as 40% or 45% have thyroglobulin antibodies.  So what we can say from these numbers is that anywhere between 11% and maybe 30% of patients, if you run TPO and thyroglobulin antibodies that have negative results on an antibody test, may still have Hashimoto’s, even if you run that antibody test multiple times.  So that’s really important for clinicians to understand, because I’ve seen a lot of patients who’ve been to the doctor a few times before they came to see me.  They said, “No, I don’t have Hashimoto’s.  I had an antibody test, and it was negative.”  Well, you can’t really conclusively rule it out just from an antibody test or two.

Steve Wright:  Did I hear you correctly there?  With these people, where you can do the antibody test like 10 times or 100 times, and they’re never going to show positive?

Chris Kresser:  I don’t know about 100, possibly 10.  I think it’s a lot less likely if you do multiple tests, which is why I always recommend that people do two to three tests over time at least, to see if we can catch it.  And I have seen that with patients, where they’ve come and they’ve had one or two negative tests.  I test them a third or fourth time, and we catch the antibodies elevated on the third or fourth time.  But even then, it’s not necessarily indicative that hypothyroidism is present or will ever be present.  So that’s another important thing to understand, that Hashimoto’s itself doesn’t necessarily mean that you have an under-functioning thyroid gland.  It means that your immune system is tagging the thyroid gland for destruction.  It doesn’t even necessarily mean that destruction of the tissue is occurring actively.  And those are all not necessarily connected.  They’re likely to be connected, but they’re not necessarily connected.  There are a certain percentage of patients, and I think it’s actually over 50%, who produce thyroid antibodies that don’t go on to develop frank hypothyroidism.  Of course, people with thyroid antibodies have a much higher likelihood of developing hypothyroidism in the future.  In fact, it’s over sevenfold; I think seven- and ninefold greater risk than people without antibodies.  But it doesn’t mean that if you have antibodies, that you a) for sure, right now, have hypothyroidism, or b) will ever develop hypothyroidism.  That’s important to understand as well.

Another test that your doctor can run—typically an endocrinologist will do this test—is a thyroid ultrasound.  So they’ll run an ultrasound on your thyroid gland and your neck area.  What they’re looking for typically are nodules, little bumps on the thyroid gland, especially if you have a multinodular goiter, like a little mild swelling with a lot of little nodules there.  That’s indicative typically of an autoimmune pattern, Hashimoto’s, or if you have hyperthyroid type of symptoms, Graves’ disease.  So if you really want to get the best view of whether you have Hashimoto’s, it’s good to combine antibody testing with a thyroid ultrasound.  Of course, you could do a biopsy, which would be the most accurate way of detecting Hashimoto’s, but that’s very invasive.  You know, sticking a needle in your neck and aspirating tissue there is not very appealing and is potentially dangerous.  Given the fact that Hashimoto’s is not fatal or not necessarily even debilitating—although it can be—it’s generally judged to not be worth the risk in the invasiveness of that procedure.  So it’s the thyroid ultrasound and the antibody testing.  In my practice, if there’s someone that’s had a negative ultrasound and they’ve had a few negative antibody tests, but I really still suspect that autoimmunity is a cause, maybe they have another autoimmune disease or maybe they just have the signs and symptoms of autoimmunity, then I will do a therapeutic trial of an immune-balancing regulating treatment and see how they respond.  If they respond really well to that, then that’s really all the evidence I need to help do an immune-balancing regimen from a functional medicine perspective.  So that’s the baseline here to understand in terms of Hashimoto’s, because there’s a lot of misunderstanding I think out there in both the conventional side and the alternative side about how to diagnose it and what it means if you actually have it.

Can You Reverse Autoimmunity?

Steve Wright:  Chris, the listener is asking about coming off medications.  But we’re talking about Hashimoto’s, and coming up and down in lab ranges that might not even be existent. We’re talking about treatments that sometimes we just use. The question I’m wondering is, “Is there a point where autoimmunity just stops?” Or are we always a little bit autoimmune? I guess what I’m trying to ask is, should people be thinking or should the goal be, to cure or reverse autoimmunity?  Or are we approaching a limit of infinity of what is actually possible inside the body?

