I get some form of this question all the time:
What if I have hypothyroid symptoms but a low TSH? Can I still be hypothyroid?
Or what if I am already on NDT but still feeling symptomatic? What then?
The answer to this question is that, yes, you can still be hypothyroid with a “normal” TSH…
And I’m going to use this patient as a perfect example of how it can work and how to treat it.
This particular patient came to me already on 3 grains of NDT (Nature-throid) with energy levels in the 4-5 out of 10 range and who had recently gained 30 pounds.
Her TSH was suppressed (TSH < 0.05 on initial lab tests), but she was obviously still symptomatic and gaining weight.
If you fall into this category, or you are taking NDT but still symptomatic or you have a suppressed TSH on levothyroxine alone – then this case study should be helpful for you.
Fast forward 3 months after working with me and making some changes and she is now down almost 20 pounds, has lost 3 inches off of her waist, 2 inches off of her hips, and 2 inches off of her thighs, and is feeling “much more energetic and alive!”.
So how did we do it, and what changes did we make?
Low or Suppressed TSH with Hypothyroid Symptoms
The evidence is mounting for the concurrent use of T3 in addition to T4 thyroid hormone (1).
In fact, perhaps in 10+ years, this will simply be the standard of care (one can hope!).
What you probably already know is that NDT is a combination of T4 and T3 thyroid hormones.
In many patients changing from Levothyroxine or Synthroid to NDT is often enough to reduce symptoms and cause some degree of weight loss (though usually not much).
But, just like many patients can still have hypothyroid symptoms on T4-only medications, many patients can also have hypothyroid symptoms on NDT alone.
Why this happens is not entirely clear, but it appears to be related to T3 levels of thyroid hormone in the body and can be made worse by high reverse T3 levels.
Due to a variety of reasons (explained more below) your body may have adequate thyroid hormone in the pituitary (reflecting a state of pituitary euthyroidism), but low levels of free T3 in the tissues.
This condition can be diagnosed and tested by simply looking at some lab values in the serum:
Patients with this condition generally have low free T3, low to mid-range total T3, and normal to high levels of reverse T3.
Any of these conditions create an environment where the body has plenty of the storage form of T4 thyroid hormone, but not enough of the active form of thyroid hormone known as T3.
I have written about this in other articles and the conditions are known as tissue-level hypothyroidism (2) or thyroid resistance.
Now that we have established that it exists, how do you actually treat this condition?
What do you do if your TSH is already suppressed but you are still symptomatic?
Well, the most basic answer is to increase the amount of T3 in the body, and that can be achieved in a few different ways…
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Increasing T3 in the Body
In the case of this patient, we increased her T3 by simply adding more T3 to her total thyroid dose.
And this is how she responded:
“Hi, Dr. Childs,
Do I even need to label my “before” and “after”? Haha.
I’m following up with you after being on your meds for 3 months now. I’m feeling great! So much more energetic and alive!
Starting weight: 167.6 pounds
Current weight: 148.2 pounds.
Down 3 inches off the waist, 2 inches off hips, 2 inches off thighs.”
As a direct result of simply adding Cytomel or liothyronine to her existing dose of NDT (already at 3 grains of 195mg), we were able to increase both her total T3 and her Free T3 levels and improve her overall symptoms.
As I mentioned previously, despite being on 3 grains of NDT (in this case Nature-throid) she was still gaining weight and had very low energy levels.
In fact, she had been on as high as 6 grains from another provider before coming to see me.
6 grains or 390mg and no changes in symptoms or weight loss except heart palpitations.
What’s important to understand here is that supplying the body with too much T4 will create an environment where the body will turn much of that T4 straight into reverse T3 which directly competes for binding with T3.
This creates a situation where thyroid hormone serum levels may be “normal” but not enough T3 is getting into the cell to do its job.
Because of this, she presented with the following symptoms:
- 30-pound weight gain over the last 3 years (now almost all gone)
- Energy levels of 4-5/10 (an improvement from 1-2/10 on Synthroid, but still low)
- Crashes at 3 pm every day (sustained by caffeine 200+ mg per day)
- Increased anxiety and depression
- Heartburn, constipation, and bloating
- Reduced sleep with a racing mind at night
As you may notice many of these are classic signs and symptoms of hypothyroidism, and she had all of these symptoms while on 3 grains of NDT and with a TSH < 0.05.
So to answer the question that everyone asks:
Yes, you can still have hypothyroid symptoms with a low or even suppressed TSH. It really just depends on what is happening at the cellular level.
But the even bigger question is why some patients need more T3 than others.
Why do some patients do well on T4-only medications, some on NDT medications and why do some need higher doses of T3?
The answer to this question is complex and really depends on the situation.
For starters, the more hormone imbalances you have (including leptin and insulin resistance), the more T3 you will need because these conditions create a pathway for more reverse T3 production.
In addition, it appears that genetics play a role in determining how much and what type of thyroid hormone patients will need.
Genetic polymorphisms in the deiodinase gene (3) may account for a majority of patients who simply don’t do well on T4-containing medications.
Changes in deiodinases will directly influence the conversion process of T4 to T3 or T4 to reverse T3.
Patients with “slow” enzymatic function will be at risk for developing high reverse T3 levels on T4-only medications like Levothyroxine and Synthroid.
On the opposite end of the spectrum, some patients with robust enzymatic function will rapidly turn T4 thyroid hormone into the active T3 hormone.
