Allow me to offer this link to anyone who is interested in a different perspective on this question, from an unconventional naturopath doctor.
Specifically, pages 26-30 are of particular interest.
drchristianson.com/wp-conte...
I look forward to any comments.
I have not read or reviewed Dr. Christianson's book, but it seems interesting. My own bias is more in line with yours given your post to my discussion with Marz. Is it just me, or does it seem the orientation on this bulletin board is to increase exogenous T4 and or T3 to the maximum levels someone can tolerate, as opposed to the focus being on what the person needs to achieve a sustainable level of acceptable well-being over time.
I;m sure there is a clearer way to say what I mean, but I;m fading.
Best wishes all.
Have you read the Tired Thyroid book by Barbara Lougheed? She and Dr. Christianson agree on the following:
1. Many people taking 3 or more grains are overdosed. (She was overdosed on 2 grains.)
2. rT3 does not block the receptor
3. Synthroid/levothyroxine is bioidentical to the T4 our bodies produce
However, he believes that patients should seek a TSH close to 1, while she believes you can't dose someone by TSH because taking any medication breaks the feedback loop. I think it's possible to have a normal TSH if taking only T4, but the minute I've added any T3, my TSH drops below the reference range. I'm not sure it's possible to have healthy levels of all three hormones (T4, T3, TSH) because of the way they're interrelated. You might find this post relevant: tiredthyroid.com/blog/2014/...
I should also point out that Dr. Christianson's paper was written for Hashimoto's patients, who may have some thyroid function, whereas Barbara Lougheed had RAI and has no thyroid function. Is supplemental thyroid hormone replacement dosing different from full replacement dosing? IMO, if a Hashimoto's patient is taking 3+ grains, they are on full replacement.
Hiya,
In response to the question of whether or not it is possible to experience a 'normal' TSH level while dosing t3, I will say that Dr. Christianson's assertion that his treatment goal is a TSH very near 1, and not much under it, must be viewed in concert with the fact that he almost exclusively prescribes NDT and we know the t4/t3 ratio in natural desiccated thyroid!
Also, rather anecdotally, my own naturopath doctor prescribes NDT as well as t4/t3 combinations and she insists that she has patients with 'normal' TSH results.
The thing is, I find it perplexing that if I posted test results showing a 4.5 (.4-4.0) TSH and claimed I was on 2 grains, the advice would be, almost unanimously, to increase my dose.
But if I posted a result of .004 TSH, on the same dose, no one would suggest the possibility of overmedication.
Rather than disregard the results of the TSH test or rely on them, exclusively, I choose instead to view it as a valuable bit of information just not the only relevant information.
I have been afforded the opportunity to command my own treatment ship, with a naturopath doctor as my guide (her words).
A few months ago, I had a TSH of .002 and she said, "Hmm, your TSH result seems to indicate that there's too much thyroid hormone on board; but your free hormone levels are well within range, so we can just continue to see what happens."
I have come to believe there is a special hell, in the limbo between overt and very obvious overmedication and optimum dosage, in which the body is in an active and continuous state of trying to eliminate excess hormone, while maintaining healthy and safe free levels of hormone. I think it's that place which many find themselves still struggling with hypo-like symptoms. Counterintuitive though it might sound, I believe many of us are just a few, small, downward, adjustments to our ideal dosages. And it's the very counterintuitive-ness that keeps us either clinging to our current dose or even worse, expecting an increase to be 'just the thing'.
My theory is based on one recurring phenomenon I've noted. That is, someone, having exhausted themselves with dose adjustments and symptom management and emotional stress and psychological stress, quits taking thyroid replacement, altogether. An interesting thing happens: they feel better! Some even say they feel 'great'. Not forever, but for a time. It is my theory that that is a result of a beautiful window of time, during which, accidentally, they actually had the ideal amount of circulating hormone. Of course, inevitably, as that magical amount diminishes and hypothyroid symptoms return, the honeymoon ends and it's tragic. But the information I've gleaned from these reports is that this hormone business is a precise and fine balance and the point between too much and not enough is much more delicate than crude, chunky, 25mcg shifts can achieve.
After more than 1 1/2 years devoted to trying varying dosages, I am willing to brave titrating downward, in small increments, in search of thyroid hormone nirvana.
