4 Conditions that make TSH Levels Inaccurate + “Optimal” Ranges & More

TSH might be one of the worst ways to evaluate thyroid function and yet it is probably the most widely used thyroid lab test out there. 


In an attempt to oversimplify thyroid function and management Doctors have become reliant upon TSH testing, but what if there was a better way?

A way that rectifies the fact that so many patients have a "normal" TSH but clearly have hypothyroid symptoms... 

Sound too good to be true? 

It isn't. 

And we are going to talk about it in detail below. 

In this post we will discuss why TSH levels are NOT the best way to evaluate your thyroid function, but more importantly we are going to talk about how to actually assess thyroid function and which lab tests you need...


​Is your TSH Normal?

​This is probably one of the most common questions I get on a daily basis (or some variation of are my lab tests normal). 

Just take a look at the comment section of any post and you will find plenty of people posting their labs with that exact question.

​So let's answer it once and for all. 

Is your TSH actually normal?

​In order to find out if it is normal we have to first understand what this test is actually testing for. 

Don't worry, we aren't going to jump into advanced thyroid physiology (you can find more about that here if you'd like) instead I want to keep things basic:

TSH stands for Thyroid Stimulating Hormone and it comes from the pituitary.

The pituitary is a ​gland in your brain that attempts to tell your thyroid how much thyroid hormone to produce. 

So why do Doctors care what the pituitary is telling your thyroid gland?

Well TSH turns out to be a quick and dirty way to diagnose both hypothyroidism and hyperthyroidism but it falls short when things get a little more complex.

In the case a standard hypothyroidism your TSH increases.

In the case of standard hyperthyroidism your TSH decreases.

​But what about the non standard cases. 

What about patients who have normal TSH levels but every hypothyroid symptom?

Does the TSH work for everyone?

Not really and here's why:

When we talk about any hormone we really need to understand how and where the hormone has action in the body.

Thyroid hormone is activated inside the cell of the target tissues and it does this through a nuclear receptor.

In simple words it means that thyroid hormone gets inside the cell and directly turns on genetic transcription (it changes your DNA/RNA directly).

​And this is good, but what is important here is that each tissue has a DIFFERENT demand for thyroid hormone depending on the situation. 

Again, let's put this into simple terms...

If you are incredibly sick in the ICU of a hospital, does it make sense for your body to put energy into growing your hair follicles or making your nails strong?

Not really...

​Instead each of your cells in your body has a different demand for thyroid hormone depending on the situation, time of day, stress you are under, etc.

Thyroid diet 4 week plan side bar

So how does this fit in with the pituitary gland?

Well the pituitary gland is just another tissue in the body which has a demand for thyroid hormone and a sensitivity to thyroid hormone.

The downside is that unlike other tissues in the body the pituitary is the MOST sensitive tissue to thyroid hormone in your body.

It has a different set of deiodinases (these are the enzymes which either activate or inactivate thyroid hormone). 

Without making it too complex the pituitary gland has only the enzyme which ACTIVATES thyroid hormone. 

Nutrients required for thyroid function

Now compare that to other tissues in the body which have the ability to both INACTIVATE and ACTIVATE thyroid hormone (your body does this through increasing or decreasing reverse T3 levels). 

It's like the pituitary gland has one switch and it's the "on" switch. 

That means if thyroid hormone is floating around in your body it will eventually make it to the thyroid gland which will cause your TSH to drop. 

But that does NOT mean that the other tissues in your body are getting enough thyroid hormone. 

Instead it's usually the opposite...​

Normal vs Optimal TSH Range

Now having said all of those things it doesn't mean that the TSH is entirely useless (in fact I will talk about how it can actually help somewhat helpful later). 

But in order to understand how to evaluate your TSH you need to understand that there is a huge difference between being "normal" and being "optimal".

To start with I have NEVER seen a healthy individual with a TSH > 1.0.

​Nowadays due to the Standard American Diet, decreased activity levels, absurd rates of insulin resistance and many other factors it is truly rare to see a "healthy" person. 

Standard american diet

That means we need to change our definition of "normal". 

If you look at laboratory tests you will see that a normal TSH level generally falls within 0.5 to 4.5 (or some small variation).

You can see the range from different lab tests below: 

Abnormal TSH kathy

​As you can see the TSH reference range is 0.35 to 5.5. 

You can see we have a problem here. 

Truly "healthy" people have a TSH < 1.0 and yet the "normal" range extends all the way out beyond 5 in this case. 

That means your Doctor won't flag your TSH as abnormal unless it falls outside of those reference ranges. 

​But as I mentioned above it is important to consider that your pituitary is the MOST sensitive tissue to thyroid hormone in your body. 

That means it is entirely possible to have a "normal" but less than "optimal" TSH! 

By these standards the optimal TSH level range should be anything > 2.0 as a problem. 

It certainly doesn't mean that anything < 1.0 is "normal" (we need your other lab tests to determine that), but it does give us some guidance in terms of understanding how someone can be inside the ​standard reference range and still have symptoms. 

​This is where things can get a little more complicated. 

There are several conditions where the TSH can be decidedly "normal" in fact it can even be sometimes < 1.0 but the patient can still be hypothyroid.