These “super converters” may explain why some patients can lose weight on T4-only medications and why some patients simply don’t tolerate excess T3.
It’s easy to get lost in this sea of information so let’s take it back a step and summarize it like this:
Each patient will require a unique amount of T4 and T3 thyroid hormones in their body.
This means that there is no “cookie cutter” approach to thyroid care.
Not every patient should be on Levothyroxine just like not every patient should be on NDT.
If you are not doing well on whatever thyroid medication you are on then you may fall into one of the categories listed above which may impact the ability of your body to properly convert and activate thyroid hormone.
If you relate to the patient in this case study then let’s talk about some of your options for increasing T3 in an attempt to help reduce your symptoms and cause weight loss…
#1. Adding T3 + NDT
One of the best and easiest ways to increase T3 in the body is by simply adding T3-containing medication to your current thyroid hormone replacement.
T3 in the form of liothyronine or Cytomel can be added to NDT or T4-only medications like levothyroxine and Synthroid.
In this particular patient, I simply added liothyronine (immediate release) in a slow titration to her existing dose of NDT.
The addition of the T3 in the body helped to outcompete the T4 and reverse T3 which allowed for higher tissue levels of T3.
This increase resulted in improved oxygen consumption (4) and mitochondrial energy production which manifested as an increase in energy and an improvement in her weight loss.
This was done with the addition of 25mcg of T3.
When you consider that each grain of NDT contains only 9mcg of T3 and 38mcg of T4, it’s easy to understand how even NDT can make thyroid conversion problems worse.
Adding 25mcg is like adding the equivalent T3 dose of almost 3 grains of NDT (without the addition of the T4).
So even small amounts of T3 can make a big difference for many patients.
Many patients and providers make the argument that the ratio of T4 to T3 in NDT is sufficient for many patients and I would agree with them under normal physiologic conditions (5).
However, in the presence of inflammation, leptin resistance, insulin resistance, or obesity, there is an increased demand for T3 in the body.
This can then result in hypothyroid symptoms in patients on NDT.
Does every patient on NDT or T4 need more T3?
No, not necessarily.
If you are a patient taking NDT with a suppressed TSH who still has hypothyroid symptoms then you may benefit from more T3.
It should be pointed out that before you add T3 to your medication you should take all of the proper steps to improve lifestyle factors such as sleep, diet, stress, and exercise.
#2. Increasing T3 Naturally Through Supplements and Nutrients
Realistically you should be adding (or increasing) your total dose of T3 in addition to improving T4 to T3 conversion through supplementation.
In this patient case study, I used a combination of nutrients to boost thyroid production and conversion in addition to adding T3 thyroid hormone.
I’ve included this section because it can be difficult to find providers willing to prescribe T3 thyroid medication, so for many of you adding nutrients and supplements may be your only option to improve T3 levels and thyroid conversion.
I’ve written about how to increase T3 levels naturally here (so take a look at that post for more information).
In addition, I’ve also written extensively about the 13+ nutrients required for proper thyroid hormone production in this post.
Your main focus of supplementation should be on the deficiencies in your body and targeted supplements at improving known conditions that reduce T4 to T3 conversion.
This particular patient had a combination of the following conditions contributing to her low T3 and poor conversion: lack of sleep, high stress and increased adrenal demand (manifesting as low cortisol), SIBO/SIFO, and high levels of non-specific inflammatory markers.
As an example, I will show you what her supplement regimen consisted of:
- Supplements to improve both the depth and quality of sleep —> GABA + 5-HTP + Melatonin
- Supplements to improve adrenal function —> Adrenal adaptogens
- Supplements to treat SIBO/SIFO —> Herbal antibiotics/antifungals and potent probiotics
- Supplements to reduce inflammation —> The combination of LDN + curcumin
This combination of targeted supplementation with the addition of T3 thyroid hormone is very powerful and can significantly improve thyroid function and conversion.
Recap & Final Thoughts
When reading these case studies remember that each patient is unique and each patient will require different thyroid medications, different dosages, different medications, and different supplements.
I continue to write up patient case studies to show that you can get the results you are looking for, you just need to take the correct approach.
This approach should center on the evaluation of the complete thyroid panel while taking into account factors that influence both thyroid production and conversion.
Your treatment should not be solely focused on the TSH as a marker of your total body thyroid status.
Remember the TSH only reflects the thyroid status of the pituitary but doesn’t necessarily represent tissue levels of thyroid hormone.
The addition of T3 to NDT can be very powerful in patients who are still symptomatic despite making the right dietary changes and including exercise in their routine.
Doses as small as 25mcg per day can positively influence hypothyroid symptoms and improve tissue levels of thyroid hormone.
In some cases, it may be necessary to drop the total dose of NDT and T4 medication while increasing T3 to compensate for high levels of reverse T3.
For more case studies please see the following links below (these are all weight loss success stories from real hypothyroid patients):
- 50+ pounds lost on Victoza + LDN
- 55+ Pounds lost on WP Thyroid
- 40+ Pounds lost on NDT + T3
- 50+ Pounds lost over 6 months with AIP + Naturethroid + LDN
Now it’s your turn:
Are you on NDT with a suppressed TSH but still experiencing hypothyroid symptoms?
Have you tried adding T3 to your regimen?
What, if anything, has helped you?
Leave your comment below!
