Thyroid Scale Overview
Dr. Rind's Thyroid Scale™ is a method of evaluating thyroid lab data (TSH, Free T4, and Free T3) relative to optimal values as well as each other to provide a clearer view of what is going on as opposed to simply looking at whether lab values are ‘normal’ or not. To get a brief understanding of Dr. Rind’s approach to identifying and correcting metabolic energy problems read his overview on Metabolic Therapy™.
- If My Thyroid Labs Are ‘Normal’, Why Do I Feel So Bad?
- Introduction to Thyroid Hormones
- Introduction to Interpreting Thyroid Tests
- Thyroid Function Tests
- Defining the Thyroid Scale
- Interpreting Results
- Thyroid Scale™: Extracting New Meaning from Labs
- Diagnostic Tool Coming Soon
If My Thyroid Labs Are ‘Normal’, Why Do I Feel So Bad?
When’s the last time you went to the doctor and gave a blood sample – that was then sent to a lab? Chances are that lab result came back ‘normal’. Too often, when interpreting lab values, the doctor looks for normal rather than optimal.
A comparison of values relative to each other yields a great deal of information that would be lost if the values were viewed independently of each other. For example, if the normal height for a man is between 5’3” and 6’ and normal weight is between 130 lbs and 200 lbs., scanning the results column of a lab or other report (for flagged abnormal values) would declare a man who is 5’3” tall weighing 200 lbs to be just as normal as a man 6’ tall weighing 135 lbs. Both are in the ‘normal’ range and therefore would be considered normal. In reality, however, simply looking at a short/obese man next to a tall/thin and a possibly undernourished man would suggest that the two are more than likely not in the same state of health.
Normal rather than Optimal. The frequently used term of ‘normal’ refers to a mathematical or statistical situation. Thus, a ‘normal’ state of health probably means you have some medical problems. It may be normal to die at 76 yrs of age, but at 75 years old, you may decide that what you really want is ‘optimal’ health as opposed to ‘normal’. Normal is not the same as optimal, whether it relates to longevity of life, a body temperature or a lab test result.
Thyroid levels are a critical component of determining the cause of low metabolic energy. The Thyroid Scale™ helps us compare thyroid lab values to each other and thus see their implications more clearly. It can be a line diagram or a table of lab values to visually depict how TSH, T4, and T3 relate to each other. It is an approximation. Nonetheless, as a clinical tool, it seems to be more informative than the alternative which is to call a lab value low, normal, or high. After using it several times, you will probably wonder how anyone can use a term like ‘normal’ to describe a relationship as complex as the one that exists between these hormones.
Introduction to Thyroid Hormones
In order to understand what thyroid lab values mean, we first need to understand what each test means individually and then combine them in a way that makes sense. First let’s get a simplified overview and then we can look at the details for greater clarity.
Gland: An organ that produces hormones.
Hormone: A chemical substance produced by the body in order to perform a job or function elsewhere in the body.
Thyroid Gland: Located at the base of the neck and makes thyroxin (thyroid hormone or T4) which signals the cells to make energy.
Adrenal Glands: Located on top of the kidneys, they make many hormones (Cortisol, DHEA etc.). Their main function is to help us deal with stress or help us survive. They help maintain stability of many bodily functions (physical, emotional, thermal, hormonal etc.). When there is stress (anything physical, chemical, emotional, nutritional, lifestyle such as sleep patterns etc. which causes us to have to adapt), the adrenals need to work. Excessive stress can exhaust them. Thyroid energy in excess of what the adrenals can handle is a stressor to the adrenals.
Pituitary Gland: Situated at the base of the brain (above the roof of the mouth), it sends out instructions to many other glands telling them how much hormone to produce. One such hormone is TSH (Thyroid Stimulating Hormone) which signals to the thyroid gland to make thyroid hormone. The pituitary gland determines how much TSH to secrete (i.e., how much thyroid hormone to tell the thyroid gland to make) based on:
* How much thyroid hormone is available
* How much thyroid hormone the body needs
* How much thyroid hormone the body (actually the adrenals) can tolerate
TSH: Is a hormone produced by the pituitary gland and whose function is to signal the thyroid gland to make more thyroid hormone. It represents the pituitary's need or desire for more thyroid hormone (T4 or T3). Thus a high TSH level is like the pituitary saying it has a ‘high need for thyroid hormone’ or the body can tolerate more thyroid energy than it is getting and it is meant to generate more thyroid hormone production. Conversely, a low TSH reflects either a low need or desire for thyroid hormone or a low tolerance for the thyroid hormone and is meant to reduce thyroid hormone production. An optimal value of TSH means the thyroid hormone levels match the body’s energy needs and/or ability to utilize the energy.
Thyroid hormones: The thyroid gland makes a hormone called T4 (thyroxine). T4 will become T3 (triiodothyronine) which causes energy (in the form of ATP) to be made in each living cell, or Reverse T3 (RT3) which interferes with the energy production in the cell. Just as a car needs an accelerator and brakes for proper function, the same is true for the body. The body needs T3 (the accelerator) and RT3 (the brake) to manage its energy needs.
