Lisa’s Question: 

I have a free T4 of 1.5, a TSH at 3.09 and I have a free T3 of 2.7. Do these seem like they are within parameters? My ENT says everything is fine with my numbers, and my vitamin D is 26.5.

Short Answer: 

This is a good example of a high normal TSH level (3.09), which does raise some concerns. Any time we see a TSH above 2.0 to 2.5, it gets our attention. A high normal TSH level, along with clinical symptoms helpt to determine the best course of action for the patient. We like to see a low normal TSH level and a high normal Free T3 level, preferably greater than 3.2.

PYHP 078 Full Transcript: 

Download PYHP 078 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: And I’m Dr. Davidson.

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

Dr. Davidson: I’m doing great. How are you doing?

Dr. Maki: Pretty good. Pretty good. 2020 is moving along.

Dr. Davidson: It sure is.

Dr. Maki: A little bit of a hiccup earlier in the year, but we survived. We’re all making it through. We’re going to continue answering some more questions. This one also is pertaining to thyroid, and this is from Lisa. So, Dr. Davidson, why don’t you to go ahead and read it from Lisa?

Dr. Davidson: Sure. So, Lisa is a podcast listener, hence we’re doing the podcast, but she has a question based on episode 38 which seems like light years away.

Dr. Maki: Yeah, it seems like it was so long ago.

Dr. Davidson: That we did that episode 38. Episode 38 was, Do you have a low free T3 level? So, Lisa’s question is, I have a free T4 of 1.5, a TSH at 3.09 and I have a free T3 of 2.7. Do these seem like they are within parameters? My ENT says everything is fine with my numbers, and my vitamin D is 26.5.

Dr. Maki: Yeah. Right. So, this is in some ways in contrast to Dinette that we talked about. In some ways, almost exactly, the opposite. So here her TSH is already on the high end of normal. 3.0, that’s a little bit of a red flag for us, right? When we talked about Dinette, her number was point– I don’t remember exactly what it was. It was 0.82 or something. So, way on the low end of normal. Now here, her number is on the complete high end of normal. Right away, that automatically puts up some red flags.

Dr. Davidson: Why don’t you reiterate what TSH does and what does it mean when it’s high and when it’s low?

Dr. Maki: Oh, well, why don’t you do that?

Dr. Davidson: Okay, I will. Well, I did that on Dinette, and I will do it with Lisa just for those of you, which I’m sure you already know, because many of our podcast listeners know this stuff forwards and backwards, but if somebody has a high TSH, a thyroid-stimulating hormone, which is a signal that comes from the brain if that TSH is high, that usually indicates that the thyroid function in the body is low. Now, this isn’t 100%. You never want to base someone’s thyroid dose or diagnosis or whatnot on a simple TSH number. But I love to get the input. Any objective data that we can get is better. So, a high thyroid-stimulating hormone definitely jumps out as saying, hey, you know what? That person’s thyroid could be low.

And now, of course, a normal TSH range on pretty much most labs ranges from 0.45 to 4.5. So here, Lisa’s got a TSH almost 3.1, so her ENT is like, “Okay, it’s fine; it’s in range.” But that’s a really broad reference range. 0.45 to four and a half. That’s huge. Anytime we see anybody over 2.5, that’s a serious red flag. That’s like, okay, something’s going on with the thyroid. We’ve got to figure it out. Sometimes even when I see it at one, depending on the symptoms, because we always say is let’s treat the person, not the numbers, but even if you see it over one and then you say, “Okay, well let’s investigate this.” But seeing Lisa’s TSH at like I said, almost 3.1, further warrants some investigation there.

Dr. Maki: Yeah, right. Yeah. Yeah. And then moving onto the free T3. 2.7 again, very common to see it in the twos as opposed to… Instead of it being 2.7, we like to see it at 3.7. Now that’s not necessarily very common, especially as time goes on, the TSH tends to rise, and the free T3 tends to go down. From a clinical perspective, we want the exact opposite to happen. We want that TSH to be nice and low. We want the free T3 to be nice and high because usually that’s where the patient is or the person’s going to feel the best in some respects. So, her numbers raise some flags there.