These conditions include:

  • Low T3 Syndrome or Euthyroid sick syndrome 
  • Cases of Partial or complete thyroidectomy
  • Cases of Insulin and/or Leptin resistance
  • Cases of Chronic inflammation (including chronic pain, fibromyalgia and/or chronic fatigue syndrome)
  • Hashimoto's or autoimmune thyroiditis

​Unfortunately patients who fall into any of these categories tend to get misdiagnosed and/or mismanaged by providers who rely solely on TSH levels for diagnosis. 

  • Bottom line: The "Optimal" range for TSH should be < 2.0, anything higher indicates potential hypothyroidism. Do NOT use the standard lab reference range as your definition of "optimal". 

Let's go through some examples so you have a better idea of what I am talking about...

Low T3 Syndrome

​Low T3 syndrome is exactly as it sounds. 

Patients have low T3 but the problem is that they have a relatively preserved TSH (in the normal or even optimal range), but free T3 levels that are either in the low end of the reference range or barely below it. 

You can see the example below which shows a free T3 level of 2.5 with the reference range from 2.3 to 4.2.

Hypothyroid lab tests

This is a big problem because T3 is the ACTIVE thyroid hormone.

So low levels of this hormone in your blood ​mean you will have low levels of active thyroid hormone despite whatever your TSH may be. 

​Low T3 syndrome is known by many names, and you can read more about it here.

Basically what happen is your body decreases the amount of free T3 and increases the amount of reverse T3 in your body. 

This is felt to be a protective mechanism to conserve energy when your body is under extreme stress.

The problem is that this condition extends beyond the typical acute illness that so many Doctors relate it to.

In fact it has been shown that calorie restriction can even cause low T3 syndrome.

Answer this question:

Have you gone through a calorie restricted diet in your life? Have you gone through the HCG diet or some other medically assisted weight loss program?

And in case you are wondering here are other conditions that can cause Low T3 syndrome and put the "brakes" on your thyroid function:

  • Chronic yo-yo dieting or caloric deprivation leading to starvation
  • Chronic illness, infection or autoimmune disease
  • Chronic medical conditions like Diabetes, cardiovascular disease, metabolic syndrome, etc.

If so, then there is a good chance you may have low T3 syndrome which is causing hypothyroidism but NOT altering your TSH. ​

​Fortunately it is relatively easy to check for and just requires the complete thyroid panel which we will be going over below. 

High TSH but Normal T4

​Another subset of patients have what would be considered subclinical hypothyroidism where their TSH is absolutely elevated (even the conventionally trained physician would agree) but their free T4 is relatively preserved. 

Let me show you an example below: ​

Abnormal TSH kathy

This TSH is elevated at > 3.0 which most physicians would agree is suboptimal (in fact some providers have recommended we change the range to include anything > 2.5 as abnormal). 

normal T4 but high TSH

​And yet despite the fact that the TSH is > 3.0 in this case their free T4 is still relatively normal at 1.17 with a reference range of 0.89 to 1.76. 

Occasionally this scenario will prompt a physician to simply recheck the thyroid lab tests within a month without proper treatment with thyroid hormone. 

And patients who are in this situation feel frustrated because they are symptomatic with abnormal labs, but still aren't getting treatment.

So why does the free T4 stay relatively preserved in some patients?

The answer depends but usually is made clear by checking reverse T3 levels.

Remember that T4 is simply a reservoir hormone for T3.

T4 is inactive unless it is converted to T3.

But it can be turned into Reverse T3 instead of free T3 which can put the brakes on the thyroid and your metabolism.

But unless you check the reverse T3 level your free T4 may appear falsely "normal" despite the fact that your body is lacking thyroid hormone at the cellular level.

​You can read more about reverse T3 and how it impacts your body here

​Partial Thyroidectomy with Falsely "normal" TSH and T4/T3

This is another big one that I will occasionally run into and it just highlights how good the body is at preserving serum levels of thyroid hormone (or how inaccurate thyroid lab tests really are depending on how you look at it). 

Below is an example of a hypothyroid patient who underwent a partial thyroidectomy some 20+ years ago.

She was functioning with half a thyroid and yet her TSH was still 2.37 with a reference range of 0.45 to 4.5. ​

Thyroid resistance lab results

Despite that her labs look "decent" she was still suffering from many hypothyroid symptoms including: hair loss, weight gain, extreme fatigue, brain fog, etc. 

And it wasn't until she was started on naturethroid that she had near COMPLETE relief of all of her symptoms over a 6 month period and her body transformed in the process. 

In fact you can see her before/after pictures and case study here:

Melanie side view 9 month follow up

​So why is it that this patient was obviously hypothyroid, but she was still able to have "normal" thyroid lab tests?

​Again it highlights the importance of not focusing solely on the TSH but instead using other markers to help diagnose thyroid issues. 

If you take a look at her numbers you can clearly see that her free T3 is in the low end of normal and her reverse T3 is > 15 indicating she has a conversion problem.

When you understand how inflammation (indicated by her high CRP) leads to T4 to reverse T3 conversion, her thyroid labs make perfect sense.

But in order to come to this conclusion you really have to look at the whole picture. ​

thyroid metabolism reset poster for side bar

High TPO antibodies but Normal TSH with Hypothyroid Symptoms

​Then of course we have the situation of autoimmune thyroiditis...

The situation where patients have hypothyroid symptoms, "normal" lab tests but elevated antibodies to either Thyroglobulin or thyroid peroxidase.

Patients in this situation are often told to take the "sit and wait" approach.

