June 13, 2014

As a functional medicine practitioner, I help you see the whole picture. Symptoms are simply symptoms – a symptom of a larger issue. Let’s take a step back to figure out where these symptoms are coming from and to address the body as a whole.

I teach each of my patients the physiology of what is going on in their system. Once they understand this to the degree that they can explain it to their friends and family members, this motivates them to work on things because now, it makes sense to them. They are able to connect the dots between what is happening between their system and their symptoms. With this in mind, let’s talk about thyroid labs. I want to help arm you with the information that you will need to have an in depth conversation with your doctor about the health of your thyroid.

When testing thyroid, the lab results can be confusing. Mainstream medicine and alternative medicine do not see eye to eye with references ranges, medication or even diagnosis.

Let’s talk about thyroid function:

  •  The pituitary gland releases TSH thyroid stimulating hormone and it does just what the name implies – it stimulates the thyroid gland to produce a hormone called T4.
  •  T4 circulates in the body and converts to hormone T3
  •  T3 is the active hormone that is absorbed by ALL the cells and tissues in the body

Functional Medicine Thyroid Diagram Clean and Lean Revolution

When testing thyroid, doctors often look at TSH (thyroid stimulating hormone) levels first. Earlier you heard me say that the pituitary gland releases TSH “thyroid stimulating hormone.” When looking at TSH we are looking at the function of the brain and not the function of the thyroid.

Your TSH level is then referenced against a standard range.

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The reference ranges created for labs are not that scientific – for TSH they took a large group of people and tested TSH and created a bell curve with the results. When you are tested, your results are compared to this bell curve. This reference range is flawed because they did not delete people that had a KNOWN thyroid condition NOR people that have unknown or undiagnosed thyroid issues. The typical lab range using this bell curve will show a range for TSH of 0.5 – 4.5. If your TSH comes back at 4.2 your doctor will likely say that you are in range. But, are you? What if you have symptoms?

You are either within range and only sick and diagnosable if you have stepped over the reference range by .1.this is a much narrower range. This is the range that your TSH should be compared to. To correctly read a TSH range, the larger the value the more hypo-thyroid you are. The lower the value (often dipping into the negative) the more hyper-thyroid you are. So, if your TSH comes back at 4.4 and you have the classic hypothyroid symptoms, you are currently in a hypothyroid state.

Another issue with testing TSH is that it fluctuates a lot – one study showed that it needed to retest TSH 100 times to get an average marker. This does not mean that this isn’t a useful marker. Simply make sure that this is not an isolated occurrence – if your TSH is off once, this isn’t a cue to medicate UNLESS there are very telltale symptoms present. Treat the patient and not the lab. Are their symptoms?? Dry skin, thin brittle hair, insomnia, fatigue, cold, constipation…. These are all symptoms of hypo-thyroid.

I have had personal experience with this. My routine labs returned a 7.25 TSH, which would make me very hypothyroid using both allopathic and alternative measures. My doctor was poised with the prescription pad. I had NO symptoms. While trying to convince me to medicate, the doctor even said, “Let’s medicate you – you will have so much more energy.” If you knew me personally, you would laugh at this. If I had more energy I would literally spin off the earth. I requested a second lab to confirm this. The second lab came back at 4.9 TSH.

These two labs were taken in a 48 hour period and both in the morning. If I had symptoms and my TSH was 4.9, I would have been open to the conversation to look at this further. Since I didn’t have symptoms and I am otherwise in good health, I simply test this each year and look at these markers with interest. Again, treat the patient and not the lab.


TSH is one marker to test. What are the other markers? Remember that TSH is released by the pituitary gland, which stimulates the thyroid to release the hormone T4. T4 converts into T3 and T3 is the active hormone that is absorbed by every cell and tissue in your sytem.

The other thyroid test markers are Total T4 and Total T3 and Free T4 and Free T3– All of these markers are hormones. Hormones are fat soluble and blood is mostly water. In order to be transported in the blood these hormones need to be bound to a protein. In order for this hormone to enter a cell, it needs to be cleaved from the protein. Once it is cleaved from a protein it is now ‘free.’

So, Total T4 and Total T3 tells us how much TOTAL bound and unbound T4 and T3 there is in the body. Total T4 is telling you how much thyroid hormone is being produced by the thyroid gland – this is important info to have. Over 90% of the hormone produced by the thyroid gland is T4.

If you have a normal Total T4 and normal Total T3, the problem isn’t that the thyroid isn’t producing hormone, it is that there is an issue cleaving the bound hormones and/or using the free hormones.

If you have high Total T4 and low Total T3, you may also want to look at another thyroid marker called RT3 or reverse T3. T4 can convert to T3 and at times of stress (whether from everyday life stress, trauma, chronic dieting, environmental toxins, ongoing low grade infections or a side effect from certain medications) T4 converts to Reverse T3. Reverse T3 sits on the binding sites for T3 and does not allow the active T3 hormone to bind and do its job.

