Danette’s Question: 

Can you determine if I should be considered for hypothyroidism? I have five of the listed symptoms, but my labs fall into “normal ranges” from my lab. Free T4 is 1.1, free T3 is 3.0. TSH, thyroid-stimulating hormone, is .82.

Short Answer: 

Many people could be considered to have Subclinical Hypothyroidism. This is when thyroid labs are all within the normal range, but several symptoms are present. In Danette’s case, her labs actually look fairly decent. Her TSH is below 1.0 and her Free T3 is 3.0, but she has many hypothyroid related symptoms. She does not have hypothyroidism, but could easily be in the subclinical category. However, many of the symptoms listed below can be attributed to many other issues including PMS, Perimenopause, Menopause and adrenal dysfunction.

Symptoms of Hypothyroidism: (not a comprehensive list)

• fatigue
• weight gain or slow metabolism
• dry skin
• constipation
• low mood
• heavy periods
• heavy irregular periods
• brain fog,
• hair loss.

PYHP 077 Full Transcript: 

Download PYHP 077 Transcript

Dr. Maki: Hello, everyone. Thank you for joining us for another episode of the Progress Your Health podcast. I’m Dr. Maki.

Dr. Davidson: I’m Dr. Davidson.

Dr. Maki: So, Dr. Davidson, how are you doing this morning?

Dr. Davidson: I am doing really good. I’m just actually looking at our little dog, Bob. His name is Bob, that we have. He’s what, 15 months old right now? 16 months old? Anyway, I just love to look at him. He’s laying at my feet with his head using, there’s on the desk here, there’s a metal rod and he likes to use that metal rod as his pillow.

Dr. Maki: Yes, yes. So, if you’re wondering, my name is Robert, his name is Bob. My dad’s name was Bob. He always went by Bobby, didn’t go by Robert or Rob. So, he passed away in 2000. But when we got him, he went through a kind of a whole bunch of awful names. Then you just came up with Bob one day like, I think we should name him Bob. I’m like, alright, that’s good. That was my pick in the first place. But you went through a bunch of, I didn’t remember some of that. There are some weird ones.

Dr. Davidson: I won’t tell you but he is a Bob and he’s very cute.

Dr. Maki: We’ve talked about him in some other podcasts, but if you’re interested, he is half Australian Shepherd, a mini Australian shepherd. He’s quarter Border Collie and a quarter Blue Heeler. Needless to say, he’s smart as a whip and he has an unlimited amount of energy, almost to a frustrating point sometimes, but nonetheless, he’s fantastic. So, we’re gonna talk about some listener reader questions. This one is about thyroid, kind of questioning whether someone is hypothyroid or not. This one honestly is something that we get quite often, this is very, in some ways, a little bit of a controversial topic. We’ll get into why that is here in a second. This comes from Danette. Dr. Davidson, once you go ahead and read it.

Dr. Davidson: Sure, sure. So, this question is from Danette and she’s actually a podcast listener. So, she had listened to an episode called, Do you have low levels of T3? So, her question was, from Danette, can you determine if I should be considered for hypothyroidism? I have five of the listed symptoms, but my labs fall into “normal ranges” from my lab. Free T4 is 1.1, free T3 is 3.0. TSH, thyroid-stimulating hormone, is .82. Like, Dr. Maki said, it is a little bit controversial because people always want to be, not necessarily people in general, But there’s always this connotation of being diagnosed, I’ve been diagnosed this, I’m diagnosed this, like this label of being diagnosed. So, if you fall in a certain reference range, then you’re either not diagnosed as hypothyroid. But if you fall just slightly out of that reference range, then you’re technically diagnosed hypothyroid. So, we look at things a little bit more fluidly. Looking at the symptoms, of course, looking at the labs, looking at the person’s lifestyle. So, this is where we’re going to kind of break this down a bit. But just to kind of back up on that episode that we did, the symptoms that we had which Danette is saying that she has five, plus of the listed symptoms. The symptoms we had written down were fatigue, weight gain or slow metabolism, dry skin, constipation, low mood, heavy periods, heavy irregular periods, brain fog, and hair loss.

Dr. Maki: Yes. That’s Episode 38, by the way, if you go back and look. It’s amazing on how long ago that was already that we’re already on, this is what I think 75 or 74, something like that. Now, we’re already almost 40 episodes past that. So, in a situation like this, her labs, again the free T3, the free T4, the TSH, those three tests, at least there is a free T3 level there. Whoever ran her numbers, the free T3 is one that we choose to do all the time. Conventionally, it does not get done very often. Even if it does get done at the patient’s request, most doctors really don’t pay a lot of attention to it. Her TSH is actually perfect. It’s below 1.8. I think is a very good number. The free T3 is a little bit kind of middle of the range, top of the bell curve. But at least it’s in the 3s. It’s not in the 2s. What we don’t know about Danette is how old Danette is. So from her thyroid numbers, she’s technically not hypothyroid. With her symptoms like you say, one of our rules always is to treat the patient first and the lab test second. In medicine, it kind of has reversed a little bit and it’s all always about the numbers and it’s not so much about the clinical presentation as it probably should be, in most cases.

