As if experiencing fatigue, weight gain, brain fog, and generally feeling awful are bad enough on their own… going to a doctor and being told everything looks fine, or worse yet, it’s all in your head (doctor code for “I don’t know what’s going on”), only adds to the despair and confusion to the nightmare you are already experiencing.
Your experience is valid. And your symptoms are not because you are lazy or depressed. This article will cover why you can still feel hypothyroid even with normal thyroid labs, and along with what you can do to finally feel great and lose weight.
Normal Thyroid Labs Doesn’t Mean Optimal
Conventional medical providers typically only test thyroid stimulating hormone (TSH) and T4 thyroid hormones. If they are abnormal, they may not ask why and test for thyroid antibodies to see if it is due to Hashimoto’s.
Since knowing the cause doesn’t change the treatment, they tend to use a one size fits all approach of thyroid hormone replacement . As a result, thyroid antibodies and inflammation markers aren’t even monitored .
If your thyroid labs are within the normally accepted ranges, there are legitimate reasons that you can still feel awful.
Aside from autoimmunity, many factors can concurrently affect thyroid hormone function without changing your TSH and T4. So, consider the following if you have “normal” thyroid levels but still have hypothyroid symptoms.
Why Normal Thyroid Tests Don’t Give a Full Picture
The word “normal” lab test comes from the Normal distribution or a bell curve. Each lab determines this by picking the middle 95% of the healthy (undiagnosed) population that they test in the region. But given that almost half of Americans are diagnosed with a chronic disease and many of them feel crummy anyways , the middle 95% is anything but healthy.
TSH is the first test doctors will run to screen out thyroid problems. The normal range is 0.5 to 5.0 mIU/L. If it’s in this range, most conventionally trained providers will say your thyroid is normal.
Studies show, and the experience of functional medicine practitioners confirm, that optimal TSH is somewhere between 0.5 mIU/L and 2.5 mIU/L [4,5].
When TSH levels start trending toward 3 mIU/L and above, many women will begin experiencing hypothyroid symptoms. Yet, they’re told their thyroid is fine.
To understand why “normal” thyroid results don’t give a full picture, let’s first understand all the players in your thyroid axis.
In your brain, the hypothalamus secretes the thyrotropin releasing hormone, which stimulates the pituitary to release TSH. TSH then stimulates the thyroid to produce and release the thyroid hormone T4. To travel in the bloodstream, >99% of T4 and T3 are bound to a protein called thyroxine-binding globulin, while the <1% are free to work. Once the free T4 reaches its target tissues, it gets activated into T3 in other tissues including your muscles, gut, and gut bacteria .
The activated free T3 can then bind to your thyroid hormone receptors, ramping up your metabolism and mitochondria (your cell’s energy factory). The following are problems that only a full thyroid panel can reveal.
Low free T3
Anything that lowers T3 or free T3 can lower your thyroid function. This may include insufficient thyroid hormone activation in tissues.
Many micronutrients such as selenium and zinc are essential to activate thyroid hormones .
Some women don’t only have autoimmune attacks on their thyroid but also the inability to activate thyroid hormones . So, it’s a good idea to ask your doctor about checking for free T3 and adding a T3 medication.
Elevated thyroxine-binding globulin
Aside from hypothyroidism, the following factors can increase thyroxine-binding globulin, which may reduce free T3 and T4 :
- Liver disease
- Estrogen medications, including hormone replacement therapy
- Hormonal birth control
- Other medications
Stress and inflammation interfering with the thyroid axis
Your stress response goes through the hypothalamus and pituitary, which also produce TRH and TSH, respectively.
Stress can reduce TRH and TSH, so you can have artificially low TSH that falls in the normal range. At the same time, stress can reduce thyroid hormone levels and the conversion of T4 to T3 .
Worse yet, stress and inflammation increase reverse T3 (rT3), the mirror image of T3. rT3 can block T3 from working, overall lowering thyroid functions .
Inflammation can also inhibit the hypothalamus and mitochondria, overall lowering metabolism and thyroid function.
Now that you understand why you still have thyroid symptoms despite normal thyroid labs, let’s talk about how to feel optimal and lose weight.
How to feel optimal and lose weight with Hashimoto’s despite normal thyroid labs
Work with a functional medicine doctor to address the whole picture
Functional medicine uses tests that can reveal dysfunctions in your thyroid and stress response axes, such as the full thyroid panel and 4-point cortisol test. But to treat you as a whole person and not as numbers, your practitioner should help you identify root causes in your current diet, lifestyle, and history. By addressing the root causes, you can optimize your thyroid conversion and functions.