Scientific References
#1. https://www.ncbi.nlm.nih.gov/pubmed/24419358
#2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3169863/
#3. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3219766/
#4. https://www.ncbi.nlm.nih.gov/pubmed/2484909
#5. https://www.ncbi.nlm.nih.gov/pubmed/12915350
Would love more info… where are you located?
Hey Damaris,
I’m in Gilbert, Arizona but I’m not accepting new patients at this time.
Are you accepting new patients now?
Hi Michelle,
I am not! My physical practice is closed.
Don’t know if this thread is still active, but here goes. I’ve been on one NDT 60 mg. daily in two divided doses. My only lingering symptom is struggling with weight. I noticed my latest blood test showed Free T3 at less than half of the top range, so I asked my doctor to prescribe 5 mcg. of liothyronine, as I was afraid to begin with anything too high. I will begin taking that 5 mcg. in divided dose twice a day, given I’ve read it has a short half-life. Am I doing the right thing? It seems like I’m educating my doctor, who thank the Lord is very open-minded, just not fully educated on alternative avenues for hypo.
Hi Jan,
Yes, starting with 5mcg is a reasonable place to begin. You may ultimately need more than that but you need to start somewhere. You’ll just need to keep an eye on your total T3, free T3, and reverse T3 as you do this.
We thyroid patients need a doctor that will listen and help us. I had I-131 in 1988 and have never been well since. To make matters worse my TSH and my symptoms don’t match. So after having my thyroid destroyed with radiation treatment, I now have to basically “fight” for the replacement hormones.
I would love to find a good doctor that I could count on to listen and help me.
Hey Susan,
It can be tough to find a physician willing to work with you, but they are definitely out there. In my experience most patients usually do end up needing to look outside of the insurance model for proper care.
Hi there…I am one of those that cannot loose weight for nada.
I have been on synthroid and take many of the vitamins or things you have discripted that could help out.But to no avail weight is still there. At my work I walk between 6 to 7 miles a day and go ride my bike when I get home for 30 minutes a few times a week.
My doctor has given me a statin to take also.
Any suggestions? I am so frustrated . I am also going on 64 so am really trying to rid myself of some weight. Also I do have a stresser point and that is I tend to my handicapped brother daily.So anything you could tell me I will definitely listen to.
Thanks
Hey Susan,
I have lots of information on youtube and such that goes over exactly how to address your problem. I wouldn’t be able to reply to this comment in fewer than several thousand words due to how complicated it can get. If you are interested in learning more I would check out this video: https://youtu.be/6x9hhnBr0mc
I can related to the patient example above,
My TSH level is .106, T4 is 1.02, Reverse T3 13.2, Thyroglobulin Antibody-21.4, Thyroid Peroxidase- 14, Free T3 2.6.
My a1c- 5.9, all Lipid Panels in good range, Ferritin- 170 H, Selenium -368 H
I would like to see my FT3 in the 3.2 range. I found a Dr who listens to me and not reacts based on test results. I am currently taking 90mg of Armour, and she wants to see how I perform with a different dose, so she upped me to 120mg. She wants me on them for 6 weeks and then we will re-evaluate. What’s your thoughts on that approach?
And has ordered a cortisol test (salvia).
Hi Dr. child’s,
Thank you for posting such an incredible amount of helpful information. You have opened my eyes to what’s going on with me. I’m on Levo 25mcg and felt great when I started 2 years ago and now I’m experiencing those crappy symptoms again of brain fog, lethargy and inability to lose weight despite being active. I asked my doctor to run tests and of course he says it’s all in the normal range and won’t put me on Cytomel. I’ve asked to move to NDT but haven’t heard back. I plan to look for a functional doctor if he won’t help me and started on some vitamins you suggest for adreanal fatigue, zinc, selenium, and berberine.
Anyways, I have a question about my T3. My test results were T3 107 ng/dL what does that mean I’m producing in Mcg? My free T4 is 1.1 ng/dL. Of course my Dr didn’t test for the RT3. Unreal.
Thank you!!
Hey Lissie,
I’m glad you enjoyed the article. There is no way to accurately figure out how much T3 your body is producing due to how it is metabolized and what kind of competition exists between free T3 and reverse T3. Dosing varies based on a combination of lab tests + symptoms.
I am so confused. I need more t3…currently on 5mcg. My t3 is low at 2.2 and high reverse t3 at 21. Tsh and t4 are optimal. But when I try to increase my t3 I get horrible anxiety and anger. Why does this happen and please give me info on how to fix…or am I just not able to tolerate t3 and will stay hypo forever?
Hey Emily,
The best thing you can do is find someone to help guide you through the many causes of those symptoms, it’s actually not uncommon but there are several things you can do to help tolerate the medication and dose.
Dr. Childs,
Thanks for offering such a great resource through this website! I’ve been learning a ton by reading many of your articles and patient testimonials.
What would your recommendations be for an individual still experiencing severe hypothyroid symptoms on 30mg Armour? This person experienced a rapid weight gain of 40 lbs in 4 months (despite managing calorie intake and being active- covering 14 miles per day through their job, walking, and workouts), with extreme fatigue, joint and muscle pain, hair loss, digestive irregularities, amenorrhea. They have also been treating symptoms of adrenal fatigue (mild case confirmed via saliva testing) with a gluten and dairy-free diet, lifestyle modifications, glandulars, and adaptogens for 9 weeks with no improvement or weight loss.