I'll keep everyone 'posted'.😉
My theory is based on one recurring phenomenon I've noted. That is, someone, having exhausted themselves with dose adjustments and symptom management and emotional stress and psychological stress, quits taking thyroid replacement, altogether. An interesting thing happens: they feel better! Some even say they feel 'great'. Not forever, but for a time. It is my theory that that is a result of a beautiful window of time, during which, accidentally, they actually had the ideal amount of circulating hormone.
Interesting theory. However, you will find that people feeling better when they stop their thyroid hormone replacement is something that happens whatever their dose, not just when they're possibly over-medicated.
I think you might just be missing something in your observations, and that is that a lot of hypos - more than is given credit for - have hormone resistance at a cellular level, and need extra large doses to flood their receptors. Of course, there's no way we can prove that, we can't know if the hormone is getting into the cells. But, it certainly happens.
I'm pretty certain that was my case. Or perhaps still is, I don't know. When I started on T3 only, I slowly worked my way up to 225 mcg, and never once felt any better. Then, for various reasons, I stopped taking it. Six months later, I restarted from scratch, and slowly got up to 75 mcg before I felt better. Two years later, as an experiment to see if I was really on the right dose, I titrated down to zero again, carefully noting my reactions. Then started building up again. And, yes, 75 mcg was quite definitely the amount I needed. So, a year later, I tried adding in 25 mcg levo, and reduced the T3. It took a bit of fiddling to find the right amount to reduce by. I even tried increasing the levo to 50, but that didn't work. And, I finally settled on 68.75 mcg T3 and 25 mcg levo. And, that seems just about right for me. So, to my mind, it would seem that the hormone resistance has improved, but not quite gone. But, I'm 100% certain that this is the right dose of me.
The problem most people have is that they don't have the freedom, the courage and/or the knowledge to experiment in that way. The treatment of doctors is so rigid. Doctors understand very little about thyroid or blood test results. So people get stuck on a dose that really isn't right for them. You have to either have a very understanding doctor - which is rare - or go out on a limb and self-treat in order to have the freedom to experiment in that way.
Having read HIFL's response above, I would say I am firmly in the Barbara Lougheed camp. 
Your response is full of interesting ideas, grey.
First off, the idea that, sans thyroid hormone replacement, someone reports 'feeling better' even if they are not overmedicated suggests that there exists a feeling 'better' than optimally medicated. Hmm...
Next, I find a 225mcg dose of t3 to seem shockingly excessive! But, what do I know? (I feel the difference between 2.5mcg and 5mcg.)
Finally, in reference to your 'fiddling', I find it curious that you could/would:
A. Survive on 75mcg t3 AND on 225mcg t3.
B. Want to change what was working perfectly.
C. Be willing or interested in stopping all t3 when you were totally dependent on it.
I'm very glad you have discovered your optimal dosage and combination!
'feeling better' even if they are not overmedicated suggests that there exists a feeling 'better' than optimally medicated. Hmm…
I can only think that it might have something to do with the fillers in the tablets. Even if you're not actually allergic to them, they could be having some sort of effect that, whilst not noticeable amongst the hypo symptoms, leaves you feeling better when you stop ingesting them. I don't think I've ever had any comments on this subject from people on liquid levo - but maybe they feel so well, anyway, that they don't feel the need to stop taking their hormone.
225 mcg is a high dose, admittedly. But I have heard of people taking more than that. These days, I do feel a difference if I increase or decrease my dose by 5 mcg, but I didn't then. And, for the record, during the time I was taking high doses - mainly 200 mcg - I did try reducing the dose, but it made me feel worse.
A. Survive on 75mcg t3 AND on 225mcg t3.
It's that fact that makes me think it was due to thyroid hormone resistance. My adrenals had been treated and I was taking nutritional supplements, so I don't know what else it could have been.
B. Want to change what was working perfectly.
I don't think perfection comes into it. I said I appeared to be the best I could. But, I wanted to be sure that a) I wasn't over-medicated b) still under-medicated. Plus, as someone who tries to help others on here, I felt it my duty to know more about how things worked for me, before I tried understanding what might work for others.
C. Be willing or interested in stopping all t3 when you were totally dependent on it.
Well, that's complicated. And had more to do with reasons that had nothing to do with thyroid, than any willingness or interest on my part.
I also believe that if I have Hashimoto's and not feeling well - upping my exogenous dosage is not always the default, just as I believe just because my LT4 dosage is not improving my well-being that I need to add T3.
