Reverse T3 Treatment Guide + How to “Flush” it out of Your Body

Reverse T3 Treatment Guide + How to “Flush” it out of Your Body & Start Feeling Better

Reverse T3 could be the missing link to finally explain why you still have hypothyroid symptoms despite taking thyroid medication. 

The crazy part is that most doctors don’t even order reverse T3 and even if they do most aren’t sure what to do with the results. 

And high levels of reverse T3 could be acting to slow down your metabolism, reduce thyroid function at the cellular level and result in full-blown symptoms of hypothyroidism.

That’s why it’s so important for you to understand the basics of reverse T3 and thyroid function so you can be informed when you see your doctor. 

And don’t worry:

I am going to make this easy on you by giving you all of the information you need to know about reverse T3 including:

  • How to tell if you have too much reverse T3 in your body
  • What blood tests you need to have your doctor order and how to calculate your free T3:reverse T3 ratio
  • What causes high levels of reverse T3
  • How to “flush” out high levels of reverse T3 and how I treat patients with Thyroid resistance and high levels of reverse T3 in my office

What is Reverse T3 Anyway? 

Are you new to this whole thyroid thing?

No worries, I’m going to make this easy on you.

There’s a lot of information out there (much of it conflicting), and it’s easy to get lost in the sea.

What it boils down to is this:

Reverse T3 is a hormone metabolite that is created from the T4 thyroid hormone (1). And it looks something like this: 

T4 can turn into rt3 or t3

Your body basically has the option of converting T4 into the ACTIVE thyroid hormone T3 or the inactive thyroid metabolite reverse T3. 

Much like the image above, it’s sort of like a fork in the road. Your body is constantly deciding which direction it is going, left or right. 

If most of the T4 in your body goes down the active T3 pathway, then your tissues get the thyroid hormone they need and everything is good.

If too much goes down the inactive reverse T3 pathway, then the active thyroid hormone is blocked and you may become symptomatic

Sounds pretty simple right? 

T3 hormone = Good

Reverse T3 metabolite (in high amounts) = Bad

Now that we know what we want the body to do, let’s focus on doing the things that help your body convert T4 into the active T3 hormone and NOT the inactive reverse T3 metabolite. 

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Why Does Your Body Even Have Reverse T3? 

That’s a great question and answering it will help you understand why, in certain situations, your body will create too much of it.

Reverse T3 is meant to be there acting as a “Brake” on your metabolism (2) during times of extreme stress.

Let’s look at chronic illness as an example:

When your body is recovering from an illness (like pneumonia or a bloodstream infection) does it make sense for your body to increase its metabolism and provide energy to your muscles? 

Of course not! It makes more sense to conserve your energy and metabolism by slowing down energy production and providing energy to vital organs

This is a protective mechanism built by your body and it may surprise you that it has a name and is well documented in the scientific literature. 

It’s known as euthyroid sick syndrome.

definition of euthyroid sick syndrome

Patients that are under stress develop this condition which results in low free T3 levels, high reverse T3 levels, and normal T4 and TSH levels. 

Hmm… does this sound like your lab results?

You see: 

Despite the fact that every doctor has learned about euthyroid sick syndrome most believe that it’s a phenomenon only seen in hospitalized patients. 

But, we are seeing more and more, that patients with multiple chronic medical conditions present with the same lab tests as those who are hospitalized. 

Studies like this one (3), shed light on the fact that other conditions, such as calorie-restricted diets, can lower free T3 levels, increase reverse T3 levels, and cause changes in thyroid function that resemble “sick euthyroid syndrome“. 

Are You Pooling Reverse T3?

Now that you know you want reverse T3 levels to be as low as possible the next thing you need to know is what causes the high levels, to begin with. 

Before we jump into the causes it’s important to know how high reverse T3 tends to present from a symptom perspective (this can help you understand if it’s even something you need to worry about). 

As you might suspect, the higher reverse T3 is in your body the lower your metabolism will be and the more weight you may gain. 

Patients with high levels of reverse T3 tend to have one or more of the following symptoms:

  • Lower-than-normal metabolism
  • Constant weight gain without changing eating habits
  • Crushing fatigue
  • Symptoms of hypothyroidism
  • Chronic pain
  • Depression, anxiety, and/or bipolar disorder

These are the most common symptoms, but realize that each person presents in a different way. 