Chris Kresser:  Well, I can tell you the conventional view, and then we can speculate and look at some alternative views.  The conventional view is that once antibody production starts to a tissue, it doesn’t stop.  That’s a good thing mostly.  If you get exposed to a virus or a pathogen—any kind of pathogen that we can produce antibodies to—that’s the way the immune system is designed to work.  If you get exposed then to that pathogen 20 or 30 years later, you have these memory cells that remember and can start producing antibodies to that pathogen again, even 30, 40 years later.  That’s the brilliance of our immune system.  So you only really have to be exposed once, and then you’re protected from that for a lifetime.  That’s when things are functioning well.  But that really clever system can backfire on us when what we’re producing antibodies to is tissue in our body, right?  Because once that antibody production starts, the immune system is designed to remember, so that it will always continue to do that.  So that’s the conventional view.  Then in that way of looking at things, autoimmune disease is not curable.  It’s only manageable.  What you can do is reduce the environmental triggers that provoke and exacerbate the inflammatory response that destroys the tissue that we’re producing antibodies to.  That’s why we talk so much about things like the autoimmune Paleo protocol and glutathione and things that promote regulatory T cell function.  Others have speculated more recently that things like intestinal permeability is a precondition for the development of autoimmunity, and that it’s possible, in certain circumstances, that healing the gut, reducing that permeability, for example, would stop the process of autoimmunity and essentially cure it.  I don’t really think we know enough about that yet to say whether that’s possible.  What I can say is it probably depends on the definition of cure.

So let’s think about something like celiac disease.  If you remove gluten from the diet and possibly other grains and dairy and cross-reactive proteins, that person could become completely symptom-free, right?  So is that a cure?  It depends how you define it.  Generally, if that person starts eating gluten again, they’re going to get very sick.  In the strict definition of a cure, that’s not really a cure, because a cure would be getting them to the point where they can eat gluten with impunity and not experience any symptoms at all.  So it’s not a cure, but it’s effectively managed to the point where they don’t even have symptoms at all, by making some relatively simple changes in their life—maybe not easy, but relatively simple.  That’s kind of the way I look at it, is that these conditions can often be managed to the point where the symptoms are either gone or not intrusive in one’s life.  But as far as that background autoimmune reaction, I haven’t yet seen a lot of evidence—either clinically or in research—that that can completely be cured to the point where there’s no change required.

Steve Wright:  Awesome.  Thanks for opening that wormhole.

Chris Kresser:  Sure.

Steve Wright:  Let’s keep rolling here.

3 Issues That Cause T4 to T3 Conversion Problems

Chris Kresser:  The third question we wanted to address was what causes T4 to T3 conversion problems.  If you recall, T4 is 94% of what the thyroid gland produces in terms of thyroid hormones.  Then that T4 has to get converted into T3, because T4 is not very active metabolically.  T3 is the thyroid hormone that really activates the cellular receptors and does everything the thyroid hormone is supposed to do.  So the thyroid gland produces most of the T4, and then elsewhere—not in the thyroid gland, but elsewhere around the body—that T4 gets converted into T3, which is the active form.

What Raven is asking about, what we often see is people who have either normal or low normal T4, and then they have low T3.  What that indicates actually is that the thyroid gland may be functioning okay, but the conversion of T4 to T3 that’s happening all around the body is not working well.  That’s a really important thing to understand.  T4 to T3 conversion problems are not thyroid problems.  They’re not problems with the thyroid gland.  They’re problems that are caused elsewhere in the body that affect the thyroid system.  They affect the cell’s ability to receive T3 thyroid hormone.  They’ll manifest in hypothyroid symptoms, but they’re not actually a problem with the thyroid gland.  It’s crucial to understand that, because it completely informs how we address T4 to T3 conversion problems.  For example, giving the patient a whole bunch more T4 medication is probably not a great idea in that situation, because the T4 is not being converted into T3.  But that’s the standard treatment for a lot of thyroid problems, is just to give Synthroid or levothyroxine, which is a T4-based medication.  So what’s going wrong in this situation?  It’s usually three primary causes: inflammation, poor gut health, and very low-carb diets, if the person is in that world.  Inflammation and inflammatory cytokines can really mess with T4 to T3 conversion in several different ways.  Let me back up.  Inflammation can suppress T4 to T3 conversion.  It just inhibits that process, but it also messes with thyroid function in other ways.  It reduces the pituitary output of TSH, and it also reduces the cellular sensitivity to thyroid hormones.  So even if you have enough T3 floating around in your system, your cells can’t receive it.  And it doesn’t activate the cellular receptors, so you end up with symptoms of hypothyroidism, even if your labs are normal.  That’s inflammation.  Poor gut health.  20% of the conversion of T4 to T3 actually happens in the gut.  If you have poor gut health, disrupted gut microbiome, SIBO, parasites, leaky gut, then it’s entirely possible that that T4 to T3 conversion that’s supposed to happen in the gut is not happening or not happening well, at least.  Of course, gut problems typically lead to inflammation, so you get a little bit of a double whammy there when you have gut issues.