* T4: Has four iodine atoms and it is a pro-hormone, i.e., it lives to become either T3 or RT3.
* T3: When the body needs energy, it removes an iodine atom from the T4 and turns it into T3 which in turn signals living cells to make energy (ATP). T3 allows the body to turn up the energy when it needs to.
* RT3: Reverse T3 is made by the body to tone down energy. It is made by removing a different iodine from T4. Like placing a ‘bad’ key in the ignition, it blocks the T3 (the ‘working key’) from signaling the cell to make energy. It allows the body to turn down the energy when it needs to.
Optimal Value: These are the values I have found, in my practice, to correspond to the healthiest segment of the population and which I find not associate with symptoms of thyroid excess or deficiency.
Introduction to Interpreting Thyroid Tests
Rather than looking at the values as low-normal-high, we can make more sense of the data if we look at each value as it relates to the optimal value. We can do this on a relative value scale as seen below:
We can then interpret lab values in accordance to how high or low they are and by plugging in the definitions noted above, we learn what is going on. To do this with your lab values, there is a thyroid scale and some possible scenarios detailed down below. For now, let’s do some simple exercises here to see how we can interpret some lab values.
* John is healthy and coming in for an annual physical.
* Thyroid lab values are in the optimal range (see the thyroid scale below) with TSH = 1.5 (optimal), FT4 = 1.26 (optimal), FT3 = 322 (optimal).
* George had a thyroidectomy to remove a cancerous tumor. He was healthy otherwise. His thyroid hormone replacement of 75mcg Synthroid is not enough to meet his needs. He is hypothyroid.
* Thyroid lab values show are: TSH = 5 (high), FT4 = 0.7 (low), FT3 = 280 (lower than optimal but relatively higher than T4)
What does this mean: The pituitary gland is sensing insufficient thyroid energy and is therefore sending a strong signal to the (absent) thyroid gland telling it to make more T4. Because there is insufficient T4, the body can compensate by converting T4 to T3 at a higher than usual rate, hence we see a T3 that is higher than T4 on a relative scale.
* Betty had mononucleosis (EBV) 10 years ago after which she developed anxiety, insomnia, coldness and PMS due to adrenal fatigue. She recently had marital stress.
* Thyroid lab values show are: TSH = 0.9 (below optimal), FT4 = 0.9 (below optimal), FT3 = 260 (below optimal and lower than T4 on the relative scale)
* What does this mean: Her adrenals can not handle much thyroid energy. The pituitary decreased its production of TSH so that the thyroid would make less T4. The recent stress further reduced the adrenals tolerance to thyroid energy so the body (for now) adjusted its energy downward decreasing its conversion of T4 to T3 hence T3 is lower than T4 on this relative scale.
Below you will find further explanation and greater detail to help you understand the logic behind these illustrations and how to interpret lab values.
Thyroid Function Tests
Hormones (T4, T3, and RT3), once released into the bloodstream, exist either as protein bound or in a free form. Protein acts as a sponge or reservoir to which hormones bind and then can be freed. Hormone in free form is then available to interact with a cell’s receptor site to produce its hormonal effect. It is only the free form hormone that is biologically available or active. When the hormone is bound to a protein it is restrained from interacting with a cell’s receptor site. Below is a brief explanation of commonly used hormone level tests.
* TSH: Reflects the blood level of thyroid stimulating hormone.
* Total T4: Reflects the total amount of T4 present in the blood, i.e., the protein bound (unavailable) T4 and the Free T4. Note that high levels of estrogens (birth control pills, non-bio-identical hormone replacement, or pregnancy) or estrogen dominance can increase the amount of the protein that binds T4. This will produce misleading elevated Total T4 values which can look like ‘hyperthyroidism’ when it is not.
* Total T3: Reflects the total amount of T3 present in the blood, i.e., the protein bound (unavailable) T3 as well as the Free T3. Again, estrogen dominance creates the same effect as mentioned in relationship to T4 above.
* Free T4: Reflects the biologically active (free) form of T4. This T4 can be converted to T3 or RT3. This value is relatively stable and not influenced by estrogen dominance.
* Free T3: Reflects the biologically active (free) form of T3 that can generate production of energy (in the form of ATP). This value is relatively stable and not influenced by estrogen dominance.
* RT3: Reflects the level of Reverse T3. I used to measure this often but found little need for it once I realized the approximate value can be estimated from knowing T4 and T3 values since we know that T4 will become either T3 or RT3. For example, if the T4 is elevated and the T3 is low, we know that RT3 (what the rest of the T4 becomes) will be relatively elevated.