Dr. Davidson: And I’m glad that her doctor ran a free T3. Most docs won’t. Usually, they’ll do a TSH, and if the TSH is out of range, then they’ll reflex to a free T4. So I’m glad that we have the free T4, the free T3, and the TSH so we can look at them together. So, seeing that TSH up there, almost 3.1, and then that free T3. Now free T3 gets a little bit confusing because they have huge reference ranges for that on labs. So, don’t listen to the reference ranges, they’re just ridiculous. The reference range for free T3 is 2.2 to 4.4, and anybody in that reference range can be “normal.” So, seeing hers at 2.7, anything under 3.0 always triggers me because free T3 is the actual active thyroid hormone.

You can have all the T4 in the world, but if you don’t have enough free T3, then you’re going to have a lot of symptoms of hypothyroid. So, her free T4 at 1.5 is astonishing. Well, 1.5 is amazing. Usually, they have this ridiculous reference range, again for a free T4 is 0.8 to 1.8, but a 1.5 is really good. And those of you that, I’m going to be redundant here, I’m sure you already know this, but the thyroid mainly makes T4, and that travels in the bloodstream, and then with the peripheral tissues, it’ll take that T4 and convert it to free T3. So T4 is a very stable molecule. It’s got a seven-day half-life. It doesn’t have a lot of activity other than it needs to convert to free T3 to have the activity. Now free T3 has a very, very short half-life. It’s 24 hours or something like that. It’s very short, but it’s very active. So, you want to make sure you have enough T4 coming out, converting to T3.

Dr. Maki: Yeah, right. And this is where we get into treatment, and this is why we differ from the conventional mode of treatment, because in this context if her TSH was a little bit higher. Then again, her ENT would prescribe her Synthroid, Levoxyl levothyroxine, which is referred to again, for those of you that know is T4 monotherapy, which we don’t ever prescribe T4 monotherapy because she already has sufficient free T4. Where she’s lacking is in the free T3 and, excuse me, pardon me. Most women in this situation, they have a problem converting their free T3 anyways, and 60% of that conversion from T4 to T3 happens in the liver. Now again, you and I being naturopaths, we always pay attention to the liver. The liver, in Chinese medicine, they refer to it as the General because it does all these different metabolic functions on a daily basis.

If your liver’s overburdened from stress, from alcohol, from caffeine, from toxins in the environment, to metabolic stress, to who knows? Now that conversion capability of converting T4 to T3 is going to be diminished. You’re not going to have as much. And then, of course, as time goes on too, the peripheral tissue, your muscles, and everything else that are supposed to be converting T4 to T3 isn’t going to happen either.

Dr. Davidson: So, whether Lisa is on a T4 monotherapy and that’s why her T4 is 1.5, which is great, or maybe she’s not, and she just makes a really good amount of T4. The problem here, like Dr. Maki, is saying, is that it’s not converting to the free T3. So, there is a problem there.

So I would say, instead of just waiting for that TSH to continue to rise, and that T3 to continue to drop, which will happen if you wait three months, six months, a year, these numbers will be “out of normal range” for these ridiculously vast reference ranges that the labs have, they will be out of range. But do we want Lisa to suffer for the next six months to a year when I guarantee just looking at where her free T3 levels are in that TSH, she’s probably not feeling real great as is.

Dr. Maki: Yeah, right. And we could almost assume, even though, like I said, when it comes to a diagnosis, it can’t always be black and white. And when you see a number of 3.1 for a TSH, that’s pretty much an abnormal number. So, when you talk about these wide reference ranges, that means that those reference ranges need to be narrowed. The lower end, the 0.45 is, I think fine, but the higher end, that 4.5 should be reduced down. I think the American Academy of Clinical Endocrinology recommends that it should be reduced to 2.5.

Now that is a mixed bag because that makes more people potential candidates for medication, but that’s in some ways the wrong kind of medication. It makes more candidates available for T4 monotherapy again, and I don’t think that does anybody any good. But there’s a large number of people, in a case like this where people are being misdiagnosed or underdiagnosed, when their numbers go along with someone that would– So technically, even though her numbers are still normal across the board, we would put her in that subclinical hypothyroid category, particularly because of the TSH and the low normal free T3.