For instance, I’ve seen people with high levels of reverse T3 present with a complete inability to lose weight and with severe depression.

If you have one or more of the following symptoms it’s going to be VERY important for you to get your reverse T3 levels checked and consider the treatment options below…

But first:

What causes elevated reverse T3 levels, and what should you look out for? 

In my experience these are the most common reasons that people have high levels of reverse T3:

  • Calorie-restricted dieting – Especially HCG diets or VLCD (very low-calorie diets). These diets (4) have been shown to reduce metabolism, increase reverse T3 and make permanent weight loss almost impossible. 
  • Chronic illness and infections – This includes viral infections like infectious mononucleosis (5), bacterial overgrowth syndromes like SIBO, and even chronic illnesses like cancer, cardiac/heart disease, arthritis, diabetes, and even obesity itself. 
  • Chronic Inflammation – ANY cause of inflammation can result in decreased T4 to T3 conversion (6) and higher levels of reverse T3. Inflammatory states include any untreated autoimmune disease, leptin resistance, insulin resistance, intestinal dysbiosis, cancer, etc. 
  • Chronic untreated Gut infections/Imbalances – Up to 20% of T4 (7) is converted to T3 in the gut, which means if you have gut issues you may be missing out on up to 1/5th of your conversion power. Gut imbalances include SIBO, dysbiosis, reflux/GERD, yeast overgrowth, history of chronic antibiotic use, and inflammatory bowel disease. 
  • Emotional and physiological stressors – This includes social issues like the death of a loved one, family problems, divorce, etc. And it also includes trauma: psychological (PTSD) and physical (motor vehicle accidents, TBI or otherwise). Read more here. (8)
  • Certain Medications – The most common medications causing elevated reverse T3 include blood pressure medications, diabetic medications, anti-seizure medications, narcotics, and antidepressants. A common example is the use of beta blockers which can be used to treat the symptoms of Hyperthyroidism (9) and they are commonly used to treat blood pressure (10). 
how inflammation impacts thyroid function

I know, I know… 

I said I wasn’t going to get technical and I did anyway.

I apologize but it’s important to know why many people are suffering from this issue. Chances are very high that you fit into one or more of the categories above and it’s highly unlikely that anyone has ever looked at your reverse T3 level.

What You Need to Know About Reverse T3 Testing

Luckily it’s pretty straightforward to test for reverse T3.

There is a serum marker for reverse T3 that most standard lab companies can run.

The tricky part can be understanding and interpreting your results. 

Before we talk about ranges you need to understand how these lab tests all fit together with one another:

One of the main reasons doctors fail to recognize the importance of certain thyroid lab tests is that they look for thyroid studies in the “normal range” as opposed to the “optimal range”. 

If you haven’t already please read this post which outlines the difference between being “normal” and being “optimal” as it relates to your hormones.  

To start you will want to get a full thyroid lab panel which includes: TSH, free T3, free T4, reverse T3, and thyroid antibody levels

serum thyroid hormone levels based on disease severity

As you can see from the image above, you can have high levels of reverse T3 and most of your lab tests will likely not be outside of the “normal” reference range provided by the lab testing guidelines.

But this doesn’t mean that your thyroid is necessarily working properly. 

To determine if that is the case you will need to look at all of the tests and look at how they fit into the big picture.

One of the most obvious changes to notice in the image above is the difference and spread between reverse T3 levels and free T3 levels. 

You can see that as reverse T3 levels rise, free T3 levels will fall and this difference is the most dramatic when compared to the other thyroid lab tests. 

For this reason, these two lab tests are critical in evaluating thyroid function. 

You can determine the spread between these two values with a simple calculation which will give you the ratio of reverse T3 to free T3.

In an ideal world, you want your free T3 levels to be as high as possible (generally upper 1/2 to 1/3 of the “normal” reference range) and you want your reverse T3 levels to be as low as possible. 

This lab pattern allows for less competition at the cellular level and will allow for T3 to do its job. 

In most patients, I find that reverse T3 levels of less than 15 are ideal

But remember that it’s possible to have a “normal” free T3 and VERY abnormal “reverse T3” which is why the ratio is so important.