I think the advise you give for Hashimoto's:
After more than 1 1/2 years devoted to trying varying dosages, I am willing to brave titrating downward, in small increments, in search of thyroid hormone nirvana.
The additional suggestion I give anyone making changes to exogenous therapy dosage is to introduce the small change AND WAIT (a couple weeks or longer) to determine the impact of a small change in LT4. Given the half-life of 7 days in people with a BMI under 26 - a bit longer in older and people with BMI over 27 - you need an extended period to determine the effect of any change, even the small changes you are making.
These are among the most powerful substances in our body. Health providers and our own community make or suggest changes of 25 to 50 percent cavalierly. All our situations are unique and both the biochemistry and metabolic pathways are complex and mediated in multiple ways (HECK - their are even 3 deiodases involved in cellular conversion). Many of use are simultaneously making changes to improve our diet, supplements, stressors and other aspects of our self-care.
I disagree that there is a 'nirvana'' , but I whole-heartedly believe there is a new-normal level of well-being. I also agree that whether adding or decreasing exogenous hormones - one rational path to better well-being is to make a small change in my dose, wait for a time period that is 2 to 4 weeks, track my symptoms, and cautiously proceed to make changes accordingly.
A couple suggestions to keep me focused
1. To help with self-discipline (and my brain fogged memory) a 28 day pill container - Use a notebook to date and track my sense of well-being over changes and over time. It also helps me track my stress level, supplements, diet changes.
2. To make sure my meds potency stays consistent, store meds in a DARK, COOL PLACE. Don't store your pills in a bathroom where the temp and humidity vary wildly.
My ultimate goal is to slowly decrease from a maximum exogenous dose I can tolerate, toward the minimum dose that I need to bring me the level of well-being I can accept as my new normal.
best wishes all
I whole-heartedly believe there is a new-normal level of well-being.
So, I reject the modified "new-normal".
I believe that each of has a personal sense of well-being. Period.
If we are properly regulated, we ought to feel it.
I do agree, 'wholeheartedly', with your assertion that hormones are powerful substances. As such, I find it almost incredible that the best medicine has to offer is these clunky doses of t4, in 25mcg increments.
If my proper replacement dose is 66mcg of t4, I'm under-medicated at 50mcg and over-medicated at 75mcg. That might not seem like a significant difference, but given time, and half-lives...Not to mention, I'm likely to bypass it altogether, experience symptoms of over-medication, misinterpret them, and increase my dose. This places me on an unfortunate roller coaster to hormone hell, from which I just cannot seem to disembark, no matter what changes I make.
Furthermore, Dr. Alan Christianson, who's writing I reference in this post (and whose writing no one responding to this post seems to have read) says that if a patient comes to him with an astronomical TSH and he prescribes a dose and they return for testing after a few weeks and their TSH has dropped to 2.5, he knows, without a doubt that they are over-replaced because of what he calls "drift". The effects will continue for upwards of three months.
When you combine all the variables, with one other possibility I've recently identified, it's no wonder people and their physicians struggle to optimize their treatment.
Finally, and, for me, this has been the most dramatic shift of all, I agree, emphatically, with your last comment.
I came to this board, ignorant and vulnerable, and whether or not it was intentional, the 'message' I continued to see was that dose increases were the thing. People wrote things like, "I've managed to get my dose up to _____."
"I convinced my GP to increase my dose."
"I'm worried that my doctor is going to lower my dose."
So, I returned, half-cocked, to my practitioner, suspicious and ready to fight for my rights to as much medication as I thought I needed.
My focus has shifted and because of that, not only am I feeling better than I have for 18+ months, I'm taking less hormone replacement (coincidence?). My new intention is simply: How little exogenous hormone do I need to assist my body with it's functions?
It might sound meaningless, but it feels like a miracle to me! And a relief.
Thank you for the well wishes. I wish you the same, and everyone who visits this site and who doesn't.
I tend more towards the broken feedback loop position, but that's probably because my TSH has never reflected the level of my free T4 and free T3, in fact, last time my free T4 went up to 18 (rare), my TSH rose as well. But it's never, ever, been as high as 1 (I have central hypo). There is generally no way to know if the pituitary is behaving properly, so I feel that it is best to ignore TSH most of the time and concentrate on getting free T3 and free t4 at a level that makes the person feel well. As one of diogenes's recent posts confirmed , that's a very individual thing.