That is sit and wait until your body destroys your thyroid gland from inflammation and autoimmunity and THEN you will need thyroid hormone.

​If the body is able to "preserve" thyroid function after a partial thyroidectomy (as evidenced above) then it is certainly able to preserve function if 10-50% of the thyroid gland is destroyed. 

This often leads patients with autoimmune thyroiditis until their TSH finally increases to a point where providers feel thyroid hormone is indicated.

​Obviously there is a better approach and that is to look and evaluate ALL thyroid laboratory tests (in addition to the TSH) and treat if there is a combination of symptoms + abnormal lab tests (even if those abnormal lab tests are just antibody levels). 

Below I've included an example from a recent patient who had undiagnosed autoimmune thyroiditis for many years:

High free T4 and low TSH in hashimoto's
elevated antibodies with high TSH

​You can see the TSH at 12.27 with a reference range of 0.40-4.50 in a patient with debilitating fatigue and weight gain for years (undiagnosed) with accompanying elevation in both thyroglobulin and TPO antibodies. 

​This is what will happen to your thyroid gland over time assuming you don't treat the autoimmunity or inflammation, and it just doesn't make sense to wait until the damage is > 50% to PROVE it. 

Changes in TSH over time and with disease severity

Why is it that in all of these conditions (they account for the majority of you guys reading this post by the way) the TSH and other lab tests remain decidedly "average" despite obvious dysfunction in other lab tests?

euthyroid sick syndrome lab values

​To better understand what is happening in your body it's best to visualize the thyroid lab tests overtime on a graph. 

Above you can see a graph which depicts all thyroid lab tests over time.

On the left is mild disease (inflammation, autoimmunity, chronic infection, dieting, etc.) and as you travel right on the X axis you can see how the lab tests change over time.

What's important here is that the TSH ​doesn't start to elevate until the disease state has reached "severe". 

Around this time is when the free T4 level also begins to drop as well below the "normal range".

​But compare those lab tests to both reverse T3 and free T3 which show changes MUCH earlier than the other lab tests, making these lab tests hold much more weight when determining if someone is truly hypothyroid. 

​This illustration helps explain (in addition to the differences in deiodinases, tissue level demands, etc.) why not all thyroid lab tests are created equal and why the TSH falls short if used by itself. 

Even if the TSH is used in tandem with free T4 it still misses the majority of cases until they are severe. ​

Instead one of the most sensitive ways to determine if tissues are getting enough thyroid hormone is the reverse T3 to free T3 ratio (which we will discuss below). ​

Conditions that make the TSH less reliable

In addition to the conditions listed above there are a few other states that make the TSH less reliable. 

I am talking about insulin and leptin resistance: ​

Leptin resistance and increased TSH

Both of these conditions reduce T4 to T4 conversion (studies showing this link for insulin resistance here, studies showing this link for leptin resistance here). 

In the most basic sense as leptin levels and insulin levels increase the body preferentially converts T4 to the inactive thyroid metabolite reverse T3.

This leads to an "adaptive" state which reduces metabolic energy expenditure.

In lay terms that means it reduces your metabolism.

The exact mechanism by which leptin and thyroid hormone are connected is not completely understood (you can read more about it here), but one thing is certain:

Leptin levels and thyroid function are connected. 

Leptin resistance and hypothyroidism both appear to be caused or sustained by caloric restricted diets (chronic yo-yo dieting) which causes high reverse T3 and low free T3 levels leading to clinical hypothyroidism.

The big problem is that this condition is not well recognized by many providers despite the fact that it is highlighted in medical literature (see links above). ​

  • Bottom line: If you have leptin resistance (as indicated by a high fasting leptin level) there is a VERY high chance you also have tissue level hypothyroidism even if you have "normal" lab tests. This condition may need to be diagnosed by testing both your reverse T3 and free T3 levels together. 

The Complete Thyroid Panel: How to Diagnose Hypothyroidism

​So let's say you are convinced that your thyroid is suboptimal and you'd like to prove it. 

What tests do you need and how do you interpret the results?

We are going to go over them below, but I need to say something first:

Thyroid lab tests shouldn't be used as THE definitive test for diagnosing and managing hypothyroidism by themselves.

They can be very helpful for the initial diagnosis and sometimes for management, but once you introduce thyroid hormone into the system exogenously (from the mouth) you have changed the dynamics of the system.

I'm not going to go into detail on this now, but just realize the lab tests aren't the end all be all for diagnosis.

Having said that they can be quite helpful, especially if you are thyroid hormone naive (meaning you haven't been on medication before).

If this is the case, then these ranges may be helpful for you:

  • Free T3: Should be in the top 50% of the reference range (may be falsely elevated in cases of high reverse T3)
  • Reverse T3: Should be < 15 (without exception), if your Free T3 is high and your reverse T3 is high then your ratio of T3 hormone in your medication is off
  • TSH: Should be < 2.0 *anything higher indicates tissue level hypothyroidism in other tissues in the body (note that a TSH < 1.0 does not indicate optimal thyroid function especially in the face of abnormal free T3 and reverse T3)
  • Total T3: Generally should be in the top 50% of the reference range
  • Free T4: Generally in the mid range (only useful if NOT on thyroid medication as high levels of T3 only hormone will drive the T4 down)
  • Sex hormone binding globulin: In women it should be in the 70-80 range and can be helpful for determining tissue levels of thyroid hormone (can't be used if a woman is on birth control medication or oral forms of hormone replacement therapy)
  • Thyroid antibodies: Should be < 30 (non existent for whatever reference range is used)
  • CRP and ESR: Both of these markers should be as low as possible (*note that these are non specific markers for inflammation and as they increase so to will the reverse T3)

​As you can see testing for hypothyroidism is far more complex than just testing the TSH (and maybe the free T4). 