To calculate your free T3: reverse T3 ratio simply divide the numbers.

Your ratio should be > 0.20. 

Any ratio < 0.20 indicates too much reverse T3 to free T3 and means that you should focus on either increasing your free T3 or reducing your reverse T3. 

How to “Flush” Out & Reduce Reverse T3 Levels

You need to realize that treating your reverse T3 problem is only effective if you treat the underlying cause (11).

If your high levels of reverse T3 are secondary to insulin resistance and diabetes and you don’t change your diet, then even with treatment your high levels will come right back. 

For this reason, it’s very important to find the underlying cause before you initiate treatment because part of your treatment needs to be focused on that particular issue.  

Having said that, there are definite ways to lower reverse T3 levels quickly…

I’ve split the treatment into 3 main categories: 

1. Thyroid Medications Can Reduce Reverse T3

The fastest and easiest way to get rid of excess reverse T3 is with bioidentical hormone formulations that contain pure T3. 

This would include medications like liothyronine, Cytomel, or sustained release T3 (available from compounding pharmacies). 

The reason this approach works so well is that when you give your body T3 hormone directly it suppresses T4 automatically which reduces the substrate that your body uses to create reverse T3. 

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Naturally what will happen with T3 supplementation is that your T4 levels will decrease, your free T3 levels will increase, and your TSH will drop.

While on T3 thyroid medication it’s important to monitor reverse T3 closely, at least once every 6 to 8 weeks. 

Typically within 2 months (and assuming your dose of T3 is high enough), your reverse T3 should drop to less than 10.0. 

As I mentioned above, this is by far the fastest way to reduce reverse T3, but it’s important to still seek out and eliminate the cause of your high reverse T3 levels otherwise they will just come back once you stop taking T3 medication. 

NDT & Reverse T3 Levels

Can NDT be used to help flush out reverse T3 levels in the body? 

It certainly can help but there are a few things to realize when trying to flush out reverse T3 levels while using NDT:

  • Each grain of NDT has about 38mcg of T4 and 9 mcg of T3, which means that NDT still primarily consists of T4. 
  • In order to flush out the reverse T3, you must lower the substrate of T4 which generally means lowering your total dose of T4. In some cases, you may have to drop your NDT dose in favor of pure T3 medications.
  • NDT dosing is static meaning you can’t individually alter the concentration of T4 and T3 unless you add additional thyroid medications to NDT.

With these considerations, and if you are on NDT but still experiencing high reverse t3, it’s usually best to decrease your total dose of NDT and add T3 in addition to the NDT. 

For most patients, dropping NDT down to 1-1.5 grains is usually sufficient.

But, remember this:

Simply manipulating the reverse T3 number by changing medications does NOT treat the cause of the elevated reverse T3, and if you don’t treat the underlying cause your levels will increase once you go back to your previous dose of NDT.

2. Supplements Can Enhance T4 to T3 Conversion Thereby Reducing Reverse T3 Levels

In addition to medications, every thyroid patient should also consider utilizing nutritional supplements.

The reason is simple:

The hypothyroid state sets the body up for certain nutrient deficiencies and since most thyroid patients are under-treated, most also have these deficiencies.

Low thyroid states lead to low stomach acid which leads to decreased absorption of nutrients.

Low thyroid states also increase your risk of developing gastrointestinal imbalances which may further impair the absorption of minerals and nutrients.

You can check out this post here for more info about which supplements you should consider using and how to check to see what your body needs. 

what is reverse t3

When it comes to thyroid conversion we only want to focus on a few certain nutrients:

The two primary supplements that you should focus on are zinc and selenium. Both of these supplements have been shown in some clinical studies (12) to increase T4 to T3 conversion, thereby potentially decreasing reverse T3.

We aren’t as concerned about supplements to promote thyroid production (such as iodine and L-tyrosine) because that isn’t the problem with conversion issues (it may be for some but not for the majority). 

If your doctor isn’t willing to change your medication you can check out this post for more info on how to naturally increase your free T3 levels. 

3. Reversing Hormones that promote T4 to Reverse T3 Conversion

As you are probably aware your hormones all work in tandem with one another. 

This means that as one system slows down it may drag down other systems or cause an increase in other hormones to make up for the deficit.