Steve Wright:  Chris, so with 20%, obviously, it’s probably not 0% to 20%.  Like, if you have a banged up gut, it’s zero then.  We’re talking about a range, so it’s some fraction of that.  Between the body and inflammation, we’ve lost 10%—is that enough that we’re going to be feeling that on a daily basis?

Chris Kresser:  I think it will depend on the person.  The more real-life scenario is probably, let’s say you lose 10% of the conversion in the gut.  But you have inflammation, because your gut is screwed up.  So that inflammation is also reducing T4 to T3 conversion outside of the gut.  So that’s maybe another 10%, 20%.  I mean, these numbers are just made up.   I have no idea.  I don’t think there’s ever been a study that shows exactly that.  Then let’s assume that your cells are less sensitive to the effects of thyroid hormone that you do have because of this inflammation.  Even though you maybe only have a 20% reduction of your T4 to T3 conversion, you’re not as sensitive to the T3 that you do have.  So you get all of these factors that combine to reduce the effectiveness of your overall thyroid system.  That’s probably more how it happens in the real-world scenario.  Then maybe you’re on a very low-carb diet, because you’re trying to lose weight or you’ve just been told that that’s a good kind of default approach.  The problem with that is insulin is required to convert T4 to T3.  We hear a lot of bad things about insulin, and certainly insulin resistance is not good.  But insulin is a vital hormone.  It plays a lot of important roles.  One of them is this conversion of T4 to T3.  And if you’re on a really low-carb diet—like a ketogenic diet—over a long period of time, you’re bound to have very low insulin levels.  This is in some people, not everyone.  I’ve talked about this a lot.  I’ve talked about it on Jimmy Moore’s show.  We’ve had a lot of discussion about this.  I want to be clear that this doesn’t happen to everybody.  But it’s more likely that someone who’s on a ketogenic or very low-carb diet will have low levels of T3.  So those are the three main issues—inflammation, poor gut health, and very low-carb diets—that can cause T4 to T3 conversion problems.  What that means, from a clinical perspective, is that just giving more T4 medication is not the answer.  And even giving T3 medication, although it can help, is not really the answer from a functional medicine perspective.  That’s because that’s kind of putting a band-aid on a problem.  And sometimes band-aids are necessary, they help protect the wound and help it to heal.  But you really want to address the underlying problem with functional medicine to get the best long-term result.  If you need to use a band-aid for a period of time while you’re doing that, that’s fine.  There’s nothing wrong with that.  I do that in my practice.  But not at the expense of addressing the underlying issue.

Steve Wright:  Yeah.  I think it’s always important to be thinking short-term, how can I have the best quality of life possible?  And then long-term, how can we get this whole thing handled?

Chris Kresser:  Exactly.  Another analogy we often use in functional medicine is a tree.  In order for a tree to have healthy branches and leaves, you have to take care of the roots.  But sometimes you need to do a little bit of pruning on the branches, in order for the tree to be healthy too.  So it’s not just that we are, at the exclusion of all else, focusing on the root cause, but it’s that we always want to do that at the very minimum.  Then on top of that, we may also need to address the symptoms specifically, just for someone to feel better and function in their lives.