When you understand the physiology and how difference aspects like inflammation, insulin resistance, and leptin resistance​ alter thyroid physiology it is easy to see how the TSH falls short. 

But remember:

Even those "optimal" reference ranges listed above can be misleading in certain cases, but if used in combination with hypothyroid symptoms (and occasionally basal body temperature + resting metabolic rate) you can really diagnose hypothyroidism. ​

I would also point out that these ranges are really only helpful for those NOT on thyroid medication already.

Once you start thyroid medication several changes take place that can artificially alter these numbers and make interpretation difficult unless you understand the physiology.

​As an example:

Increasing doses of Synthroid or Levothyroxine will certainly drop the TSH (remember there is no competition for reverse T3 in the pituitary) but may actually make thyroid function in the peripheral tissues worse due to T4 to reverse T3 conversion.

So lab tests in this instance would look something like this:

  • TSH decreases
  • Free T4 increases
  • Free T3 drops
  • Reverse T3 Increases
  • Sex hormone binding globulin stays the same indicating low tissue levels of thyroid hormone

​This pattern is seen very frequently in patients who are treated based off of the TSH alone but have insulin/leptin resistance and/or a history of calorie restricted dieting. 

If you call into that category you will need advanced thyroid testing and a provider who can interpret them for you.​

When is the TSH Helpful?

We just spent all this time discussing why the TSH doesn't provide very much value, but it turns out that it does have some limited value. 

TSH can actually be very helpful in initially diagnosing hypothyroidism and (sometimes) helping to determine dosing of thyroid medication. 


If your TSH is > 2.0 you are hypothyroid period. If you fall into this category you should be treated (or undergo a trial) of thyroid hormone. 

And Second: 

The rate at which your TSH drops can be helpful in determining your total dose of thyroid hormone needed.

Let's say you start with a TSH of 3.5. 

You start titration with Natural desiccated thyroid and after 2 months your TSH drops to 1.0 on 2 grains (130-135mg) of NDT.

This indicates your total dose will likely need to be much higher than someone who drops their TSH down to 0.05 with the same dose.

This highlights that each patient has a unique demand for thyroid hormone in their body and standard dosing should NOT apply to everyone.

It's also important to remember that BOTH T3 and T4 will cause your TSH to decrease. ​

In fact T3 thyroid hormone is 3x more potent at decreasing your TSH than T4 thyroid hormone, so put that into perspective when using medications like cytomel, liothyronine or NDT.

​So if you are started on any medication containing T3 and your TSH does not drop very quickly then that is an indication you might need higher doses of thyroid hormone. 

​Once you start treatment with thyroid hormone the TSH generally has less utility than the other thyroid lab tests indicated above, but it still can be useful under certain circumstances. 

Recap + What to do Next​

Let's wrap this long post up with a recap and some direction if you feel you fall into any of the categories listed above. 


TSH can be a helpful test but it really falls short under many circumstances in both the diagnosis and management of hypothyroidism. 

For several reasons (including pituitary sensitivity to thyroid hormone, hormone changes and differences in thyroid medication) measuring the TSH isn't the most accurate thyroid lab test. 

In fact, even with the combination of all thyroid lab tests sometimes diagnosis can still be difficult (meaning it must be based off of a combination of symptoms and lab tests). 

In cases of low T3, subclinical hypothyroidism, partial thyroidectomy and autoimmune thyroiditis the TSH may NOT accurately reflect the thyroid status of your body. 

If you feel that your TSH doesn't reflect your thyroid status then your best step is to look for a knowledgeable provider to order ALL of the tests necessary for diagnosis. 

Generally this means you will have to look outside of the insurance model (I know it's not what you want to hear but it's just the truth right now) because most Doctors practice what is known as the "standard of care" and that standard is to test only the TSH. 

If you are working with someone and they don't order the tests, or balk when you ask for certain tests that is a good indication they are not the provider for you. 

No matter how hard you try you will never be able to "force" your doctor to listen or order the right tests - so don't waste your time. 

Find someone who can help you. 

Now it's your turn:

Do you feel the TSH has been helpful in diagnosing or managing your thyroid condition? 

Why or why not?

Leave a comment below! 

Dr. Westin Childs

I'm Dr. Childs and I write these posts. I'm a physician that specializes helping patients lose weight, have more energy and FEEL better. My practice focuses on hormone imbalances, thyroid issues and weight loss resistance. My goal is to provide the BEST information out there on the internet that is both actionable and trustworthy. Get my free ebook: Hashimoto's Diet Guide here. You can also find more about my personal journey back to health here.

Click Here to Leave a Comment Below 42 comments
Julie Aliff - November 10, 2016

My TSH was 3.189 in June. My MD put me on hormone cream containing estrogen, progesterone and testosterone and retested my TSH in August and it was down to 2.030. This isn’t below 2.0 but would this be considered close enough to be optimal? My health has improved, but I still feel fatigued and tired daily even after a good night’s sleep.