Latest thyroid labs:
TSH 2.2
Free t3 2.2
Free t4 0.6
TPO 4
TgAB 7
Serum Cortisol 11am 9
Would this person benefit from a major increase in thyroid medication? Would low dose naltrexone help with their thyroid symptoms, inflammation, and depression? Thanks in advance.
Hey LA,
I can’t comment on specific medical questions unless that person is a patient of mine.
Management of thyroid and other hormone problems usually requires a combination of extensive history + lab testing for proper treatment/results. Even these case studies don’t show 100% of my treatment plans.
Good morning,
I’m a 46 year old female that has Hashimoto’s and I am being treated by a wonderful osteopathic doc. I am currently on NDT and my doc has recently decided to add Cytomel to my regimen. I’ve struggled with losing weight since I was diagnosed hypothyroid when I was 18. Anyway, I love my doctor and I feel like we are working together to improve my health! However, I really wanted to thank you because I’m really loving all of the info on your site! It is so understandable, practical, and applicable! I don’t know if you’ve considered it, but adding a search to your site would be so helpful!
Thanks again SO MUCH! I haven’t understood many things about my health, but your information and Podcasts are helping me to do so!
Hey Heather,
Thanks for the comment. I actually recently just removed the search bar, I will have to add it back!
I am post RAI for hyperthyroid, was originally put on levo 112, just didnt feel right on that…so had it switched to 88 levo and 5 cytomel, seemed better but still not perfect. Then got put on armour 90…felt alot better but I get occasional hyper symptoms causing me to skip pills here and there and then I follow with hypo symptoms after that. My free T4 runs below normal @ .7 which the low normal range for the test is .76. My Free T3 runs upper third at 3.6 and upper limit on test is 4.1. No matter what my T4 never changed on Armour…my T3 bounced around here and there but never deviated much from the 3.6..always stayed mid to higher end. I just recently decided to add 25 levo to help bring up T4 and alleviate some hyper symptoms from the T3. I am not sure if this is a good thing or not, I just wish I could have my thyroid back. I regret getting the RAI.
Dr Childs,
As far as i understand, there’re different opinions regarding T3 regimen. Some people take it only once a day, some people take it every 6 hours, some- twice a day. What is your idea of using it? Thank you
Hi Olga,
I generally have patients take it once per day, unless they get jittery when taking it.
Hi Thank for you letter it is interesting.
I have no thyroid not overweight which is the most important thing in your writing.
I am on 2 grains of NDT per day the only symptom is fatigue. I have a suppressed TSH which my surgeon wanted. I might add a half of 25 T3 per day and see if that helps. Who knows, it is a lot of research for everybody. Anyway thank you.
Hi Josephine,
No problem and I hope you found it helpful.
Hi. At what dosage should i start with T3 currently on 2 grains NDT
with a reading T3 of 3.6 (3.2.-6.8) pmo/
thank you
Hi Dr. Child’s! I just stumbled upon your website. I want to know if you have ever had a patient have a side effect of eye disturbances with using WP and/or LDN? I tried both and my eyes became terribly disturbed. I am in remission from a neuromuscular autoimmune dis-ease called Myasthenis Gravis and the eye disturbances reminded me of that. I also suffer from SIBO and instant weight gain. I know that my T3 is low and reverse is high. I have extreme hair
Loss and low testosterone and adrenals compromised. I am at a loss. InLove in the California area and looking for an Functional Medicine Endocrinologist like you. Do you know of any doctors in Northern California like you? I am exhausted on time, money, and practitioners.
My doctor doesn’t listen I’m on 25mg of T4 however feel constipated bad skin unwell fatigued most of the time I’ve gained 8pounds out of no where I feel depressed can’t get T3 in the uk on the NHS so I’ve bought it myself online. If I’m taking T4 at 25mg do I do the same with the t3 ? Or do I up the dose . I’m a model and this weight gain is effecting me working earning. I really do worry if the weight gain won’t stop please help
Hi Sarah,
It’s really important that you try to find a physician to help you. The primary reason is because you may have more than just your thyroid contributing to your weight gain (most weight gain isn’t due solely to thyroid function). It’s also dangerous to use T3 without physician supervision as taking too much may cause problems. I do discuss how to titrate T3, if you have a doctor willing to work with you, in my weight loss guide and videos.
Also, as a quick aside, it is possible to get T3 in the UK. I only know because other patients have commented on my blog and have said that they are taking it. I think these people went to private doctors.
Hello. I have enjoyed reading your information! I had TT 2 yrs ago. Take Levo 137. Sept 1 was on Levo 175 then to 150 at end of Sept due to palpitations. Had cardio workup. Nothing significant. Have insomnia a lot. If I sleep 5 hrs it’s a miracle. I’m so tired esp in the afternoon but the palp is the worst. Hair is thin when I always had thick hair before.
Labs
TSH 3.04 (.47 – 4.68)
8.23 6 wks prior
FreeT3 2.33(2.77-5.27
2.39 6wks; 2.80
10 wks prior.
Free T4 1.36 (.78-
2.19);
1.50 6 wks prior
1.94 10 wks prior
Had RT3 done at different lab. Was 26 which was one point higher than range.
My endo is not receptive to change but I’m at the point I just have to do something. Palp making me feel awful daily. So tired. Any help would be greatly appreciated. Just don’t know where to turn. Thank you!
