04/18/2026
Let’s talk about thyroid management. Maybe the endocrinologists will also see this and be able to better help people. If I had a dollar for every time a patient tells me, “My doctor said that my thyroid levels show I’m hyperthyroidism.” First of all, I encourage my patients to not let any other doctor test their hormones, including thyroid, but sometimes it happens.
There is a lot in this post because there is a lot of nuance to thyroid management. Let’s first discuss the symptoms of low thyroid. These can include weight gain, difficulty losing weight, cold all the time, constipation, hair skin and nails not growing well, fatigue, sleeplessness, menstrual cycle irregularities, puffy face, high cholesterol, heart disease, and sleep disturbances. Thyroid and testosterone are the feel good hormones for men and women.
Thyroid management, in corporate medicine, relies solely on one test. That test is the TSH or the thyroid stimulating hormone. The problem with the TSH is it only tells us what the pituitary is doing. The pituitary gland in the brain is the master gland that sends out signaling hormones for the endocrine system. The TSH tells us what the pituitary is doing, but it does not give us any insight into the actual thyroid hormones.
Our thyroid makes five hormones, including T1, T2, T3, T4, and calcitonin. The actual thyroid hormones that we measure are free T3 and free T4. When measuring the actual thyroid hormones, T3 is the metabolically active hormone of the thyroid. That means T3 is responsible for resolving all the symptoms we think of, with hypothyroidism. Therefore, that is the most important one to look at. In corporate medicine however, they will test a TSH with a reflexive T4. That means if your TSH is elevated, signaling low thyroid, it will automatically do only a free T4. However, T3 is the one we’re really concerned about.
Patients with hypothyroidism are prescribed levothyroxine or Synthroid. Both of these medications are T4 only medication. That means you are completely missing the T3 portion of replacement. The T3 that resolves all the thyroid symptoms. When you give a patient a T4 only medication, you turn off the thyroid gland, which is normal, but now you’re only giving back T4 and not T3. The endocrinology world believes that if you need T3, you will automatically convert T3 from T4. I say that could happen if you also have unicorns, Rainbows, and sprinkle cupcakes. Many people lack the proper enzymes to do that conversion. That conversion also happens in the liver, which in our society our livers are bogged down.
If you are on a great dose of thyroid medication, the pituitary stops, sending out TSH. When the pituitary stops sending out TSH, it gets very low and even sometimes suppressed. A suppressed TSH is where most people, including me, feel their best. There’s nothing dangerous to it. In fact, endocrinologists manage patients with thyroid cancer, who have had their thyroids removed, by suppressing the TSH.
I have showed a couple case studies before on hyperthyroidism but I’m doing it again with someone that I just recently saw. It’s so interesting to me and such a stark contrast when you have endogenous hyperthyroidism versus someone on medication for hypothyroidism. This will hopefully help you see the difference between true hyperthyroidism or endogenous hyperthyroidism and a suppressed TSH that is manipulated by medicine. I always say I am not anointed enough to create endogenous hyperthyroidism in someone just by giving them thyroid medication.
The first picture is The patient that I just recently saw with true hyperthyroidism. Her TSH is suppressed just like the next picture of one of my patients and my own labs. The difference, and it’s huge, is the fact that her free T4 is 3 to 4 times the upper limit of the range and her free T3 is 3 to 4 times the upper end of the range. That makes her free T3 18.1, whereas mine and my other patient’s are at 4 to 5. Just because a free T3 is elevated, doesn’t make it hyperthyroidism. Just because a TSH is low or suppressed on thyroid medicine, doesn’t make it hyperthyroidism. THAT’s JUST SILLY! And in my opinion, a bit embarrassing to claim that.
Thyroid optimization is an integral part of a complete hormone protocol. Many of my patients get thyroid optimization even with a so-called normal TSH level.
I hope this helps. I’m a bit of a thyroid nerd because I enjoy thyroid management so much. Like hormone replacement therapy, thyroid management is sorely lacking in the corporate medicine world.
Don’t worry about my estradiol level at 60, as I increased my dose after these labs. Don’t worry about my other patients estradiol level at 69, as her labs were late in the afternoon after 3 o’clock. That means the estradiol she took in the morning is starting to wane . These are the nuances of hormones and the reason you need a subject matter expert in hormone therapy to take care of your hormone needs. ❤️❤️