    Dr. Westin Childs - November 10, 2016

    Hey Julie,

    I think you answered your question with this comment “but I still feel fatigued and tired daily even after a good night’s sleep.” 🙂 If you feel fatigued I certainly wouldn’t consider that optimal, but it’s also important to consider that other things besides your thyroid can contribute to fatigue and other symptoms.

Emily Bentz - November 10, 2016

When you mentioned that SHBG should be around 70-80 or else it can indicate tissue levels of thyroid hormone, what exactly do you mean by this? I have hashimotos and my shbg is 33. I have hypo symptoms but tsh, t3 and t4 are withing range. T3 and t4 are lowered (not optimal). Thanks for your time.

Andrea - November 10, 2016

Dr. Childs, I am loving your articles! I sit with your articles and my lab results and try to compare how I am doing. I really appreciate your time and knowledge. It is such a relief to know that there are doctors like you who get it. I’m trying to figure out why my Free T4 is always low at .86 ng/dL. TSH: 1.49, Free T3: 3.1, Reverse T3: 11.5, Sex hormone binding globulin: 54. Much appreciated.

Pauline Ong - November 10, 2016

Dear Dr. Westin,

I am from Malaysia and I got my blood test results yesterday as follows:

Anti-TG 973
FT4- 12.5
FT3 – 5.2
Serum Iron – 14.3
TSH – 1.300

Julia Tanoukhi - November 14, 2016

Hi Dr Childs. I enjoy your posts. I won’t go into detail… I just know I have a thyroid issue that is not being addressed. Where are you located?. Are you taking patients? (TSH >8 /antibodies >900. Exhausted, …no one believing there’s a problem)…I respectfully do not feel my endocrine Docter is really “treating” me. Hoping you can help. Sincerely. Julia T.

Cindy - November 18, 2016

Dr, Westin –

I think my body is not responding like a normal person’s body. I cannot get my T3 in an optimal range with the TSH dipping down to .01 or .02. Also, there is disagreement with some online posters of an online community I participate in as to whether or not my original labs indicated that I did have hypothyroidism. I do have symptoms – mild weight gain with no change in diet or activity level, very cold hands and feet, and easily fatigued. I have been a fitness instructor for 15 years so up until last year have been in fairly good shape. Based on your article, I am think I may be suffering from Low T3 Syndrome. I contacted your office this week and they have me on your waiting list. I would love to be your patient, as I feel like you could really help me based on your videos – I have watched the 3-video series!

My first labs before treatment were:

TSH 1.5 (range 0.4 – 4.5)
Free T4 of 1.2 (range 0.8-1.8)
Free T3 of 2.9 (range 2.3 – 4.2)

Question #1 : Is this truly suboptimal thyroid? I am beginning to question going on treatment given that it is 2 years later and my labs are not that much better (see below).

Current labs with 75 mg. Synthroid and 20 mcg Cytomel

TSH .04 (range 0.4 – 4.5) LOWER than my initial labs with NO meds
Free T-4 .09 (range .08-1.8) LOWER than my initial labs with NO meds
Free T-3 2.9 (range 2.3 – 4.2) Same as my initial labs WITH 20 mcg. Cytomel

Question 2: I had been feeling well and had symptom relieve with 75 mg. Synthoid and 20 mcg. Cytomel for almost a year, and out of the blue, I started getting symptoms of hypo again last month, and are still going on (total of about six weeks). WHY out of the blue on the same dosage would symptoms come back? Nothing else has changed!

Question 3: My doctor said when I asked about increasing dosage was that the .04 was already super low and she would NOT up my dosage. Doesn’t the T4 being low mean that it would make sense to increase the dose, even though the TSH is low? Also, WHY is my T4 decreasing to even less than it was without meds? Isn’t this what the Synthroid is for – to INCREASE the T4 (which it didn’t) and to DECREASE the TSH (which it did)?

    Michelle - December 15, 2016

    I have similar readings…
    Low tsh – 0.09
    Free t3- 0.7
    Free t4 – 2.7
    Was on 100 mcg levothroxine..now taking 75mg Armour
    Symptoms…better…but not great. Endo won’t increase my Armour either…

    Have you hear anything back here?

      Dr. Westin Childs - December 16, 2016

      Hey Michelle,

      Thanks for sharing. As mentioned in this article if you treat based on the TSH you most likely will not feel optimal for the many reasons listed above.

Dhyanna - November 25, 2016

Dear Dr. Westin,

HELP I have almost non existent TSH with low normal FT4 and FT3 with lots of low thyroid symptoms and no high thyroid symptoms and I am underweight. I discovered I had mercury poisoning in 2003 and have had my amalgams out and have done chelation with Liquid Zeolites. I was diagnosed with Hashimoto’s in Sept of 2016 but probably have had it for a long time.

Tests TSH
1999 10.2 (2 months later 6.88)
2004 .01
2007 70.431
2013 .01
2015 .08 (8 months later .02)
2016 <.015

I have had chronic hives for over 20 years
In 2003 I was tested for Mercury, my results 75, toxic dose 3
I used Aminophylline cellulite cream and broke out in hives that week
In 2003 I broke out in open sores all over my body for 2 years the day after a perm on my hair (have had many perms until then), this is when I did the chelation and had the mercury out of my teeth.
/Chronic fatigue, restless leg, food sensitivities, chronic sinusitis, dry skin, colder than the elderly, high cholesterol, (2003 had a live blood cell test – sluggish immune and lymphatics.), decreased stamina, low grade fever mostly under control, low blood pressure, insomnia, mental fogginess

I have been on bioidentical hormones since 2007, recently I have decreased -he estradiol and testosterone that were a little high.