I live in the UK and the NHS are withdrawing T3 because of the huge increase in cost. I have been on T4 & T3 for 20 years with great success ie:- weight loss, increased energy levels, increased sleep and many more. Since having my dose reduced from 40mg of T3 a day to 20mg every other day since March 2017, my weight has increased by 21 lbs, I can’t sleep without waking and thoughts start racing, my anxiety is returning with a vengeance, my hair is falling out again…I could go on….. now they won’t prescribe it any more and what can I do???? Against the NHS I don’t stand a chance
I am on 125 mcg of Synthroid. I recently got my lab work back and my T3 is low. My doctor suggested if I wanted to decrease my Synthroid to 110 and add Cytomel 5 mcg. I am a little reluctant because of the possible side effects. I haven’t been able to take any weight of and most of my symptoms have come back. I and don’t like feeling this way. I watched your ytube video on Cytomel and you stated there are natural supplements you can take to increase T3. I could not find that video. Could you please tell what supplements they are? Thanks Jen
Hi Jennie,
This is most likely the supplement I was referring to: https://www.restartmed.com/product/t3-conversion-booster/
You can also find further information in this blog post: https://www.restartmed.com/increase-free-t3-naturally/
Im on 2 grains of thyroid s and 20 mcg Liothyronine and have terrible brain fog, no leg or arm hair and migraines with TSH of o.o2. Need advice if possible……
This patient sounds exactly like me, but I haven’t added T3 yet but I’m about to start. I really hope it works because for 35 years I’ve felt dreadful, and been FAT! My doctors are none too keen on adding T3. I’ve saved this article to show them.
Can you add T3 when your reverse T3 is a little high or will it make more of the t4 in the Ndt convert to reverse T3?
This information is tremendous, thank you!
Quick question….how do you address the timing of when to take an NDT + T3 regimen?
Take each twice a day alongside each other?
I keep searching for a mention in all of Dr. Childs’ material of someone like me who is struggling to GAIN weight and whether changing from Levothyroxine to Naturethroid would help. Have I missed it? I’m a 77 yr old woman in good health, eating healthy & organically, 5’6″ with weight in mid 120’s all throughout adult life until now. Have taken these meds for many years without feeling better but we used to be told one must continue, once started. Last few years began losing weight to a low of 102 some months ago – now averaging 105 or 106 at the present time, with going up & down in 1/2 lb increments through the days & weeks. Experiencing HYPER-T symptoms and did not refill my 75 mcg Rx, but finished previous leftovers in the bottle of 88 mcg by cutting into halves, and now none for several days since running out. Am feeling a little better, but not much.
Hi Sharon,
If you are being overmedicated then that would explain your difficulty. You mention that you are experiencing hyperthyroid symptoms so that would be the first place to look!
I am currently taking 3 1/2 grains of NDT and though it has helped remove the brain fog, I have not been able to lose weight regardless of what I eat. I have gained almost 100 pounds in about 10 years time. My inflammation is high and I am menopausal. I would like to start adding T3, and you mentioned starting with 25mcg in addition to this patient’s NDT. Do you recommend breaking this up throughout the course of the day, or ? I currently take 2 1/2 grains of NDT in the morning (6:30) and the other grain midway through the day (2 pm). At what point would I add the T3, or am I not dosing my NDT correctly? Any help is appreciated – I have Kaiser and they don’t recognize symptoms of hypothyroidism, only TSH and I am beyond frustrated.
Hi Chris,
Breaking up your dosing probably won’t do anything for your weight loss but it may help alleviate symptoms of thyroid excess if you have any.
Can you take Armour Thyroid with Cytomel to up the T3 numbers? If not, can you help me understand why? My physician said I cannot take them together, but that seems incorrect based on your article. Thank you much.
Hi Holly,
They can be safely taken together provided your dose and lab tests are monitored.
sdmac@telus.net
Hi Dr Childs,
When I raise my NDT or add cytomel I seem to have an afib attack. I was taking 120mcg 4 days NDT and 150 3 days… I went to 150 daily and after three weeks had the first attack and dropped back dow to 120mcg NDT daily… but labs show low ft3 ao endo put me on 25mcg split twice a day and 90mcg NDT… I had my second afib session after about 4 days of the T3…. so now was gping to drop to 60 mcg of ndt and add 12mcg of t3…. I also have low cortisol and DHEA and iron???? Help would be appreciated
Hello Dr I know you are not taking new patients at this time, I live in Atlanta,Ga could you recommend a Dr for me? I have been all over the internet and can not find one. Please help me. I have gained 30 Lbs in 14 months . Thank you Rosemary
Hi Rosemary,
Unfortunately, I don’t have anyone to recommend or I would happily do so. I’m working on a list of approved doctors, though, and will let everyone know when that list is available.
I read this blog post a while ago and had talked to my nurse practitioner about adding some Cytomel to my NDT (I take NatureThroid). She wouldn’t.
However, I found a new functional medicine physician (MD) I pay out of pocket to see. She ran my labs and suggested we add some T3 to my 3grains of NatureThroid.
I’m on the second week of adding it (the T3). I do twice daily, raising the amount weekly by 1/2 of a 5 mcg tablet. I feel great with each increase. I have a feeling I will keep going and going until I find my right dose, haha!