If you have low T4, then the thyroid is not producing enough T4. You will need to look at the specific key nutrients needed to support healthy thyroid function: like iodine, iron status, assess that you are producing enough stomach acid to convert plant based iron into the absorbable form of iron; you need adequate amounts of selenium, zinc and cofactors that we get from vitamins A, C, E and the amino acid tyrosine. You should also address your gut health. Why gut health? Because around 20% T4 is converted into T3 in the gut. Yes, EVERYTHING is related to the gut!

Free T3 and Free T4 are arguably the more important labs to run because Free T3 is the hormone that is available to the cell to use. The majority of allopathic doctors do not run these labs. They look at TSH and Total T4 and Total T3 and that is it. Another good point to make here, is that allopathic docs don’t look past this lab because they wouldn’t change their intervention. There are two synthetic thyroid medications that are widely used, across the board, with the idea that they can treat EVERYBODY. And this simply is NOT the case.

TAKE HOME MESSAGE – please do not go out and start to over supplement with anything that I just listed out. It is important to work closely with a functional medicine practitioner to assess which pathway within the thyroid matrix needs to be addressed and then to work to bring this back into balance with a custom approach that addresses your individual needs.

I am going to leave you with one more recommendation:


If you have been diagnosed with a hypothyroid condition, then you must insist on also having your thyroid antibodies tested. This is the MOST common cause of hypothyroid in the United States. Over 90% of hypothyroid diagnosis is due to an autoimmune condition called Hashimoto’s. Sounds like a scary word and it is not. This is simply the name of the doctor that discovered this. If your body is producing antibodies to your thyroid, this antibody tests will come back positive. The therapy for this is medication AND you’ll need to address the autoimmune condition; doing everything that you can to reduce inflammation in the body. This include addressing gut health, removing known food sensitivities/ allergies, addressing stress, getting plenty of rest and leading an active lifestyle.

Hashimoto Hypo-Thyroid Clean and Lean Revolution

When you ask to have your antibodies tested, you may get some push back. A patient of mine requested an antibody test and the nurse said, ‘what would you change if that test came back positive?’ My patient said that she didn’t know. The nurse said, “Exactly – nothing would change” so she didn’t do the test. This is simply not true. First, if you had an autoimmune condition, wouldn’t you want to know it? Wouldn’t you want to know that you need to double down on living a healthy lifestyle and that you need to address inflammation as much as possible? Wouldn’t you want to know that just because you have a diagnosis of hypothyroid and you are given a medication, that you may not recover your symptoms because you are not addressing your autoimmune condition at the same time?

Wouldn’t you want to know that once you have an autoimmune condition, that you have an overactive immune system and you are more prone to getting a second autoimmune condition?

The patient I just mentioned, who was denied antibody testing by the nurse, was finally tested for antibodies and she did turn out to have Hashimotos, in fact her antibodies levels were incredibly high. Once this was identified, I put a program in place that addressed both hypothyroid AND the autoimmune condition and she went from 232 pounds to 142 pounds within eight months. As always, knowing the bigger picture is the best approach to treating a condition.

Angela Pifer is a Functional Medicine Nutritionist and Licensed Certified Nutritionist with a Master’s in Nutrition out of Bastyr University. She has been a practicing nutritionist in Seattle for over a decade. You can work one on one with Angela if you live in the Seattle area through her private practice www.NutritionNorthwest.com (she also works long distance via Skype).

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from 15 people


Hi Angelika,
I do apologize for the delay. Sometimes my blog post replies suffer a bit as I am working more with my private practice patients. I did just graduate a few patients and have now reopened for new patient appointments. I absolutely work long distance via Skype video. If you are still searching for a practitioner to work with, I recommend reaching out through scheduling http://www.nutritionnorthwest.com/contact/ I hope that the testing showed favorable results. I look forward to meeting you.



Angela | July 23, 2016


HI Angela
just found your interesting approach to thyroid issues, i am lightly hypo
and take treatment nature thread 1/2 grain, but i have two nodules, one right , one left side, the endocrinologist just runs a tsh checkup which i assume is not enough, and the ultrasound again next week to see if those nodules grew in the meantime. i live in connecticut, i do not know if you might consider long distance Skype consultations and if that might work,
i am searching for a more holistic approach and healing to all this.
thank you

Angelika | November 10, 2015


Hi Michelle,

I hear this story so many times. I am sorry to hear that you are struggling with this. When you say Levo you may be referring to levothyroid or levoxyl - both offer synthetic T4 only. They are synthetics. Most people with Hashimotos do better on synthetics than on the bioidentical, because the body will see the biodentical as 'self' and it may amplify the autoimmune reaction. You may be reacting to other ingredients in the medication. Depending on the dose that you are taking, both medications have blue, red or yellow dye, aluminum lake - red and blue are the most excito-toxic of the dyes.