Here is the list of labs in a full thyroid panel. Note that normal ranges can vary from lab to lab, or even region to region.
|Test name||Abbreviation||Normal range ||Optimal range||Unit|
|Thyroid-stimulating hormone||TSH||0.450−4.500||.4-2.5 ||μIU/mL|
|Total Thyroxine (T4)||tT4 or total T4||4.5−12.0||4.5-12 ||μg/dL|
|Free Thyroxine||fT4 or free T4||0.82−1.77||.6-1.2 ||ng/dL|
|Total Triiodothyronine||tT3 or Total T3||71−180||71-180 ||ng/dL|
|Free Triiodothyronine||fT3 or free T3||2.0−4.4||2.0-4.4 ||pg/mL|
|Reverse Triiodothyronine||rT3 or reverse T3||9.2−24.1||9.2-21.1 ||ng/dL|
|Serum thyroxine binding globulin||TBG||13−39||14-31 ||μg/mL|
|T3 Resin Uptake||T3RU||24−39||23.4-39 ||%|
|Thyroid peroxidase antibodies||TPO Ab||0−34||0-34 ||IU/mL|
|Thyroglobulin antibodies||Tg Ab||3-40 ||0-40 ||ng/mL|
Aside from autoimmune attacks on your thyroid, inflammation can make you feel awful despite having a normal thyroid, so you want to also keep track of the inflammation.
Joint pain, brain fog, midsection weight gain, and depression are inflammatory symptoms. But there are also a handful of labs that can objectively measure your whole-body inflammation.
High sensitivity CRP (hsCRP) is an ideal blood marker to monitor chronic inflammation levels. It is commonly used to assess heart disease risk. However, the results are relevant to monitoring inflammation in general. The lower your hsCRP levels, the better. The results come in three tiers, rated as cardiovascular risk. Maintaining hsCRP levels as low as possible is ideal.
|Complete Range||Heart Disease Risk|
|0-10 mg/L||Low: <1 mg/L||Average: 1-3 mg/L||High: >3 mg/L|
The labs below are also markers of inflammation, usually of higher, acute levels. People experiencing uncontrolled autoimmunity will often have elevations in these prior to treatment, which is used to help make the diagnosis. Optimal results are within the normal reference range.
|Test name||Abbreviation||Normal range ||Unit|
|Erythrocyte Sedimentation Rate||ESR||0−40||mm/hour|
|Platelets ||150 to 400 × 109||Per Liter|
These labs can serve as a helpful gauge for your current inflammation levels as well as to monitor improvements from treatment and lifestyle changes.
Follow an anti-inflammatory diet and lifestyle
Many Hashimoto’s women find that the following changes improve their Hashimoto’s symptoms. Studies also confirm it.
The Autoimmune Protocol Protocol (AIP) is an anti-inflammatory diet that can help manage Hashimoto’s and improve symptoms. It reduces inflammation from food and helps you identify potential food sensitivities that can cause inflammation .
Addressing stress and traumas as chronic stress responses worsens Hashimoto’s. It is essential that you incorporate regular stress reduction practices that work for you. This may include mindfulness meditation, nature walks, and therapy.
Sleep is critical to keep inflammation, stress response, and hormone balance in check, so you want to allocate enough time to sleep and optimize sleep quality.
Exercise and build muscles without overdoing it. Exercise helps balance out the inflammation, while muscle tissues help convert your thyroid hormones [6,25]. Most importantly, building muscles help you preserve your metabolism, making it easier to lose fat. In Thyroid Strong, I’ve guided thousands of women with Hashimoto’s through safely exercising and building muscles. It’s a key part of finally feeling great and losing weight.
Rule out and address other similar or comorbid conditions
Many other health conditions have overlapping symptoms with Hashimoto’s. It’s entirely possible that your thyroid is functioning well but there’s another problem to be addressed.
These health conditions may include:
- Polycystic ovary syndrome (PCOS)
- Pernicious anemia
- Type 2 diabetes
- Iron deficiency anemia
- Chronic infections
- Mold toxins or other toxic exposures
- Other nutrient deficiencies
- Other autoimmune conditions
I know it is frustrating and depressing to know something’s off and be told everything is fine. But the good news is that the power is within you to address the root causes.