On a side note, we ruled out Hashimoto’s, yay! My antibodies were SUPER low, under the range. Also, I didn’t have a high reverse T3. I also should note that I’m my healthy weight, 105 pounds at 5’2, but adding the T3 medication hasn’t reduced my weight much. My “weight issue” is fluctuations, but most women get that 2-5 pound change with their cycle.
To be honest, I feel some of my estrogen dominance the new physician discovered in me has suppressed my thyroid, especially my TSH. It’s total insanity that my prior physician and his nurse practitioner wouldn’t listen to me! I’m feeling better, not having afternoon slump and brain fog is reducing.
I’m not even sure how I feel about NDT medication after 20 years of dealing with manufacturing issues, shortages, and inconsistency with their formulations. I ponder what it might do for me to take Synthroid and Cytomel together. If I stick to NDT, I might switch from NatureThroid to NP Thyroid. I’m not sure as of yet.
NatureThroid worked great for me when I switched from Armour to it in 2016. Since then, it’s been junk I think. In the past year, I had gradually doubled my dose of NatureThroid from 1.5 grains to 3 grains with blood work in between. I hope to reduce my NatureThroid dose as I increase my Cytomel dose.
It’s been quite the year. I had a thyroid ultrasound and it was normal supposedly. I’m just so tired of thyroid stuff and reading about it online, haha! I do follow your blog, podcast and videos online. I like your information, even though I eat a vegan, whole food plant-based diet and don’t agree with your dietary philosophies. Thanks for the work you do.
Hi Lisa,
I think NDT is fine but I’m certainly not one of those proponents who recommend it over all other types of medication. For what it’s worth, I found that most of my patients did very well on a combination of NDT and T3. It sounds like you are on the right track! Keep us updated on your progress.
Dear Dr. Childs,
Thank you for a very interesting article! This may very well explain why I have difficulty losing weight despite high doses of NDT. Of course, every time I add another 1/4 grain, I also get more T4, not just T3, and I may in fact need just T3.
What is interesting is your advice to add T3 to a reduced dose of NDT, and not go on T3 only. All other articles I’ve read on the subject stress the importance of going off T4 completely and taking T3 only, usually until the rT3 levels are in range, although some recommend taking T3 only for life (I think the late Dr. Lowe took T3 only).
But, in your opinion, it’s possible for some patients on NDT to lower their dose and add some T3, instead of going off all T4 meds? Personally, that’s what I’d prefer as I like the idea of also getting T1, T2 and calcitonin with my NDT.
I realize you cannot give individualized advice, but just wanted to hear your comment more generally on this issue as it’s the first time I’ve seen a physician recommend adding some T3 to NDT to correct problems such as insulin resistance and elevated rT3, rather than taking T3 only.
Thanks,
Anna
Hi Anna,
Yes, you can sometimes do that but it really depends on you. Most people who just add T3 will probably not see their weight normalize, however, unless they also take into account other hormone imbalances.
This is an extremely interesting article, thank you Dr. Childs for posting! I live in Europe where knowledgable thyroid doctors are few and far between. I found one prescribing NDT (Erfa), but he keeps raising it as I remain symptomatic. ALL of my unresolved symptoms are the ones you describe here…I now realize more T4 is not always the solution. Most articles on the combo of NDT and synthetic drugs advocate T4 in addition to NDT (claiming that the T3:T4 ratio in NDT is wrong for humans). Few doctors seem to know anything about rT3. When I read about patients taking as much as 250 or 300 mcg of T4 daily with no symptom relief, I cannot help but wonder if they have rt3 dominance made worse by increasing the T4 meds…
Hi Anna,
I’ve never found NDT + T4 to be effective in any setting so I’m not sure why people even talk about using that combination as some standard. It’s far better to use NDT + T3 or any combination of T4 + T3 to get the ratios you need.
Dear Dr. Childs,
Thank you for a most interesting article! I display all the symptoms you describe, have taken up to 6 grains of NDT daily and kept gaining weight which my doctor could never understand or explain. At one point, I was told to add 1/2 or 1 grain of NDT and see if it made a difference. It didn’t. Now, I think I understand why. The next challenge will be to get my doctor to agree to a trial period of T3 added to a reduced dose of NDT. At least my doctor does not freak out about my suppressed TSH which most docs do in my experience…
I recently read an article about leptin resistance. It was about leptin levels and low carb diets. Low carbs diets have long been touted as a miracle solution for those of us with blood sugar problems (I’ve been diagnosed with insulin resistance and decided to try berberine rather than Metformin). Low carb diets are said to cause fat to miraculously melt off our bodies no matter how many calories we consume, and without exercising. I have not had great success using a low carb diet where I eat ca 20 g of carbs daily, all coming from low glycemic vegetables.
The article I read claims that low insulin levels (which we end up with on low carb diets) will in turn cause low leptin levels as they interact. Which would mean that people on low carb diets at some point risk ending up with too low leptin levels and putting on weight as a result of this. The solution proposed was to raise carb intake to ca 30 g daily and see if it made a difference.
Is this anything you recognize and agree with with? I have to admit I was very disappointed to read this after all the fuzz about the miraculous low carb diets and how they would change our lives once we cut back on carbs. Now, it seems they risk making you fatter in the long run…?!