Okay.  The last piece we need to talk about is what’s the significance of a TSH of zero—or 0.07 I think it was for Raven—and low T4 when you’re taking thyroid medication, particularly thyroid medication that has T3 in it.  Typically, with a TSH of zero, it either means you have hyperthyroidism, if you’re not taking thyroid medication, but if you’re taking thyroid medication, it means your dose is too high.  That’s because if you recall how the thyroid system works, the pituitary is a gland in the brain.  It’s like the control tower that’s constantly monitoring the levels of all hormones in the body, and in this case thyroid hormone.  When thyroid hormone levels are high or higher than what the pituitary thinks they should be, it will reduce the output of thyroid-stimulating hormone (TSH).  That’s the signal that it sends to the thyroid gland to tell it how much thyroid hormone to produce.  So if thyroid hormone levels are high, TSH will drop, because the pituitary is basically saying to the thyroid, “Hey, we’ve got more than enough as it is, s don’t make any more.”  On the other hand, if thyroid hormone levels are low, then you’ll see TSH go up, because the pituitary, at that point, is shouting at the thyroid gland, “Hey, kick things up a little bit.  We’ve got low levels of hormone.”  So when you see a level of zero, that means the pituitary is like slamming on the brakes and saying, “No more thyroid hormones.  This is too much.”  That’s a sign that your thyroid medication is too high typically.  So you’ll want to speak with your doctor about modulating the dose of the medication, so that your TSH range is back in that normal range of 0.5 to 2.5.  That’s the functional optimal range for TSH.

In terms of low T4, that’s also typically a reflection that you’re taking thyroid hormone, particularly T3, because if you think about it again, the way that the body protects itself from too much hormone is it would tell the thyroid to produce less thyroid hormone.  Then the thyroid itself would produce less thyroid hormone, which is T4.  So seeing this pattern is very typical when someone is on thyroid medication.  Now I do want to say that if TSH is normal or at the low end of the range—like 0.5 or something like that—and T4 or free T4 is slightly low—maybe 0.8 for free T4 or maybe 5 for total T4—that’s not necessarily a problem.  That’s indicative that you’re taking supplemental T4, T3 combination or just T3 alone, and it’s not a problem.  What determines whether it’s a problem is the TSH level.  So if the TSH is at zero and T4 is low, I would say that’s a clear indicator that the medication dose is too high.  If the TSH is normal and the T4 is slightly low, I would say that’s probably not an issue.  Of course, we have to say that before you make any changes to your medication, make sure to speak to your doctor.  Don’t take this as medical advice.  I’m just sharing with you what the research says about these numbers and what this means.

Steve Wright:  What happens if TSH is above 2.5, like 5 or something?

Chris Kresser:  If TSH is above 2.5, it means your dose is too low or you’re not addressing other fundamental problems, like the gut issue, the inflammation, and some of the other things that we talked about.  That’s probably a topic for a separate show.  But the lab range for TSH, as I mentioned, is too broad.  It’s usually 0.5 to 4.5.  But more recent studies have shown that the normal range for a healthy, functioning thyroid, the TSH range is 0.5 to maybe 2.2, at most 2.5, but definitely not 4.5.

Is It Possible to Get off Thyroid Medication?

Okay, let’s wrap this up.  I know we’re probably going a little longer than normal today.  Let’s circle back now to Raven’s main question, and a lot of people’s main question.  I hear this all the time.  Is it possible to get off thyroid medication?  The answer, after everything that we just went through, is it depends.  It’s always the answer, and it’s true.  It depends, of course—I hope you can see this now—on what’s causing the problem.  In Raven’s case, if she truly doesn’t have Hashimoto’s, it’s possible that fixing the gut and reducing inflammation, if that’s what’s causing the low T4 to T3 conversion, would be enough to resolve the problem, and she wouldn’t need to continue to take thyroid medication.  Or maybe in another situation, if we found out that Raven was iodine deficient and that was the real cause, or selenium or zinc deficient—I’m going to add this back to T4 to T3 conversion problems.  Selenium deficiency and zinc deficiency can also cause problems with T4 to T3 conversion.  If we find that she’s deficient in selenium and zinc, we restore those nutrients, the T4 to T3 conversion improves, no more need for thyroid medication.

Steve Wright:  Since you just opened the wormhole again, do you want to throw neurotransmitters in there too?

Chris Kresser:  That will just take us too far down the rabbit hole, so we’ll come back to that.

Steve Wright:  Okay.