This holds true with thyroid hormone and leptin/insulin levels.

The link between these three hormones is clear:

This is very important because hypothyroidism leads to a state where developing both insulin and leptin resistance becomes much easier. 

Why do we care?

Because insulin and leptin resistance both cause inflammatory states which contribute to T4 to reverse T3 conversion.

Not only do they contribute to high reverse T3 levels but they also make weight loss very difficult.

Is this sounding familiar now?

Patients with high reverse T3 levels almost always have high fasting insulin and high fasting leptin levels.

In fact, I don’t think I have ever seen a patient with a reverse T3 greater than 25 with a normal insulin or leptin level.

an example of an extremely high reverse t3 level
example of a high leptin in the setting of high reverse t3
high insulin in the setting of high reverse t3

You can see examples from several patients above showing abnormal reverse T3 levels, high fasting leptin, and high fasting insulin levels. 

These values may fall within the “normal” range but they are far from normal and will lead to symptoms of hypothyroidism, weight gain, and weight loss resistance

Another big reason I want to talk about these hormone imbalances is that doctors don’t frequently run tests to check for either of them. 

Providers will check hemoglobin A1c but rarely do they order fasting insulin and fasting leptin levels.

This means that if you have known high levels of reverse T3 (by the way, they don’t always order this test either), it’s probably going to be up to you to request these specific hormones.

Treating and reversing both insulin and leptin resistance is very important for not only lowering reverse T3 but maintaining low levels over time.

To learn more about how I address these hormone imbalances (including treatment options) please see the following case studies below:

These case studies provide a step-by-step walkthrough of how to approach leptin and insulin resistance including medications, hormones, and supplements designed to help both conditions. 

If you know you have insulin resistance then you can consider using these supplements to help lower your levels: 

  • Berberine: Helps reduce cholesterol, improve fasting glucose, and may help with weight loss.
  • Alpha Lipoic acid: Helps sensitize the body to insulin and may help to reduce nerve damage in certain patients
  • Chromium: Helps improve insulin sensitivity to cells and may help reduce cardiovascular disease in certain patients. 

If you prefer the natural approach to treating leptin levels you can find more info here on how to target supplements towards OTHER imbalances for the most benefit

4. Addressing Inflammatory Levels and “Cooling Off” Your Body

Everyone knows inflammation is bad for the body (15), but very few people understand how it makes things worse and more importantly how to treat it if present.

Part of the reason for this is that the markers we use for inflammation are non-specific.

That means most of the time we know inflammation is present, we just don’t necessarily know where it is coming from.

Sure, in the presence of other abnormalities we might be able to take a guess, but we will rarely ever know with 100% certainty.

But how does inflammation relate to thyroid function and reverse T3 levels? 

It turns out that inflammation directly promotes the production of reverse T3 (16) by pushing your body down the T4 to reverse T3 pathway.

So if you have high reverse T3 levels you need to be actively searching for sources of inflammation and treating the cause or source.

You can easily test for inflammation by ordering these lab tests:

  • CRP: You want this to be as low as possible but definitely < 1.0 for optimal thyroid function
  • ESR: Another non-specific marker of inflammation (17), for optimal thyroid function this should be < 10
  • Ferritin: Both a marker for iron stores and an acute phase reactant (18) this marker can be used in certain instances to help isolate non-specific inflammation in the body

These are non-specific serum markers and are helpful for determining if there is inflammation present in the body.

If you know that you have both high levels of inflammation and high levels of reverse T3 then you can safely assume that the inflammation is likely worsening your thyroid function.

The next step is to find where it’s coming from.

In hypothyroid patients it’s usually in these three places:

  • Hormone imbalances (especially insulin and leptin resistance)- Please refer to the section above to understand how to both diagnose and treat these conditions. 
  • Undiagnosed gut imbalances like SIBO and SIFO – Both of these gut issues promote inflammation (19) in the GI tract and lead to increased intestinal permeability. You can find more about both here
  • Undiagnosed food sensitivities – These sensitivities promote inflammation (20) and further food sensitivities unless treated. 

Bottom line?

If you have both high reverse T3 and elevated serum markers for inflammation you should be looking at the 3 main causes above and treating those if applicable.