In my Thyroid Strong program, I guide you through safely exercising with Hashimoto’s. Along with the exercise program, it also comes with bonuses that will help you follow the Autoimmune Paleo Protocol and stay informed about root causes of Hashimoto’s.
You’ll also join the community of motivated women and receive the accountability you need to successfully lose weight and put Hashimoto’s into remission.
Affiliate disclaimer: This article contains affiliate links, which means that Thyroid Strong may earn a small percentage of your purchases if you use our links and coupon codes, while the prices will be the same or at a discount to you. This income supports our content production. Thank you so much for your support.
1 Clinical Case. (2022, February 1) Hashimoto Thyroiditis Treatment & Management.
2 Clinical Case. (2022, February 1) Hashimoto Thyroiditis Workup.
3 Raghupathi, W. and Raghupathi, V. (2018) An Empirical Study of Chronic Diseases in the United States: A Visual Analytics Approach. Int. J. Environ. Res. Public Health 15.
4 Talaei, A., Rafee, N., Rafei, F. and Chehrei, A. (2017) TSH cut off point based on depression in hypothyroid patients. BMC Psychiatry 17, 327.
5 Henze, M., Brown, S. J., Hadlow, N. C. and Walsh, J. P. (2017) Rationalizing Thyroid Function Testing: Which TSH Cutoffs Are Optimal for Testing Free T4? J. Clin. Endocrinol. Metab. 102, 4235–4241.
6 Peeters, R. P. and Visser, T. J. (2017) Metabolism of Thyroid Hormone. In Endotext (Feingold, K. R., Anawalt, B., Boyce, A., Chrousos, G., de Herder, W. W., Dhatariya, K., Dungan, K., Hershman, J. M., Hofland, J., Kalra, S., et al., eds.), MDText.com, Inc., South Dartmouth (MA).
7 Triggiani, V., Tafaro, E., Giagulli, V. A., Sabbà, C., Resta, F., Licchelli, B. and Guastamacchia, E. (2009) Role of iodine, selenium and other micronutrients in thyroid function and disorders. Endocr. Metab. Immune Disord. Drug Targets 9, 277–294.
8 McDermott, M. T. (2012) Does combination T4 and T3 therapy make sense? Endocr. Pract. 18, 750–757.
9 (2022, May 9) Thyroid-Binding Globulin.
10 Helmreich, D. L. and Tylee, D. (2011) Thyroid hormone regulation by stress and behavioral differences in adult male rats. Horm. Behav. 60, 284–291.
11 Search Our Health Care Diagnostics Tests Menu.
12 T4, Total (Thyroxine). Health Matters. https://healthmatters.io/understand-blood-test-results/thyroxine-t4
13 Free Thyroxine. Health Matters. https://healthmatters.io/understand-blood-test-results/free-thyroxine
14 Total T3. Health Matters. https://healthmatters.io/understand-blood-test-results/total-t3
15 T3 Free. Health Matters. https://healthmatters.io/understand-blood-test-results/free-t3
16 Reverse T3, Setum. Health Matters. https://healthmatters.io/understand-blood-test-results/reverse-t3-serum
17 Thyroxine-binding globulin, TBG. Health Matters. https://healthmatters.io/understand-blood-test-results/thyroxine-binding-globulin-tbg
18 Tri iodothyronine (T3) Uptake. Health Matters. https://healthmatters.io/understand-blood-test-results/tri-iodothyronine-t3-uptake
19 Thyroid Peroxidase Antibodies (Anti-TPO Ab) . Health Matters. https://healthmatters.io/understand-blood-test-results/thyroid-peroxidase-antibodies
20 Peiris, A. N., Medlock, D. and Gavin, M. (2019) Thyroglobulin for Monitoring for Thyroid Cancer Recurrence. JAMA 321, 1228.
21 Llc, H. io. [No title].
22 (2021, June 1) High-Sensitivity C-Reactive Protein.
23 Platelet count. Mount Sinai Health System.
24 Abbott, R. D., Sadowski, A. and Alt, A. G. (2019) Efficacy of the Autoimmune Protocol Diet as Part of a Multi-disciplinary, Supported Lifestyle Intervention for Hashimoto’s Thyroiditis. Cureus 11, e4556.
25 Sharif, K., Watad, A., Bragazzi, N. L., Lichtbroun, M., Amital, H. and Shoenfeld, Y. (2018) Physical activity and autoimmune diseases: Get moving and manage the disease. Autoimmun. Rev. 17, 53–72.