Chris Kresser:  So if the cause of the thyroid problem in the first place can be addressed, then yes, you can get off the thyroid medication.  But what if Raven does have Hashimoto’s, and what if she had it for 20 years before she developed hypothyroidism, which is entirely possible and often common?  And what if, over that period of time, the immune attack against the thyroid gradually destroyed the thyroid tissue, which is where thyroid hormone gets produced?  In that case, it’s probably not possible and not even desirable to get off of thyroid medication, because thyroid hormone is so essential to every cell in the body that any potential downside of taking thyroid hormone replacement—either like a pharmaceutical approach, synthetic, like Synthroid or levothyroxine and Cytomel, or bio-identical porcine thyroid source medication like Armour or Nature-Throid or desiccated pig thyroid that you can buy over the counter—that would all be advisable over the long term in a person like that.  That’s because they need the thyroid hormone to function well, and their thyroid gland is compromised.  And as far as we know, that tissue doesn’t grow back.  So in that situation, in that person, it wouldn’t be possible for them to get off thyroid medication.  It wouldn’t even be a goal that they should be thinking about.  So it really depends on the situation, as I hope you can see from today’s show.  Raven, I hope that answers your question.  I hope everybody else got something out of that as well.  It was a lot of information in a short time, but hopefully, that helps.

Steve Wright:  I think the wrap up there was great, Chris.  We didn’t start the show like that because it would have led to a five-hour show.  But the thyroid is part of the HPA TG axis.  The thyroid is right in the middle of that large acronym of basically all of your hormone structures.  So if you’re someone who’s bent on getting off your thyroid medication or stay in this, you’ve got to think about that whole chain, because they all interact together.  We’ve only touched upon that topic today.  It sounds like Raven has a lot to work with.

Chris Kresser:  I hope so.  Thanks again, everyone, for listening.  Steve, good to have you back.  We’ll see you next week.

Steve Wright:  Thanks, Chris.  For listeners looking for more information in-between episodes, make sure you go to Facebook.com/ChrisKresserLAc and Twitter.com/ChrisKresser.

107 Comments

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  1. Chris, I’ve been taking Nature-throid and just reduced from a grain and a quarter to one grain per day. I think after repairing many gut problems I’ve had in the last few years, my Ft3 jumped from 2.8 to 3.4 and Ft4 gradually increased from .79 to .99. Tsh is .108. I’ve been concerned that my tsh is so low, but ft3 and ft4 are mid normal range. I’ve had, the last several months, burning sensations in my chest that I think are related to my thyroid medicaton. Do you think I’m on too much medication with a low tsh like that? I’ve been gradually trying to reduce the medication and see how I feel. I don’t really understand why my tsh is so low, when I feel my ft4 and ft3 are more optimal. Is it possible that, for me, it’s too much ft3 and ft4?

  2. This is great article and discussion. Thank you Chris. I have a question regarding iron supplementation and ferritin levels. My ferritin is currently 16. My other iron markers are in the low end of the reference range. I have other scary autoantibodies that I am working hard to keep in the ‘silent’ phase, as per my Cyrex autoimmunity panel. I have not been able to get optimal on WP-Thyroid. My TSH is still 3.5 and my free levels are in the low range of normal. I have weird tendon pain that flares when I try to raise my dose of thyroid hormone, so I always back it down and limp along at a health plateau. I work with a trusted functional medicine practitioner, he does not like to supplement with iron because he said it is one of the most inflammatory things you can give an autoimmune patient. I feel caught in a Catch 22.
    I have added liver and grass fed beef to my diet with marginal effect on my ferritin. I am working hard on healing my gut. I am wondering if I could get optimal on compounded synthetic thyroid hormone, without having to raise my ferritin levels? One other big issue against supplemental iron, right now, is that I cannot get constipated. I had diverticulitis flare up when I went on the autoimmune paleo diet before I was on thyroid meds. So, for now, it is all about gut healing. I am hoping someday to be able to have optimal thyroid levels…I have been hypo for far too long. Can you speak about optimum ferritin levels and thyroid hormone, as well as, the controversy of supplemental iron and autoimmune patients?

    • Ferritin of 16 is definitely low and indicative of need for iron. Liver is very rich in iron, and doesn’t tend to cause constipation. Also, heme forms of iron like Proferrin or bovine lactoferrin don’t tend to cause constipation either.

      I don’t think that iron is inflammatory to autoimmune patients across the board, and I’ve never seen research to support that. However, iron overload is certainly a concern when levels are high. It doesn’t appear that you fit into that category, though.