The biggest problem I have is finding information for a non existent TSH and Low thyroid symptoms with Hashimoto's and low normal FT4 and Ft3.

My question is, would you consider putting me on low thyroid meds if my tsh is non existent with no high thyroid symptoms, but many low thyroid symptoms.

I do hope you can help,

thank you so much, Dhyanna Goulet

    Dr. Westin Childs - November 25, 2016

    I think I mention in this article but yes, you can suppress the TSH with T4 but that doesn’t mean you are converting or increasing cellular levels of thyroid hormone. Patients routinely come to me with a suppressed TSH and if necessary I will increase the dosage or change around the ratio of T4/T3.

Maura Gallagher - December 15, 2016

Dear Dr. Childs:

I have been reading your articles on thyroid disease and want to congratulate you for your great contributions to helping patients get the help they need. I feel completely abandoned by the healthcare community and this is why. According to my mother, who is now passed, in 1947 I was tested for Thyroid disease two days after I was born and the doctor discovered a lump on the left side of my neck. The test was negative and it was determined I did not have thyroid disease. Six weeks later, the lump had grown and my mother developed a breast infection from nursing me. The lump was incised and drained. Fast forward to 2016, I suffered all of my life from related thyroid diseases — too many to go into now. When I was sixty-five and admitted for yet another incident (17 all together) paralysis of my facial muscles, a liver specialist found nodules on my liver and said he had a hunch. He ran a full profile of thyroid testing and after said “Hasn’t anyone ever told you were “hypothyroid”? I am still suffering despite the endocrinologist testing that determined I should be on 100 Synthroid. I can’t research for one more doctor to help me . . . I have been around the world with them. I rely now on posts like these to help me. Thank you.

Dhyanna - December 15, 2016

Dear Doctor Childs, I appreciate getting these updates but I have never found any articles describing what the problem is when the TSH is <0.05 and I have low thyroid symptoms. I had mercury poisoning and probably still do to some extent even though I have done chelation. I had a new doctor when I got on medicare and she took me off thyroid meds. I have high Lead also. I was diagnosed with low thyroid years ago and was on Armour thyroid but now my doctor does not want to give me hypothyroid meds because the TSH is basically non existent. Unfortunately, I cannot find any info for my situation, non existent TSH…

I actually don't have high hopes to get the answer, it's been a long road to hoe…I don't want to give up, especially because I just got married last year at age 67, but the low sex drive (use to have high sex drive) is a major bummer. And being so cold all the time with many other symptoms of hypothyroid.

Thank you,


    Dr. Westin Childs - December 15, 2016

    Hey Dhyanna,

    This isn’t uncommon at all, I have many patients who present to me with a low TSH level but still remain symptomatic. It’s usually a combination of the wrong medication, high levels of reverse T3 and/or other hormones contributing to hypothyroid symptoms.

      Dhyanna - December 16, 2016

      Dear Dr. Childs,

      I’m very glad that someone is familiar with this, thank you. I’m not on any thyroid meds
      I have never tested the Reverse T3
      I do use Bio-identical hormones and recently the testosterone and estradiol were high and consequently have been lowered.

      However, I am pretty sure that it is quite complicated with me, since I have had serious Mercury poisoning, have suffered with Hives for over 30 years, and for two of these years I had open sores all over the trunk of my body. The hives are better but I still get them often.

      What I am concerned about is being on thyroid meds (Amour thyroid)for my hypothyroid symptoms. From what I understand,taking meds for low thyroid can support my Hashimoto’s disease so it doesn’t get worse and so it doesn’t progress too far and then be unable to heal at all.

      My doctor would not give me hypothyroid meds because my TSH was so low. She is afraid that I will end up with too much thyroid even though the only high thyroid symptom I have is the outer third of my eyebrow is gone. It makes sense to see a specialist, the right specialist. Not sure I could afford one, however, where there is a will there is a way.

      I guess the question is, what do I say to my doctor so she will understand. She does deal with Cancer and Autoimmune diseases so she is up on a lot. Of course I wouldn’t want to have too much thyroid either, but I’d love to get some help with the low thyroid symptoms. I asked her for a trial of hypothyroid meds and she said “No”.

      Thank you for answering my last message, hope I get lucky again…

        Dr. Westin Childs - December 16, 2016

        Unfortunately you will never (well, maybe 0.1% chance) get your Doctor to change their opinion on prescribing medication so it’s generally not even worth the trouble. Your best bet is to find someone who is more knowledgable about thyroid function and hormone balance in general, that will make things to a lot smoother for you.

        If you spend some time reading comments on here you will find that your question has been asked many times over. If you read through them you will see the frustration of many patients as they go through the same thing you’re going through.

Jen - December 15, 2016

My TPO was over 1000 a year ago, my TSH is now 7.9, just been put on 50mcg of Levo 2 1/2 weeks ago. How long until I feel better? My T4 was 9. Thanks

    Dr. Westin Childs - December 15, 2016

    Hey Jen,

    It depends on dosing and a number of other factors, levothyroxine may not even be the best medication for your body so you may not get any improvement.