It's strange that objectors to thyroid diagnosis/treatment by accepted medicine accuse them of shoehorning the patient somewhere into "the normal range" and claiming success, whereas they fall exactly into the same trap by saying for example"TSH should be close to 1" as if this was a magic goal. From whatever angle commentators/diagnosticians come, they should realise that there is an individual goal for each person, which is not the same for another. And specifically, TSH close to 1 on treatment is not optimal. Papers show that "normal" biochemical function occurs in the TSH range 0.03-0.5. And in some cases, undetectable TSH is acceptable provided the FT3 is well into its range. FT4 is much less useful as a diagnostic on treatment whether by T4 only, or combination.
A TSH range of "0.03-.5" ? Whoa!
I am very interested in reading the "papers" you cite, diogenes.
Will you please provide links to them or links to sites on which they are discussed?
Thank you. 😊
The paper is:
Ito. M, Miyauchi A, Hisakado M et al.
Biochemical markers reflecting thyroid function in athyreotic patients on levothyroxine monotherapy.
Thyroid 2017:27; 484-490
I believe a copy of this is held by TUK.
Thank you, diogenes.
I have Hashimoto's Thyroiditis, so I'm uncertain to what degree this single study, of 133 patients without any thyroid glands, is applicable to me.
But I have read a study comparing the differing needs of patients with overt hypothyroidism vs. subclinical hypothyroidism and it clearly found an increased dosing requirement for the "overt" group,
Much thanks for the speedy response!
I don't think it matters whether total lack of thyroid comes from surgery or antibody destruction. The same outcomes will apply. If you have some gland left then the situation is in beween having none and being entirely healthy.
After more consideration, I think the reason Dr. Christianson sets a 'near 1' goal for TSH, based on a Turkish study of persons without any thyroid dysfunction, is that the study demonstrates that there was very little variation, not only among the participants, but even in the participants' individual results, daily and hourly.
The idea being that, when the body is functioning properly, and can have any level of thyroid stimulating hormone it needs, it remains very steady, at or very near 1.0. This brings to mind the question of whether or not TSH has other function(s) than hormone production, as jgelliss mentions. If, in fact, TSH is needed for conversion and we are suppressing ours, how sadly counterproductive.
Diogenes You Never stop to amaze me with your Vast Knowledge of our Thyroid dilemma . I'm Grateful and Appreciative of Your Insights and for Sharing with Us .
If I understand you correctly thyroid lab results are the same for patients with or without their functioning thyroids ? Further If I understand Correctly FT3 and FT4 are more important than TSH ? Yet many of us who have no thyroids at all and don't convert well are told that we need some TSH for conversion purposes from T4 to T3 .
I know you addressed this to diogenes, but I must acknowledge your contribution to the discussion.
Specifically, thank you for suggesting that TSH has additional function, beyond stimulating the production of hormone.
The truth is there are many, many, variables in this biochemistry, including the role of rt3 (which I have heard no one, including those in the medical profession, refer to with any certainty or clarity).
I have even examined a study that seems to question the formerly accepted practice of TSH suppression in cancer patients in an attempt to limit thyroid activity, entirely.
So, despite the fact that you produced another question, rather than another 'answer', I really appreciate your comment.
Hi there roxanaleah ,
I know that having had TT myself suppression is only for the first few years after the TT . I think about five years . Once the Tg is at <.01 plus your sonograms come back clean . Dr's will allow the TSH to come up a bit to 0.5 -1 . RT3 most Dr will not even care . Yet if it's high it can signal some inflammation going on . Also If I understand correctly high RT3 will not allow weight loss to occur .
Also If I understand correctly high RT3 will not allow weight loss to occur .
That's a new one on me. Where did you get that, jgelliss?
greygoose,
I spoke to people that had TT and told me that when their RT3 was high they could not loss weight . I'm afraid the same happened to me too . There must be some connection .I don't know weather it happens with patients that have no thyroids that might have this problem ? I wonder what Diogenes's thoughts are on this if there is a connection between RT3 and not being able to loss weight ? It would be very interesting to know .
I would think that it's more likely to be low T3 rather than high rT3 causing the inability to lose weight. One of the causes of high rT3 is the inability to convert T4 to T3. So, the FT4 rises to a point where it converts to more rT3 than T3, and the FT3 stays low.