  3. Hi Chris – love your podcast. You mentioned having low T4 as a good thing – but David Borenstein, an integrative physician, suggests that optimal range for free T4 is between 1.3 and 2.8 (For T3 he suggests optimal range is 3.7 – 4.2) How can a patient (me) make sense of these ranges? (including lower range you suggest…) Thanks so much!

    • I didn’t say low free T4 is good, I said that it’s not unusual to have low free T4 when you are taking a medication that contains T3 in it. Those are very different things.

      • Thanks Chris – so does that mean that the goal would be to aim for higher free T4? And conversely, is a low free T4 a bad thing?

  4. Chris, thanks for the post. This topic is very close to my heart, I’ve suffered from it for my whole life. I think I’ll accept it as fate to continue having this problem.

    Just a couple questions here. Regarding the TSH, you said that should be within 0.5 to 2.5, and not anything lower. What if I only feel good (symptoms free) when I take enough dessicated thyroid to the point of TSH 0.07? Should I dose by the symptoms or should I dose by the lab?

    Another question is that I’m on a very low carb diet due to a blood sugar issue that’s caused by adrenal fatigue. Should I increase my carb intake for my thyroid health, ignore my blood sugar level and let my insulin handle the fluctuation?

    • Suppressing TSH to nearly zero with meds isn’t a good idea in my opinion. In most of my patients, if they only feel good with a TSH of zero it means we haven’t addressed the underlying issues (autoimmunity, gut infections, nutrient deficiency, etc.).

  5. Dear Chris,
    Thank you for all the great info. I have been detoxing and working on my gut and decreased my medication from 90 to 30 mcg of Armour. Now my T4 and T3 are low, and my TSH is 249. I feel well and have no symptoms. If I take my Armour I get hyper and can’t sleep. My doctor is very alarmed and wants to increase the Armour. Is high TSH dangerous and what should I do if I feel just fine? Everybody is talking about about TSH within 0-5, but what about extremely high? I would apprecite very much any insight.

    • High TSH, especially at that level, is cause for concern. Thyroid hormone is used by nearly every cell in the body and plays many important roles.

  6. I latetly had problems with blood in one eye from landing of plane. It happened three times on a different trips. I went to the optometrist for my check up and asked him about that. He told me that it is from a little vein who pop out and do a little hemorragi outside my eye. But he said if that happen inside the eye or in the brain it can be very serious. And he asked me if I was taking blood thinner medication, and I told him no. But after words I realized that the last three year my platelets are a bit lower than normal. And lately I saw a study made in uk about patients taking levothyroxine who had platelets lowered by that medicine. And I thing it’s my case. I take pills for thyroid since about 5 years and I hate that very much. The doctor gave me that following blood test and from family history, my mom is on that since forever. But for me I never ever had any symptoms of anything related to hypothyroid problems and now I realize that this medication started to give me other problems like this platelets problem. I really really would like to get out of that medication but I don’t know what to do. I would like to be coach by a doctor and I just don’t know if it’s possible. And when I read all the comments from the people I am lost with all these term like T3 ,T4…etc so what do you think I should do. I’m suppose to travel for thanksgiving and now I’m scare.

  7. I was diagnosed as Hypothyroid more than 15 years ago. I continued blindly taking Levoxyl until about a year ago when it finally occurred to me I may have been misdiagnosed. Long story short, I was switched to Armour Thyroid with a reduced dosage (.15 instead of .75) and spent a few months adjusting to the change in hormones (anxiety, mood swings etc). I started to feel much better. This past April I went off the meds completely and my numbers are normal (right in the middle) and my hormones have adjusted. Additionally, rashes I had for years on my upper arms are gone, and my hair is no longer thinning, as symptoms I attributed to the disease were actually a result of the medication for a disease I probably never even had.

    • Hi Lisa – Did you make any other changes (diet, supplements, stress moderation…) when you went off the meds?

  8. Chris,

    You mentioned that one could no longer aim to get off thyroid medicine if the thyroid tissue had been gradually destroyed.

    Is there a way (specific tests or procedures) to determine conclusively if this is the case in a patient?

    Thanks so much,
    Sandra

  9. Thank you for all of your work!! I have had high antibodies for 5 years that go away when I’m pregnant but always return and some symptoms of hyper/hypo thyroid however all thyroid number have always been in range.
    Because of my symptoms I have been on a low dose (25 mcg) of Levo which sometimes helps sometimes doesn’t.
    If one of your patients had antibodies and had perfect thyroid numbers all around would you treat them with natural thyroid or look at something else for them??? Would you consider they had Hashimotos just because of the antibodies?
    Thanks again!