Dr. Davidson: Exactly. So, we’re just looking at the labs and Danette’s probably feeling frustrated with her doctor because they’re telling her she’s normal, but she’s not feeling normal. But like Dr. Maki had said with the reference ranges, and honestly, the reference ranges are really vast that most people when they do their lab work for their thyroid tend to fall in that normal range. But her TSH like he said, the thyroid-stimulating hormone at .82 is actually really good. The usual reference range for a TSH is anywhere between point .45 and 4.5, which is a very big reference range, .45 to 4.5. So, in the way the TSH works, the thyroid-stimulating hormone is a signal from your brain and it monitors overall thyroid status in your body. So, if the thyroid levels go down in your body, that TSH from the brain goes up. So, when you see a high number of TSH, then you think that person’s thyroid is probably low. I’ve had plenty of patients and I’m sure you have too, Dr. Maki, that come in and their TSH is actually down at you know, .45, maybe even a little lower than that, or .75 and they’re like, my TSH is so low is my thyroid low? Actually, I have to tell them, it works in the reverse, which is called a negative feedback. So, if that TSH is low, that means your thyroid levels possibly pretty much are probably on the higher end and vice versa, if that makes sense.

Dr. Maki: Yes, right. Yes. So, it’s kind of the opposite. When the TSH goes up, then your thyroid function is lower. But there’s a lot of controversies out there in the non-conventional world of not really paying a lot of attention to the TSH, which we do agree with. Now, we test the TSH, we want to pay attention with the TSH is because it still provides us some good information. But we don’t necessarily make all of our decisions based on that one test. Conventionally, when people finally come to us, they’ve been to multiple doctors, they might have been to their general practitioner or even an endocrinologist. If that TSH comes back normal, they are not going to do nothing. That’s where we differ with that a little bit, in a lot of cases, because with everything like, you said earlier about being diagnosed. There’s this kind of, I have it or I don’t kind of a concept in medicine. With thyroid, I think thyroid has certain levels of severity. Now, if that TSH, let’s say hers is at 8, you know, it’s 8.2 instead of .82, well then automatically she’d be diagnosed and she put on she’d be put on Synthroid or levothyroxine or Levoxyl, but that’s also a treatment style that we don’t necessarily agree with either. Her numbers, technically she is not hypothyroid but she had a list of five of the plus five plus symptoms on the list that we read off earlier. So, we would put her in a category of subclinical hypothyroid at least potentially anyways, but there’s a whole bunch more information about her lifestyle, her age, her menstrual history, where she is, is she in menopause? Is she not? If she’s in perimenopause or menopause, that could account for all of her symptoms. But if she was, and I believe that she probably isn’t, I would say if she was in menopause, or even close to menopause, her thyroid numbers probably look worse than they do.

Dr. Davidson: Yes. Usually with menopause, that TSH will start to come up and like Dr. Maki said is that we don’t want to fixate on the TSH, we just want to have it in our [inaudible] to be able to put all the pieces of the puzzle together. I do think that Danette’s free T4 at 1.1 is pretty good. I like to see the free T4 right around 1.1, 1.2. You don’t necessarily want to see it too high because a lot of the reference range is vast, .8 to 1.8. Because if your T4 is too high, that means it’s pulling and it’s not converting to the free T3 because the whole goal between free T4 is to have it convert to the active form of thyroid which is the free T3. So, with Danette, her free T3 at 3.0 again, the reference ranges are huge 1.8 to 2.9. Some of them are like 2.2 to 4.4 everybody is, they have all these reference ranges all over the place with these labs. I’m sorry, the typical reference range is 2.2 to 4.4. But anytime you see it around 3 or below, you think that free T3 is low. But that’s where like, Dr. Maki said, we want to treat the individual. We don’t want to treat the numbers. Danette would not feel good if I said okay, your free T3 is low, let’s just throw you on some thyroid, she’d probably feel horrible because her TSH is pretty good. Her free T4 is pretty good. There’s probably something else behind the scenes that’s creating that free T3 to go down. Usually, your first thought is like we had talked about perimenopause, menopause. I’m thinking it probably is a little bit more to do with her adrenal glands.

Dr. Maki: Yes, right. There’s definitely a connection between the adrenals and thyroid function. Depending on what symptom she has there, adrenal issues, stress is going to cause irregularities to the period, it’s certainly going to cause weight gain is going to certainly cause fatigue, dry skin, constipation, even low mood. If you look up anything that relates to hypothyroid, those come up quite often. But there are lots of other things that those could pertain to. They’re classic hypothyroid symptoms, but there are other things that could lead to those as well.