Dr. Davidson: And, if I had a patient that had similar numbers like this, I would put them on some T3, some compounded sustained release T3, because when people think of T3, conventional medicine for T3 is Cytomel, which is just garbage. It’s instant release; it’s hard on the heart and the cardiovascular system. I would never put anybody on Cytomel. Would you? I mean maybe there might maybe–

Dr. Maki: I know there’s a lot of talks online about Cytomel. People take some crazy doses of it. They can’t take it all at once because it will give them cardiovascular symptoms. They’ll start getting palpitations or anxiety or jitteriness. So, people have to take it multiple doses. That’s why we, most of the time, prefer the sustained release because the numbers improve, and it’s much more tolerated over time.

Dr. Davidson: Yeah. You can take it once a day as a sustained release, it doesn’t have that input– impact on the cardiovascular system, and it doesn’t have that impact, like you had just mentioned, about anxiety. And it has that sustainability throughout the whole 24-hour period.

So I would– and she would probably feel so much better just raising that free T3 from 2.7, even to 3.4, would probably be dramatic. But ideally, we like to see that around 3.7 to 4.4 if you’re looking at perfect numbers. But we always say, we want to treat the human, not the numbers. So definitely, like Dr. Maki was saying, Lisa has definitely got a low free T3, a problem with her conversion from T4 to T3, and also, I would diagnose her as hypothyroid with her TSH number.

Dr. Maki: Yeah, right. Yeah. So again, that’s where the controversy is because technically, she is not hyperthyroid because her number is not above four, her TSH is not above 4.5. That is, the diagnostic criteria for someone being hyperthyroid is the TSH only. That’s the only number that you go by for a technical diagnosis.

And we don’t agree 3.1 or 3.09, in our opinion, is close enough. And like you said too, with a TSH of 3.09, she’s going to have multiple symptoms there. So, it’s the doctor’s discretion to treat the patient, not the lab test. In this case, you’re doing both because, more than likely, she does not feel great with a TSH of 3.09.

Dr. Davidson: And, I know we’re talking about free T3, low levels of free T3 and thyroid, but Lisa does mention that her vitamin D is a little bit low, it’s at 26.5. Now the reference ranges again on most labs are ridiculously vast. They’re at 30 to 100, but she is low. She is technically low.

Dr. Maki: Yeah. Right. Yeah. I mean, I lived in the Southwest for 15 years in a very sun abundant environment between Las Vegas and California, and everybody had low normal if not abnormal Vitamin D levels. Now I believe, and there’s probably some research, whatever, but whether the test is wrong, whether we’re testing, or the test is inaccurate, something is going on here.

For people that live in the geographic area, they should have normal, actually high, normal vitamin D levels. For everyone to have low, it’s not– And maybe it is a sunshine problem. I mean, maybe in the desert where we used to live, maybe because people were inside so much in the summertime. But that’s only three months of the year; maybe it is a sunshine problem because everyone’s indoors all the time. I think it’s a more of a sign that there’s some kind of inflammatory and some other hormonal process going on that is dragging that vitamin D level down.

Dr. Davidson: Possibly. But I do think supplementing with vitamin D is a great idea. I love vitamin D. I take it myself. But of course, you don’t want your reference ranges to go too high because vitamin D is technically a hormone, and it’s technically fat-soluble. So, taking too much of a fat-soluble anything can store itself in your body and become toxic. But at 26.5, that probably is a little bit on the low end. Vitamin D is great for bone density. If you’re a female and we’re looking at keeping our bone density good for years and years and years, vitamin D is a must. But, for me, I love vitamin D for the immune system. I think it’s great for keeping the immune system strong without overstimulating it.

Dr. Maki: Right, right. So certainly, with a level of 26.5, you definitely would want to supplement with that. Then, of course, sleep and metabolic status, insulin, cortisol, those types of things, that number should rise from supplementation, and then kind of level off. What is your range? Where do you like to see it? Somewhere between, let’s say 45 and 65, somewhere in that range?

Dr. Davidson: Yeah, I like 55. I think if you can maintain right around 55 to 60, that’s perfect because you’re never going to take too much to end up going over a hundred. I have had patients that take too much vitamin D, and we check their reference ranges, and I’m like, “You’re taking too much vitamin D. It’s 120. We don’t want that chronically.