Dr. Childs,
It would be interesting to hear your opinion about this article:
http://www.tiredthyroid.com/insulin-resistance.html
/Catherine
Hi Catherine,
Yes, it’s true but only if you use too much. Both states of hypothyroidism and hyperthyroidism cause insulin resistance, but if used correctly it won’t. You can learn more here: https://www.restartmed.com/hypothyroidism-high-blood-sugar/
Dear Dr. Childs,
It’s a pleasure to find such a great blog which I’ve been reading for a few months now. I’m from France so I hope I’ll be able to explain everything correctly. I’ll do my best 🙂
I think I’ve read all your articles and especially how the combination of T3 & T4 might be optimal in many cases.
As a matter of fact, I’ve started with both of them in 2014. Most of doctors didn’t want to treat me (since my TSH & T4 looked OK) but I met a great doctor who did more tests such as T3. And it turned out that I had a low T3 rate (but not dramatic I had 2.7 when the norm began at 2.8…) so very close to normal!
Therefore, the doctor decided to put me on 5mcg Cytomel & 25 Levothyrox and we gradually increased to 100 Levothyrox & 25 Cytomel. And I was feeling GREAT! For 3 years, had a perfect baby, lost weight, was happy, in shape, …
Then, in 2017, the Levothyrox formula changed in France (it has been a mediatic scandal here) and I started feeling really really bad (I knew a few month later that the formula had changed, and understood the link right away). I was gaining weight, nauseous, sad, crying all the time, exhausted, stomach aches. And so on. I was having again all the former symptoms. I managed to get the former formula 1 year later but it has never went back to normal since… I tried and tried different dosage and saw many endocrinologists. Most of the time, they don’t do accurate tests (such as Reverse T3 they even laugh about it). I’m ok with insuline, adreline, vitamine D, iron… so I have no clue what’s going wrong with me?
So when I read you, I feel like I know how I should feel… I would give anything to go back to that state…
Some doctors tell me that I shouldn’t have taken Cytomel in the first place, that I didn’t need it and that it boosted me for a while but that it has weakened my thyroid in the end… and here I am.
I don’t know what to believe and I’m completely lost. I’ve read all your articles and took many (quality) vitamins and minerals as well.
Lately, I’ve been taking 25 Cynomel and 100 T-Caps but I don’t feel good (maybe a little bit better). The energy and sleep are OK but I have stomach aches, don’t digest at all, gain weight, feel sad and depressed, … I’m really gaining a lot of weight so I know something is really wrong but my labs are normal so the doctors say it’s fine…
Do you have any idea of what I might miss? I think I’ve read and tested pretty much everything I’ve read on your blog.
Thank you… and thank you so much for that blog!
Catherine from France
Dear Dr. Childs,
I love your blog which I find very helpful and really look forward to trying your supplements (arrived yesterday).
I understand many thyroid patients who feel miserable on T4 only and switch to NDT do great at first, sometimes for years, before hypo symptoms reappear and, along with them, bothersome symptoms such as weight gain and fatigue. I first read about this in the “Paleo diet” book by thyroid patient Elle Russ, but later found out this problem is common. Recently, the same thing has happened to me.
Do you have any idea why this happens?
Hi Kate,
And yes, it has to do with the fact that thyroid levels fluctuate naturally over time. Your thyroid, if functioning properly, can accommodate for these changes without you realizing it by either increasing thyroid hormone production, slowing down conversion, etc. But when you take thyroid medication you blunt the HPT axis which means your body cannot react to these changes. If you don’t adjust your medication to accommodate then you will notice symptoms (either hyperthyroid or hypothyroid). Thyroid medication adjustments are needed constantly throughout your life and will need to be adjusted during times of stress, when you lose weight, when you gain weight, etc.
Hi Dr. Childs,
I am reading with great interest your blog from here in Europe. I am a 50 old yrs. man( overweight), hypo due to RAI, who did not feel well on the levo(125mcg/daily). I decided to move on ndt but I didn’t feel optimal. So I think I fall into that category you describe above. Recently I added some t3 (6mcg) to my ndt morning doses(2 grain-Thai ndt). I take another grain in the afternoon. I really noticed an increase in energy and well being. I would like to increase the morning t3 dose but I noticed that I sense a kind of drowsiness, immediately after taking the pills and keeping me for several hours. I can’t keep my eyes open. Do you have any idea why this happens?
Dear Dr. Childs,
I just wanted you to know that this article changed my life for the better!
Like the above-mentioned patient, I struggled to get optimized on NDT. On 3 grains daily, I felt under medicated. But as soon as I tried to raise it, I ended up feeling tired and wired at the same time. Plus, the weight wouldn’t come off and that has been my worst problem for years. To make matters worse: most doctors don’t seem to understand that weight loss can be impossible due to hormonal imbalances, and is not just a matter of willpower. I could go jogging seven days a week while being a WW member and still gain a pound a week, while doctors told me to “get off the couch and start moving”.
Inspired by this and other articles you’ve written on the subject, I asked my doctor to order extensive testing. And, sure enough, my FT3 remained low because my rT3 levels were high. It was also discovered I suffered from insulin resistance.
I managed to get my doctor to prescribe Saxenda and T3 alongside NDT. Since my doctor does not know much about using these drugs, I’ve used your articles as a guidance.
Slowing adding 25 mcg of T3 to 3 grains of NDT made all the difference in the world. Suddenly, the brain fog lifted, and it was like I could see clearly for the first time in years.
Saxenda has decreased my appetite by 50% and eliminated cravings completely. I am now able to eat three healthy main meals a day without any need for snacking. The weight is slowly but surely coming off. Or I should not say slowly, really, as I am losing 1-2 pounds a week which I understand is healthy in the long run.