    • Hi Chris,
      Hi Kate,

      I have a very similar question to Kate’s. I just received my blood test result and while my TSH, T4, and T3 are all in normal range, my thyroid peroxidase antibodies number is 139. Should someone start taking thyroid medication when everything but their antibodies is in normal range? Or is it more important to focus on healing the gut, inflammation, etc. first before moving on to medication.

  10. What about pacients who had to remove their thyroid due to cancer? The supplement is usually done with T4, and I heard we had to eat some more carbohydrates to the t4 be converted in t3 by the body… not to mention that our t4 dosage is usually a little higher than the commom people to supress the possibility of the return of the cancer…

  11. I’ve had hashimoto’s for 31 years and have had big problems keeping my
    Meds stable. I also found out recently if you have thyroid you should NOT eat gluten. I cut it out of my diet and the weight falls off if you. Plus it is crucial that your doctor test your vitamin D as it is critical to the thyroid.

  12. Hi, I was diagnosed with graves disease (auto immune over active thyroid) and was told that I needed to take medication for rest of life. But to cut a long story short, it seems that eating gluten /grains contributed significantly to the cause of the problem, and staying off them, I don’t need to take any medication. I haven’t done in four years and all blood work is normal.

  13. Hi Chris,

    What irks me, is that I was not informed that once thyroid medication was started, it should not be stopped! Had I been told that, before, I commenced taking this medication, I would have researched it myself and would definitely have tried a natural approach first! Also, I am curious as to the high percentage of people walking around, oblivious to the fact that they have a thyroid problem, so are not on any meds, yet they have not apparently keeled over and died!! I was told that I could not stop taking these tablets, as I could go into a coma?? Why are there not people all over the world, falling into coma’s, if they don’t know they have an existing thyroid problem?? Is it because they have not begun using medication to ‘so call’ assist with the problem?? If that is the case, why start taking this medication in the first place?? It would appear to be replacing one problem, with a much larger one?? All patients suffering this disease, should be fully informed of the pro’s and con’s BEFORE commencing any such medication. It should be mandatory!! We are entitled to make an informed decision prior! I am very angry that I put my trust in a doctor, without all the facts!! 🙁

    Thanks Chris

    • Colleen,

      I’ve had many patients who were able to stop thyroid medication without adverse effects. I’m not sure who told you that you would go into a coma if you stopped taking thyroid medication? I’d like to see research that supports such a claim.

      • I want to get off of Levothyroxin that I was put on many years ago without being told I would have to stay on it the rest of my life. The doctor has just upped my dosage from 50 to 75 mgs daily. I have fought depression almost daily since I’ve been on it and never knew that the Levothyroxin could be the cause of it although I never had it before. Any help you could give me would be greatly appreciated! I do eat fairly healthy but need to cut down the sugar. Thanks much!

  14. Just wanted to add that another issue that can decrease T4 to T3 conversion is iron deficieincy. The site stopthethyroidmadness recommends thyroid patients keep their ferritin levels at >70. People have problems with their thyroid meds not working when their ferritin is below 70.

    • I don’t necessarily agree with this. I haven’t seen any research to support it, and there’s evidence that blood sugar control starts to decrease as ferritin climbs above 100 in women. I’ve had women come to me supplementing with iron based on that advice, and when I run a full iron panel they are in iron overload, with high iron saturation, low TIBC and UIBC, and borderline high ferritin.

      Certainly, iron deficiency is a problem but I haven’t seen any evidence that ferritin <70 indicates that in women.

      • Thanks for your reply Chris! Of course there is an upper limit, and going too high is bad too. Supplementation should be done based on testing, not just randomly because you read some advice on the internet! (As you have said before, and I agree.) I definitely don’t advise anyone to do that (and I did not do so here), I merely wanted to point out another avenue to look into, and ferritin testing is done pretty routinely (a full iron panel would be best, I agree, but the doctor may not).

        I don’t recall offhand what the recommendation was based on, but it was either some paper, and/or or the experiences of the patients who contributed to the site. There were definitely people who reported that they finally responded to their thyroid meds after reaching 70. And I’m pretty sure you’d agree that patients’ experience counts as evidence too.