Dr. Davidson: So, granted, this question is one sentence with a couple of lab numbers. But just to kind of really extrapolate a little bit, looking at what she’s saying, I would say out of her symptoms, she probably has fatigue, because of that low T3 level around 3.0 is probably making her tired. She probably is getting weight gain, or she’s stalling and not losing weight. And I would say probably the other ones would be the dry skin, the low mood, and the brain fog. She might be having some hair loss, but usually, that free T3 has to be below 3.0 to really see that hair really fall out a lot because it does when that T3 starts to a dropdown. But I would say definitely she’s probably tired and it’s that metabolism.

Dr. Maki: Yes, right. Yes. With numbers like this, again, with that free T3 being right on the top of the bell curve, so the reference range for free T3 is 2.3. Some labs it goes all the way down to 2.0. Some of it goes down to even like 1.8 and it goes up to 4.2 to 4.4. So the 3.0 would be pretty much at the top of the bell curve. A lot of times, we see that number for women, especially of all different age ranges, we see it in the low 2s. It’ll be 2.3, 2.4, 2.6, 2.7 and as you said, that’s where some of the more predominant hypothyroid symptoms come in. Usually, if that’s the case, what we want to see when we’re managing someone’s thyroid, is we want to see a low normal TSH, a high normal free T3. In some ways, hers is exactly that. She’s got a low normal TSH, I wouldn’t say a high normal free T3, but it’s in a good range. It’s in a relatively good range free T3, as opposed to being in the lower 2s. So then, if let’s say fatigue was one of her symptoms or the weight gain, then you would think more insulin stress, cortisol stress, maybe there are some other things going on there that are making those symptoms manifest on a consistent basis.

Dr. Davidson: Yes. You’ll see that TSH actually drops and then the T3 drops when you see somebody that’s under a tremendous amount of mental or physical stress, like, for example, people that are training for a marathon. When they’re really getting up there in those high mileage numbers, their free T3 will tend to drop a little bit because they’re putting such a tremendous amount of pressure on their bodies that their body is not really understanding. So, it’s trying to conserve energy, and you’ll see the T3 drop and the TSH go down. You see that also when people go on a diet, you know, right? Our typical day, hey, I grew up in the 80s. and 90s, we were told if you wanted to lose a few extra pounds, you just stop eating. Now, we know that’s not right. So, when you try to restrict your calories, the body thinks it’s starving itself. So, what does it want to do? It wants to conserve energy. So, you’ll see the TSH drop and you’ll see the free T3 drop. So, in some respects, like we’ve talked about in the past and Dr. Maki is super passionate about, is Danette may be over-exercising and under-eating.

Dr. Maki: Yes, that’s possible. That may be just because her TSH is below one, but maybe the free T3 would be a little bit lower than that if she was. I wouldn’t expect it to be 3.0 if she was. But when you see more psychological stress, stress at work, stress in the family, financial stress, or they’re approaching menopause, which is a different kind of stress. Now, you start to see that TSH starts to rise, it’s 1.5, then it goes to 2.2, then it goes to 3.2 and it hovers in that upper end of that range, then usually those symptoms are are pretty predominant at that point. So, in this case, if her TSH like I say was 2.5 or higher, even 2.0 or higher, we probably approached this a little bit of a different way. But because her TSH even though that’s not the end all be all as far as thyroid testing. If we put her on medication with these numbers, her TSH would just drop too low of a range, it may not necessarily make her feel any better.

Dr. Davidson: No. So, I had a patient that had this type of profile, definitely like we mentioned looking into the adrenal glands looking into the lifestyle, maybe doing some nutritional supplements to help the T4 convert to T3 and maybe even checking a reverse T3. So, if her T4 is converting to reverse T3 and her reverse T3 is a little bit on the high end, then you know that, hey, we need to do something to get that conversion to go to the free T3, and you can do that. There are lots of different supplements that we use. There are lots of lifestyles. Dr. Maki had even mentioned something about sleeping and cortisol and insulin and glucose. If she’s not sleeping, then her free T3 is going to drop down whether she can’t sleep because her body won’t let her sleep or she can’t sleep because she’s not letting her sleep. So it’d be really looking into a little bit more lifestyle and then after working with her for maybe about six to nine weeks, then we would probably retest, maybe some other adrenal profiles, but then look at this thyroid panel again, to see okay, where’s that T3 now?

Dr. Maki: Yes, right. Yes. Now, again, we don’t know where she is if she’s in perimenopause or menopause. If she’s in menopause, looking at female hormones, definitely it comes into play, even into perimenopause that’s going to have a factor and all those symptoms are going to kind of mimic a hypothyroid-type of situation. So, I think we kind of hashed this one to death, right? I think we beat this one thoroughly. We could probably keep talking about it. I mean, we talk about this stuff all the time. But this one, I think it’s a fairly straightforward case for the most part, but there’s a lot of information that we don’t know, so we’re making some assumptions to be able to… that we would have to know in order to make full clinical decisions about this situation. So, Dr. Davidson, do you have anything else to add about this?

Dr. Davidson: No, no. This was really fun.

Dr. Maki: Okay. Until next time. I’m Dr. Maki.

Dr. Davidosn: I’m Dr. Davidson. Take care.

Dr. Maki: Bye now.