If you don’t know where the inflammation is coming from you can still do some good by taking supplements designed to help reduce inflammatory levels and promote the “clean up” of breakdown products in the liver:

  • Milk thistle + MSM: Designed to help improve liver function and promote proper phase 1 and phase 2 elimination of medications, supplements, and other products that need elimination in the liver. This combination may also help reduce AST and ALT levels (21)(if you have fatty liver). 
  • Omega 3 Fatty Acids: Omega 3 fatty acids can help reduce inflammation by reducing inflammatory cytokines. 
  • Curcumin: This well-studied herb activates PPAR-gamma levels (22) helping to reduce inflammation in the body. 
  • Quercetin + Bromelain: Particularly helpful in patients with digestive issues and those with chronic sinus/upper respiratory illness-like symptoms (post nasal drip and chronic stuffy nose). 

This approach isn’t ideal but it’s better than simply ignoring it.  

Remember to work with your doctor if you suspect you have an inflammatory process contributing to your high reverse T3 levels.

5. Lifestyle changes to Balance Hormones and Promote Thyroid Function

Never underestimate the power of these 4 major areas when it comes to your health:

If you don’t practice these 4 basic things it doesn’t matter what you do, you won’t get better. 

These are particularly important for those with high reverse T3 levels. 

Remember that your body is a network of systems and hormones that all interact with one another. 

When one system isn’t working properly, it will bring other systems down.

These areas are so important that many people can see significant improvement in their thyroid symptoms without the need for additional treatments or medications.

Final Thoughts

High levels of reverse T3 can be a very serious issue for many thyroid patients and may help explain why you’ve been consistently symptomatic and resistant to weight loss despite taking thyroid medication. 

In order to diagnose high levels of reverse T3 and thyroid resistance, you need to look at both serum levels of reverse T3 and free T3.

Measure your ratio of these hormones (as this is the most sensitive marker for tissue levels of thyroid hormone). If your free T3/reverse T3 ratio is < 0.2 you have too much reverse T3 in your body.

The best treatment for reducing these levels is by taking pure T3 thyroid medication, taking supplements to increase T4 to T3 conversion, and by making the appropriate lifestyle changes to balance other hormones in your body.

Doing these things will finally help your body regain balance and get rid of your hypothyroid symptoms.

Now I want to hear from you:

Is this the first time you’ve heard about reverse T3?

Have you had your levels checked? If so, was it high or low?

What type of treatments have you tried to lower your reverse T3?

Have you tried medications that contain T3 like Cytomel or liothyronine? Did they work for you?

Leave your questions or comments below!

#1. https://www.ncbi.nlm.nih.gov/pubmed/3428867

#2. https://www.ncbi.nlm.nih.gov/pubmed/7355063

#3. http://www.ncbi.nlm.nih.gov/pubmed/12055988

#4. http://www.ncbi.nlm.nih.gov/pubmed/12055988

#5. https://www.nlm.nih.gov/medlineplus/infectiousmononucleosis.html

#6. http://www.ncbi.nlm.nih.gov/pubmed/11716958

#7. http://www.ncbi.nlm.nih.gov/pubmed/3049061

#8. http://www.ncbi.nlm.nih.gov/books/NBK28/

#9. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3475282/

#10. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5369873/

#11. http://www.ncbi.nlm.nih.gov/pubmed/16399020

#12. https://www.ncbi.nlm.nih.gov/pubmed/8157857

#13. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3608008/

#14. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3356957/

#15. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3492709/

#16. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3978663/

#17. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4653962/

#18. https://www.ncbi.nlm.nih.gov/pubmed/24549403

#19. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3099351/

#20. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1774228/

#21. https://www.ncbi.nlm.nih.gov/pubmed/17548789

#22. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2234255/

everything you need to know about the reverse t3 thyroid lab test

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About Dr. Westin Childs

Hey! I'm Westin Childs D.O. (former Osteopathic Physician). I don't practice medicine anymore and instead specialize in helping people like YOU who have thyroid problems, hormone imbalances, and weight loss resistance. I love to write and share what I've learned over the years. I also happen to formulate the best supplements on the market (well, at least in my opinion!) and I'm proud to say that over 80,000+ people have used them over the last 6 years. You can read more about my own personal health journey and why I am so passionate about what I do.

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