Sandra Perrier - December 29, 2016

Hi Dr Childs

My test results are as follows

Thyroglobin Antibodies <1

Thyroid Peroxidase Andibodies 1

T4 Free 1.0
T3 Free 2.7
T3 Reverse 12
TSH 0.96
Leptin 21.6
Iodine 32

I have been on bio idendical hormones for 3 years now since my partial hysterectomy, all my symptoms are under control, sleeping 7-8 hrs, no night sweats etc..but I gained 50 pounds and NOTHING will make the weight come off! i am not gaining,cause i am constantly on a form of diet. I bloat even after drinking water, so i do IF daily it helps, my hair is thinning and falling, My question to you is its obvious i am Hypo, I saw your video on Phentermine, do you think with these #'s i can ask my hormone Dr to put me on Armour, and phentermine and I am also aready on bio testoterone. My only issue is the weight! Please and thank you!

    Dr. Westin Childs - December 29, 2016

    Hey Sandra,

    You can ask your Doctor to change your medication but more important than the type of medication is the dose, so if they aren’t familiar with dosing it likely won’t help with weight loss.

Celena - January 5, 2017

I would say I have a lot of the symptoms of hypothyroidism or Hashimoto’s at 24 years old: 60-70 lb overweight (gaining steadily for the past 10 years) and have found it impossible to lose weight, recent episcleritis once in one eye, chronic urticaria for the past two years mostly controlled with 3x daily dose of Zyrtec, fatigue, muscle cramps (feet and hands, recently back), joint pain and stiffness (doctors have always suggested going to a rheumatologist because of a lot of joint issues but never actually referred me so I have not gone), menorrhagia, coarse and dry hair, hair loss, forgetfulness, depression. My TSH levels two years ago were 2.0 mIU/L. I have also had thyroid levels checked before but I do not know if T3 etc where checked. This 2.0 level seems borderline but my doctor disagrees because the lab has a 0.4 to 4.0 normal range. Would you recommend asking again? And if so, what should I say? I do not have the option of going to a different doctor.

    Dr. Westin Childs - January 5, 2017

    Hey Celena,

    Unfortunately there is very little you can do in the way of convincing your Doctor to run the right tests or to treat you correctly. If you poke around the comment section of this blog you will see numerous people who have tried without success. The single best thing you can do for your health is to find a new provider to help you further (one that knows and understands this type of information) even if it means paying out of pocket.

      Celena - January 5, 2017

      Do you have any references or literature showing that TSH alone is not effective in diagnosing hypothyroidism? I am trying to go back with papers or literature rather than anecdotal information off of blogs etc. As a graduate student, I have a student health services system that will not allow me to go to another provider without a referral and I do not have the money for paying out of pocket.

        Dr. Westin Childs - January 5, 2017

        Pretty much anytime I make a claim in an article I will source the claim so relevant links will be in the body of the content itself.

        There are others in the comment section of the blog who have tried to bring literary sources to their provider and most of the time it is not met favorably. There is a lag time of about 17 years between research and clinical action and the reason for this has to do with how physicians are trained and really highlights that they are unwilling to change their practice (even in the face of evidence). It certainly doesn’t hurt to try, however.

Ash - January 26, 2017

Dear Dr Childs,

I wish to discuss my case with you. Hope you can provide some advice. I will write in detail, is that ok? Briefly, I has diagnosed with sub acute thyroiditis in December 2015. Am I okay to write to you in details of my circumstances.

thank you


    Dr. Westin Childs - January 26, 2017

    Hey Ash,

    You are welcome to share your case if you’d like but I can’t give you any medical advice because we don’t have a doctor patient relationship.

      Ash - January 26, 2017

      Do you mean you will read but not comment on where I stand or what I should do? How do we establish a doctor patient relationship? ☺

Kaybee - February 8, 2017

Dear Dr. Childs,
Thanks for usefull info. Im from Malaysia. My lab test in october 2016 as followed: TSH 1.00, FT4 12.9, FT3 3.8 and My TPO antibodies is 541. I experienced hypothyroid symptoms which included hair fall, weight gain, intolerant to cold, forgetfullness as well as muscle spasm. At this moment no dr can answer my question and i left untreated. Please give an advice..Thanks

    Dr. Westin Childs - February 8, 2017

    Hey Kaybee,

    The best thing you can do is find a physician who understands what I’m talking about here so you can get help. You will never be able to convince conventional doctors that their is a problem.

Julia Smith - March 3, 2017

I have just come across your post whilst looking up thyroid info on the web. I am in the U.K. So am lucky to have free NHS treatment but I do see that different doctors vary wildly in how they interpret test results. I started my problems in the mid 1990’s when I dropped so much weight everyone was convinced I was anorexic yet I was eating vast amounts of food. I also had a very fast pulse (140bpm at rest) I got pregnant with my second child in 1995 and was in and out of hospital throughout with early contractions, both me and baby weren’t gaining weight and I wasn’t sleeping etc. I haemorrhaged after giving birth to a healthy boy but I just seemed to feel ill all the time, hand tremors, sweating profusely, racing heart, weight loss. I then lost my voice and my eyes were protruding so my GP decided to check my thyroid. I cannot remember the results but the doctor said I had a very overactive thyroid, higher results than he had seen before and referred me urgently to an endocrinologist. I was diagnosed with Graves’ disease after full screening including antibody tests. They wanted to treat with either an operation to remove the thyroid or radioactive iodine but I declined both due to aging two small children and a husband with leukaemia so my hands were full. I started taking carbimazole and beta blockers but carbimazole didn’t suit me so then took propylthiouracil. I reached a time where I just knew I didn’t need them so stopped taking them. Several months later I saw my endocrinologist who was unhappy I had stopped taking them until he saw my blood results and agreed I was in normal ranges and was having no symptoms. He discharged me with a warning I would develop problems in the future.