That said, having a TSH in range (depending on what range it is in - standard medical range or functional range) does not mean that this issue is fixed. The main focus with Hashimotos is to address the autoimmune condition (and assess for others - these often come in pairs - like Celiac) and to see which thyroid pathways need to be supported. Further testing will let us see if you are having an issue with T4 to T3 conversion, if your thyroid binding globulin levels are too high (T4 is staying bound and not 'freeing' to convert to T3), if there is an issue in the liver and gut (this is where the vast majority of T4 is converted to T3).

There is a LOT to assess and consider here. TSH will never tell the whole story. I work extensively with thyroid and autoimmune. I am happy to work with you. I will have my assistant Sophia reach out to offer you an appointment.



Angela | November 7, 2015


I was diagnosed with Hashimotos in March. I have put on 20 pounds and have always had to watch everything I eat fron the time I was in high school. I know my thyroid antibodies were very high and have been over the last few years yet noone seemed to notice! I have very little energy and am greatly depressed. The endo put me on the lowest does of levo but based on my research, I read that Hashimotos patients should not take generic levo? Correct me if I am wrong. I pushed to be put on Tirosin. I started therapy on levo in May. Oddly enough, it is after I started levo that I gained most of the weight. Needless to say...I feel like heck and pushed for them to up my dose to no avail. They said my TSH was in range. Is there any way that I can do a one on one with you? Also, I was trying desperately to lose weight on Medifast and lost nothing on it! Please let me know.

Michelle M | October 31, 2015


Hi Vibeke,

I am sorry to hear that your sister is struggling with Hashimotos. Pregnancy can often trigger shifts with an autoimmune condition. In a healthy individual we have a balance of TH1 and TH2 immune pathways - one should not be more dominant. During the third trimester, the body shifts into TH2 dominance to protect the baby (so our body does not attack it as foreign). Post partum, the body shifts into TH1 dominance and then it takes a few months to shift back to a more neutral spot. Depending on the autoimmune condition - some are TH2 dominant and others are TH1 dominant - so pregnancy can make things worse or better, depending on what she has.

I do work internationally with patients (yes, via Skype) and I am happy to work with your sister. Please have her reach out directly to scheduling@SIBOGuru.com and Sophia will share the next available appointment times.


Angela | November 7, 2015


My sister has just been diagnosed with Hasimotos with extreme high antibody numbers, gaining weight since the birth of her first child 22 years ago. Now she know the problem after all these years being overweight, sleeping very poorly and retaining water in in her body, but what would you recommend as a plan? Sound like you had a good plan for the woman you mentioned loosing so many pounds....do you take clients from europe? Skype maybe?

Best regards,

Vibeke | October 26, 2015


Hi Nancy, If your thyroid function (numbers) is in the normal range and you are not experiencing any symptoms, then I would not see any reason to treat this with thyroid medication. I do wonder, what prompted the testing of thyroid antibodies in the first place? If there was a reason to look at this, perhaps there is something (symptoms/ change) that provoked the need to have this test done.

If not, my best advice is to pull gluten and address the autoimmune piece by OVERLY focusing on stress reduction, self nurturing and get plenty of sleep.

I would then retest the antibodies in 3-6 months to see where they are at. These should shift down if the body is being taken care of.

Treat the patient and not the lab!


Angela | September 6, 2015


Hi my name is Nancy. I just found out I have Hashimotos . I have great tsh and free t4 and I feel great never thought I had anything wrong what do I do take med

nancy | September 5, 2015


Hi Carolyn,

You can meet with an endocrinologist, a naturopath or a functional medicine practitioner to work through this. Each will add something different, in the way that they practice. If you thyroid numbers are in range, then it may be time to look for other reasons that this is happening. Stress, sleep disturbances, blood sugar imbalances, adrenal, gut inflammation. Reviewing your health history and current symptoms set will give the practitioner the direction that they need to support you.



Angela | July 23, 2016


I am being treated for low thyroid but I'm still not able to lose weight. Is a encrinlogist the one one I need to check for immune problem?

Carolyn Shoemaker | July 31, 2015


Hi Sarai,

Treating autoimmune means that you would need to address the oxidative stress and inflammatory load that is on the system and work harder on healthy habits and lifestyle routine. Getting 8 hours of restorative sleep, eating whole foods consistently, moving and thinking well - supporting the body in an even more diligent way to lessen the burden so the autoimmune condition is not consistently being triggered and made worse and setting you up for another autoimmune condition (these often come in pairs). Gut healing, rebalancing... pulling gluten is a must.



Angela | June 26, 2015


I am getting a requisitions at my next dr's appointment to get my thyroid antibodies checked. I was told when I first was diagnosed with hypothyroid that it was Hashimoto's but I don't know what my antibody levels were. What kind of diet or treatment do you suggest for treating an autoimmune disorder?

Smsincanada | June 16, 2015


Hi Sonali,
I just followed up privately with you - please let me know if you did not receive it.


Angela | February 9, 2015


I suffer from Hashimoto's. I would like you to be my Functional medicine nutritionist on a one on one basis. I am living in Nairobi Kenya.
Can we first hv a Skype meeting to connect and see how we can work together.

Sonali | February 9, 2015

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