However, there are many causes for high rT3, and I don't think you can jump to any conclusions without knowing the cause of the rT3. How was your FT3 when your rT3 was high? Correct me if I'm wrong, but I believe you have a conversion problem, no?
greygoose Yes I'm not from the Best converters . But on one of my last lab results my FT3 was high FT4 was high too and so was my RT3 . It was puzzling to me too . The Only thing I could think of is that I was on too much T4 that might have caused this .
Too much T4 would cause the high rT3, yes. But, weight-loss doesn't happen over-night. And, as you said, this was just one blood test, so can't be taken as proof of anything. What did the next blood test say? It would have to be long-term high FT3/rT3/FT4 to even give you an inkling of what was causing what. And, remember, that over-medication can also affect your weight/weight-loss.
greygoose
My T4 was lowered since and I'm looking forward to my next lab results to see if by lowering my T4 what effects it will have on my FT3/RT3/ FT4 ?
Well, lowering your levo will obviously lower your FT4, but also your FT3. As to the rT3, depends what other problems you have. You might have a virus, or low ferritin, or something, which will also affect the rT3. rT3 doesn't rise for no reason.
greygoose
I was wondering and this is just my being my own "Lab Rat " . I was on 200mcg Selenium for years . And Selenium is supposed to help with conversions . I'm suspicious I'm not sure yet the Selenium might have caused my erratic lab results . I had terrible headaches pressure in my jaws . I took the Selenium out of my arsenals . I can tell you that after one week my headaches disappeared and my jaw tightening did as well . It is possible that I don't do well with Selenium . Or I had too much over the years built up Selenium in my system . This is Just My Hunch .
Both are possible. I couldn't take selenium at all. I can't remember what it did to me, because it was a long time ago, but it didn't suit me. And, I've read, with selenium, you're not supposed to take it continuously, because it can build up to toxic levels. Just take for the time it takes to empty a bottle, then have a rest for a while, before buying another one. How long had you been taking it before you started having those symptoms?
greygoose
For years . I was told to supplement daily with Selenium 200mcg . For conversion purposes and for cancer protection too . I am so happy to have eliminated the Selenium . As I said earlier my side effects stopped that when it hit me like a eureka moment . I heard that some don't do well at all with Selenium or some just take it 2-3x /week . Right now I'm just laying off of it .
Would you know greygoose for those of us that are not from the better converters what helps with conversions ? When on lower T4 with NDT combo for my T3 My FT3 are at the highest at 2.9 pg/mL (2.0-4.4) FT4-1.20 ng/dL (0.82-1.77) TSH-0.041 uIU/mL (0.450-4.500) . My dose at this lab results was 50mcg T4 with 1.25gNDT .
When I was on Higher T4/NDT combo all my results where over range .
I'm hoping that with my lowering now my T4 to 75mcg but raising it a bit higher from 50mcg T4 with 1.25g NDT . My ranges will go into place .
So many things are necessary for good conversion, and I'm sure we don't even know them all. Good iron and cortisol levels, for a start, selenium and zinc, and other nutrients. But, also getting enough calories - and this is where a lot of people fall down by reducing their calories to lose weight, and finding that they actually put weight on - but also good levels of Human Growth Hormone. It's really a lot more complicated than just taking a few supplements, and sometimes can't be fixed at all - like, for instance, if you have Hashi's. There's not much you can do about that.
I don't think rT3 by itself is forbidding weight loss. High rT3 is often accompanied by low FT3 and this, together with stress-cortisol results, is the principal factor. rT3 seems simply to be a marker of this condition without itself being the cause.
No, the opposite. Thyroid function tests have a different meaning as to whether you have any thyroid or none. TSH and FT3 especially. TSH range will be lower with no thyroid and FT3 also compared with those with some working gland. With no working gland, TSH is much less relevant in therapy with T4.
Diogenes
That is very Interesting . I wonder why patients with TT or no working thyroids at all are always compared to healthy thyroid lab results ? Shouldn't TT patients have their own set of lab results that work best for them ? Granted we are all different with different comfort zones .
Diogenes
Thank You for validating something that I think should be taken into consideration - case by case . Especially with patients that don't have their own functioning thyroids . We are all so different with different comfort zones that makes us feel Optimal .
Thanks for the link to the book, very kind to share
Any link between high T3/ over replacement or under replacement and asthma?
Blood results? Under or over 
Symptom of under medicated 
Teenager under medicated 