We have a strong family history of autoimmune diseases in the family (my mothers side) including Graves, vitiligo, crohn’s and myasthenia gravis and all have been severe cases – my mum and aunt are identical twins and collapsed on the same day – mum didn’t make it but aunt did and was diagnosed with MG which left her on a ventilator – she is doing well now with plasma exchanges and other treatments and is home. My son is awaiting tests to see if he has crohns as he passes lots of blood and mucus several times a day, diarrhoea, mouth ulcers, weight loss – unfortunately the waiting time on NHS for tests is 4 months!

Four years ago i started gaining weight for the first time in my life, I was having to watch what I ate and still was gaining weight, my abdomen was bloated, I started needing a lot of sleep, even having to pull over from driving to take a nap, I was so cold all the time, my menstrual cycle got heavy and painful, my lovely nails became brittle with ridges, my hair became dry and thinned, my blood pressure was low as was my mood, my vision deteriated, my memory was shocking, no sex drive at all and I ached all over. I didn’t tell my doctor all this for awhile as thought with so many random problems, he would have had me down as a hypochondriac- I never thought they could all be connected. Eventually a new doctor ran blood tests and diagnosed under active thyroid and I was referred back to an endocrinologist and they put me on Levothroxine. I got lucky and he treats the symptoms not just the blood results so the dose was raised over time, even when my TSH got down to 2.5 he raised the dose further to 100 mcg as I was still having the symptoms. My TSH then stabilised at 0.88, other tests also stabilised but can’t remember numbers and I felt well. He told my GP I am biochemically euyroid when TSH is less than 1.0 For a few years all has been good until a few months ago when I started eating less but gaining weight, feeling tired and cold all the time. I even had a heater under my desk whilst others were complaining of the heat. My hair has started falling out and my hairdresser has had to cut a lot off to help it look better, nails are a mess again, menstrual cycle is heavy and painful again, I ache all over and breasts hurt and have lumps in them (moveable thankfully). Went back to doctors but could only see nurse practioner (nightmare getting doctors appointment these days) she ordered TSH but not T3/T4 tests. blood results of TSH back today 1.85 so they say normal even though I have all the symptoms and endocrinologist said to keep it below 1.0 now got an appointment to see nurse again on Monday (no doctors appointments available again)

I wish all doctors/nurses would realise no two patients are the same and treat the symptoms not just the blood tests!

Julia Smith - March 3, 2017

Great article! Very informative. I understand general practioners aren’t specialists In all fields. I just wish they would accept this themselves and instead of going straight off lab results and treating/not treating accordingly, they would listen to the patient who knows their own body and refer them to a specialist for treatment to sort out so that the person can be treated well by a specialist and subsequently be discharged healthy. Then if the patient returns and says the problems have reoccurred, the general practioner should listen and refer them back to the specialist. It shouldn’t be difficult to get treatment to live a normal life when the treatments are readily available.

Molly Scanlan - March 19, 2017

I have Ra. Last year my tsh was .74. I have been exahused, cold. My body temp is now 7.5 instead of the usual 7.78. Snd mt tsh is now 2.37 with a free t4 of 1.49. Nobody believes i might have a thytoid proplem. Even when i pointed it to my rheumatologist she still said Its stll within normal limts. Drs. Dont even listen to u. They just look at your labs in isolation. They notice trends. My wbc and diff has changed dramatically from what it was in the last five years. But it is almost in normal limits. I am going to see a rhematoligist at the Cleveland clinic in 3 weeks. Would they be bright enough to pick up on this? If not who can i see to help me. Thanks, Molly

    Dr. Westin Childs - March 19, 2017

    Hey Molly,

    No, most likely not. Places like the mayo clinic and the cleveland clinic will pretty much tell you the exact same thing that your primary care/endocrinologist tell you. Your best bet is to look outside of the insurance model, or find someone who has a more functional/integrative/anti-aging approach to hormones.

Jill - April 14, 2017

So very helpful!! I’ve been on this roller coaster for some time now. My emotions are out of whack! I’ve had what feels like a lump in my throat (no masses) just this feeling on heaviness. I’m tired, angry, emotional, cry for no reason, exhausted, run down, can’t focus…..I’ve been searching for something like your article to help me. Thank you so much for this information!!! My current TSH is 1.08 and I get the same “it’s in the normal range” answers all the time, yet I still feel crappy! I looked back at my TSH results and in 2015 I had 2.28 levels and I weighed less than I have for a long time & I was super active!

Thank you for your amazing article!

    Dr. Westin Childs - April 14, 2017

    Hi Jill,

    No problem and I hope it helps.

      Jill - April 18, 2017

      Good Morning Dr. Childs!
      I received my thyroid test results this morning from my Dr. My TSH is .55, my Free T3 is 2.3, and my T4 Total is 6.2. My Dr. is saying they are all in the “normal” numbers, but I feel like crap! Your thoughts on my levels?


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