So usually, if you can keep it around 55, you’re not going to have any trouble going too high or too low unless somebody has any kind of autoimmune condition, especially like MS, I definitely– or any connective tissue autoimmune disease. I love to keep that vitamin D up closer to about 75 because, like I said, it’s great for the immune system, but it doesn’t stimulate it, but it’s just strengthens that immune system. So, I find that it’s good for those autoimmune conditions. But of course, if somebody is having a vitamin D around 75 or 80, I keep a little bit closer tabs a little more frequently to make sure it doesn’t end up cusping over a hundred.

Dr. Maki: Yeah. Right. And then of course with bone density issues, like you mentioned, if someone’s osteoporotic, a dosage of anywhere from 5,000 to 10,000 IUs is not unreasonable, whereas someone that is just trying to maintain a certain level, they might do 2 to 5,000 IUs. Maybe, in this case, she’s pretty low at 26.5, so maybe she’d start out at 5,000 IUs daily for three to six months, retest, see where it comes up to. And then from there, depending on how high it goes, you can determine– Let’s say her number shoots up quite significantly higher on 5,000, then she probably cut back. She could probably maintain at 2000, and the number would stay probably right around your 55 like you mentioned.

Dr. Davidson: Yeah, exactly. Typically, what I find just with the patients that I’ve worked with is that females don’t need more than 5,000. It tends to start to run a little too high once– because it builds up in the system over time. So usually 5,000 is pretty good, keeping it to about 35,000 IUs to maybe about 25 to 35,000 IUs per week, because sometimes I’ll do Monday through Friday with women and then we’ll take off the weekends. But men can do a little bit more, but we still keep an eye on that. But exactly. Once you found that level, then you can just– Everybody’s different. For me, 5,000 works for me. But I have some that take 2,000 and that keeps their levels up there at 65.

Dr. Maki: Yeah. Yeah. So yeah, if you are taking vitamin D, you don’t want to just take it unabated or without any objective information. You want to make sure that you’re at least testing those levels, so you don’t get that– For a short amount of time, having a level a little over a hundred is not a big deal. I’m not even sure. Do you even know what vitamin D toxicity even looks like? I don’t know. I’d have to look it up.

Dr. Davidson: It’s very bad for the kidneys, and it’s not good for the liver. So, it puts huge burdens on there. I’ve only run into people that maybe they came in and we test– they’d been taking it on their own, and it’s about– I think the highest I’ve ever seen was 120. They didn’t, of course, have any beautiful health, perfect health. There wasn’t any issues there, but it was like, “Okay, we’ve got to back off.”

I’ve never really ran into anybody that was taking more than that. But usually, the patients that I have usually start off with not taking vitamin D and then I test it, and then we add it in.

Dr. Maki: Yeah. Right. Right. Right. Right. Now I know, so vitamin D deficiency, as we’re kind of wrapping this one up, vitamin D deficiency is called rickets. That, I don’t think really– I mean I know that nowadays, they talk about all these vitamin deficiencies are starting to come back a little bit because we’re, in some ways, in America and a lot of industrialized nations, we’re overfed, but under– a lot of calories, but our nutrition isn’t as great from a micronutrient perspective, macronutrient meaning carbs, fats, proteins, calories, micronutrients, meaning the vitamins and minerals that we need. And in a processed food world, the micronutrient content is going to always be different.

But that’s the thing about vitamin D is that vitamin D does not really– there’s not a lot of food sources. Natural food sources of vitamin D comes from the sun. So that’s why when you see it low like that in a very sun-abundant environment, it just questions as to why is everybody of all different age ranges coming up at either abnormally low or low normal. I think something else is going on there.

I have some theories, and I have some ideas, and I know there’s probably some other ones out there online as to what that’s all about. But sometimes we do see, and I know you’ve seen it too, you don’t do anything with vitamin D, no supplementation at all, the patient starts to feel better, they’re sleeping better, they’re doing this, and their vitamin D just comes up on its own. I know that you and I both have seen that a few times, which is very interesting.

So anything else to add about Lisa?

Dr. Davidson: No. No. Thank you, Lisa, for listening and also thank you for your question.

Dr. Maki: Yeah, right. I’m not sure what the ENT is going to do, but I would keep looking for more answers or looking for someone that is able to help you because just saying that your numbers are fine, I don’t think is sufficient. I think in your case, I don’t think that those numbers are fine. I think it warrants a little bit more investigation. So, until next time, I’m Dr. Maki.

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

Dr. Maki: Bye now.