        I do know that at <50 ferritin, fatigue and cognitive symptoms become apparent (there's a paleo doc who blogged about this at some point, and that cut-off point had both a paper and clinical experience backing it up). My own doc (MD) wants my iron in the 70-80 range.

      • The site I mentioned actually addresses some/most of your concerns (they recommend the full panel and discuss iron overload, etc). http://www.stopthethyroidmadness.com/ferritin/
        They’ve linked to some papers, but they’re of mixed quality. The one they point to as relevant to the iron and T4 to T3 conversion is a rat study: http://ajpregu.physiology.org/content/239/5/R377
        (I’m not affiliated with them, btw, just someone with thyroid issues.)
        It’s interesting you haven’t come across these types of patients though. With thyroid symptoms and a normal TSH, all my doc will look into is iron deficiency.

        • Yes, I’ve seen that research and I’m not impressed. I do pay attention to anecdotal experience from patients, but given the considerable research I’ve done on the effects of iron overload, I’m as concerned about that as I am with iron deficiency.

          I’m all for what helps people, as long as it doesn’t cause harm!

          • OK, that’s totally fair! Thanks Chris.
            Btw, I’m currently looking up articles on iron deficiency and came across this one that may be of interest to you: http://www.bloodjournal.org/content/123/3/326?sso-checked=true
            It goes into mechanisms of iron deficiency related to Celiac, autoimmune gastritis, low stomach acid, and H. pylori. Reminded me of the article that mentioned low stomach acid in acne patients. If Celiac caused atrophic gastritis in this patient population, it would make sense why going off gluten fixes acne in some people.

        • Have you investigated Wilson’s Temperature Syndrome, a condition that describes a person with all normal hormone blood tests but a low body temperature with hypothyroid symptoms?

    • Ferritin is iron *storage*, what the body has sequestered *apart from* circulation. From my experience and observations over the last 20 years, I haven’t found that a ferritin of at least 70 is necessary to get thyroid into cells. Ferritin 20-30 has worked fine for me. Less than 20 could be a problem. I’ve recently seen a reference range that goes down to 5 on the low end, but that’s close to running on empty.

      • Yup, I’ve known people who are fine at ferritin of 20 too. There’s a subset of people who seem to do better (not just with thyroid issues) at ferritin >50, and usually 70-80 is the target. Not sure why, could be genetic.

        The problem with just presenting anecdotes is that other people have different anecdotes. Your anecdote doesn’t invalidate mine. I guess that’s why the reference range is so wide; each person’s optimal range will fall within the population range.

  15. Hi, Chris. Your discussion today is really pertinent to me. I was recently diagnosed with Hashimoto’s. I’ve been on Snythroid since I was 15 years old and am now in my early 60’s. After an ultrasound and a number of blood tests, my TPO came back at 4481. My ENT increased my Synthroid; prescribed more Vit D; iron for anemia. After doing some reading on your website, it looks like I should also be taking Selenium. My question is how/when will I know that the Hashimoto’s is being properly treated. Will the TPO numbers become more in line with a normal range?

    Thanks so much for your thoughts.

    • Francine, Have you been tested for celiac? Low vitamin D and anemia together are indicators, and already having one autoimmune disease only increases your risk.
      Chris: great post! Also enjoying the recent ‘defining low carb’ series. I was definitely unintentionally low carb, and have really been noticing an energy boost since increasing carbs to the low-moderate range. Thanks!

      • Hi, Lauren. I was tested for celiac disease a number of years ago and it was negative. I have a number of long standing food allergies (eggs, oats, some fruits) which limits what I can eat – particularly for breakfast. However, about a year ago, I cut out any bread products after breakfast – and as a result, lost my “wheat belly” and reduced the inflammation in my fingers. So while I am not completely gluten free, you have given me something to think about. Thanks for your comments.

        • Just because a celiac blood test came negative doesn’t mean you don’t have celiac. I lost 10 years of my life because of that faulty test (the test itself is not very sensitive). If you have all these allergies you’re mentioning, this points even further to celiac disease, because gluten is great at disguising itself as an allergy to another food.

  16. Chris,
    It sounded like you might be repeating the antibody testing several times in your practice. If so, why? It seems like a waste of time and money.

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