Before going on Saxenda, I did not control my cravings – they controlled me.
So, this is just to show you that you can be an inspiration to someone thousands of miles away!
I take 30mg Armour and 5 mcg Cytomel in the morning at 6:30am and 30mg Armour and 5 McG Cytomel again at 3pm. I feel great, much better than when they had me on just 30mg Armour once a day.
Hi Amy,
Thanks for sharing and glad you are finding what works for you!
Did she take all 3 grains of NDT + 25mcg T3 first thing in the morning all at the same time or was this divided in multi dosing?
wow, I don’t know how I missed this one because it describes why I feel so poorly. I felt like you were describing the last 10 years of my life on Levo! Crashing at 3pm on the dot, abysmal total T3 levels despite low-mid range FT3, cold limbs, hoarse voice, aches and pains and the biggest one -Insulin resistance. Never in ten years have I regained my appetite and completely rid myself of hypoglycemia. Now I know why. I’m clearly suffering from tissue level hypo. It really confounded my GP for years and he finally started blaming fibromyalgia. This has made me see that I need to change my game plan because even when I add T3 to my current dose of levo it compounds the conversion problem more and I can’t get the T3 I need at a cellular level. I also had a TSH of 0.05 on 2 grains and I felt terrible because of the increase of T4 from 1.5 grains to 2 grains is quite a lot with just an increase of 5mcg of T3! It still left me with total T3 levels of 117. That’s not great. Sounds like I need to try this again but reduce the NDT to 90mg or 60mg and add T3. Is there an optimal range for TT3 to shoot for and does adding T3 overcome T4 depletion. I’m so scared of T4 depletion again. Thanks for this article!!!
I forgot to add that I think an elevated TSH close to ‘2’ whilst having optimal T4 levels and low TT3 is a sign of some form of tissue level hypo.
In 2017 I read an article about the connection between low T3 and migraines. (My T3 has always been below normal with only a couple of times the exception over years.)After numerous labs and tracking migraines it held true for me. I asked my primary for a script for T3 but she wasn’t comfortable with the dosage. I went to the endocrine doctor she referred me to who grudgingly gave me 5 mcg of Cytomel twice a day but to start, take once a day, and reduced my synthroid to 100mcg. I was on 150mcg of synthroid. To make a long story short, in less than a week, I ended up in the ER with a diagnosis of acute hypothyroid. (TSH 7.69) With that I had a good year of hell with symptoms that I had never experienced in my life. Also left me with severe tinnitus in both ears. (Left ear two different tones.) It has taken me this long to see another doctor to treat the low T3, because losing weight in spite of exercise (walking 3+ miles a day) and diet changes seems impossible. (Has always been difficult) Also, migraines exacerbated. I am hypo due to left lobectomy of the thyroid due to a benign node. New doctor after labs, flagged TSH, hyper, says will give me 5 mcg of Cytomel, no change to synthroid, once TSH stabilizes. (6 weeks). She doesn’t seem to subscribe to any effect of low T3 given she said they seldom even check it. I discussed with her low T3 and metabolism, she dismissed that! After what happened to me it is terrifying to try anything new. But I understand the need to do so. But now I have went from one extreme to another of the dosage of my synthroid to the Cytomel. I currently take 150mcg of synthroid x 7 days and one day with 12.5 mcg. Look forward to your thoughts.
Hello Dr. Childs,
I hope you are well. My doctor started me on T3 (got up to 45 mcg) 1.5 years ago and when the additional 10+ pounds of water weight did not come off even with exercise, he added Tirosint for 2 weeks. I was more achy in my back and had slightly more water retention. Then we tried 1 grain of Armour with the 45 mcg of T3 and again more achiness (no water weight loss) so I stopped after 10 days. My question is how long would it take for a patient to know if NDT is working for them or not after adding it to T3? Keep up your great work. I can tell you are a very intelligent young man. Thank you.
Sincerely,
Andrea
Chandler, AZ
Hi Andrea,
It takes about 6-8 weeks for any changes in a thyroid medication to manifest clinically.
Thank you, Dr. Childs.
I don’t agree with adding T3 to NDT. If the person is on the correct dose of NDT and the FT3 is in the upper range they should feel well and not put on weight anyway. I have been on NDT for years at the correct dose and have never lost or gained any weight feeling well for years with no thyroid.
Hi Josephine,
Each person has a different need for T4 and T3. Some people need very little T3 and others need a lot more. The big problem with NDT dosing is that the T4 and T3 components are static so they simply won’t work for every individual. I’m glad that your dosing of NDT works for you, but there are plenty of people out there who need individual titration of their T4 and T3 dosing which is why different combinations of thyroid medication are needed.
Dr Childs, should the liothyronine be taken separately from NDT, or can they be taken in conjunction with one another? I take NDT first, then T2 Essentials an hour after, and then T3 Conversion Booster/Thyroid Adrenal Reset Complex an hour later along with other nutritional supplements. Just want to make sure my timing with all hormones/supplements is optimal. Tried looking through all your responses here but did not see anything specifically addressed. Thank you!
Hi Sylvia,
I think it’s best to split apart and NDT and T3 by 12 hours but it’s not required. It’s certainly possible to take both at the same time, along with T2, if needed. But that can be a lot for some people so it’s generally best to split them apart.