* T3 Uptake: This test is mentioned only as a warning not to use it. In fact, it does not measure T3 levels at all – the name is misleading. It is an old test designed with a purpose of indirectly measuring T4! It was developed before we were able to accurately measure T4 levels. The assumption was that if the patient had a high T4 level, the blood proteins would be saturated with it. Therefore when mixed with T3 (which is easier to measure), the blood proteins would take up very little T3. Thus a low T3 uptake implies elevated T4 levels and vice versa. Thus the T3 Uptake test is actually an antiquated, inaccurate way to measure T4 levels.
* Free Thyroxine Index: This test uses T3 Uptake as one of its factors and therefore is as useless as the T3 Uptake. Again, I list it here only as a warning to not throw your money away on this and save it for a meaningful test.
* Antibodies: Autoimmune thyroid disease falls into two main categories: Hashimoto’s Thyroiditis and Grave’s Disease. Hashimoto’s Thyroiditis is typically identified by checking antibodies that attach the thyroid tissue. We find Antithyroglobulin Antibody (ATA) in 70% of the cases and Antimicrosomal Antibodies or Thyroid PerOxidase (TPO) antibodies are found in 95% of the cases. Grave’s Disease is typically diagnosed using Thyroid-Stimulating Immunoglobulin (TSI), Long Acting Thyroid Stimulator (LATS) and TSH-Binding Inhibiting Immunoglobulin (TBII). These are different names for the same test.
Which test to use? I typically test for the following:
* Routine Testing: Free T3, Free T4, TSH.
* If there is a suspicion of Hashimoto’s Thyroiditis, I include TPO and ATA. I also use this to monitor the severity of the Hashimoto’s Thyroiditis and to see if therapy is working.
* If there is suspicion of Grave’s Disease, I include TSI.
Which lab values are the most meaningful? Lab reports tend to provide only the high and low limits of ‘normal’ values. Since we are striving for ‘optimal’, the ranges for optimal are noted below along with standard lab high and low values. These optimal range values are based on my observation of nearly 5,000 patients and reflect the lab test values that my healthiest patients tended to have, e.g. a professional tennis player with a sprained ankle. Remember that the optimal zone is an approximation and that it is meant to be used as a rough guide. People can feel well outside the optimal range but the chances of feeling well become more remote the further we get from the optimal zone. Note that laboratory techniques for these tests vary and lab values may have a 5-10% margin of error depending on the laboratory used.
|Test||Lab Low||Optimal Range||Lab High|
|*Some labs divide FT3 results by 100 thus 230 is the same as 2.3, etc.|
In the cases of Free T4 (FT4) and Free T3 (FT3), the optimal zone is roughly half way between the usual lab normal Low-High values. Note that the normal range for these hormones may change a bit from lab to lab. In the case of TSH, the optimal zone is skewed far toward the low end of the standard lab Low-High range.
Defining the Thyroid Scale
The Thyroid Scale™ is a powerful tool. It is a relative (to optimal) scale that converts different thyroid hormone values to a common unit of measurement. By looking at values relative to optimal (and each other) on a common scale, one can obtain a clearer picture of what is going on.
On the relative scale, zero (0) reflects the optimal range. The higher the number (positive or negative) on the relative scale the further the value is from optimal. Plus and minus five (+/- 5) reflect the ‘normal range’ of typical lab High-Low values, respectively.
Using a fairly proportional distribution between Low and High lab values relative to Optimal, the relative scale lab value ranges are as follows.
View the Thyroid Scale Range Definitions.
Simply plot the different hormone lab values on the relative scale using the provided lab value ranges. Remember that this is not an exact science and that the purpose of the relative scale is to help us understand where lab values sit relative to optimal and then each other. There needs to be sufficient detail to do this but not so much detail that the scale becomes too cumbersome. The below diagram shows an example of a completed Thyroid Scale™ diagram for what may be a metabolically healthy individual – the T3, T4, and TSH are all in the optimal zone.
The reason why we go through all this effort is because there is great diagnostic value in how the different lab values line up on the Thyroid Scale™.
Helpful Hint: Whenever you see the term TSH, T4 or T3, it helps to keep the following images in mind:
* TSH: Pituitary’s desire for thyroid hormone.
* T4: Body’s ability to make T3 (accelerator pedal) and RT3 (brake pedal). It is made by the thyroid gland, taken as a pill, or both.
* T3: Body’s initiator of cellular energy product (accelerator pedal).
Some common results and interpretations:
If the T4 is in the low (but still ‘normal’) range and the T3 is to the right of it in the low but normal range, it means that the T4 is converting to T3 at a high rate (more T3, less RT3). This is typically found when the thyroid gland is unable to keep up T4 production to meet the body’s needs. The body can compensate by increasing conversion of T4 to more T3. We see this in hypothyroidism. (e.g. TSH 5.5, FT4 0.85, FT3 294)
Conversely, if the T3 is relatively lower than T4 (i.e., to the left of T4 on the Thyroid Scale™), it means the body is jamming on the metabolic brakes. This can be seen in early Hashimoto’s Thyroiditis where the T4 is high (because of spillage from a damaged thyroid into the blood stream). The body can protect itself from excessive stimulation by converting more of the T4 into RT3 and less of it into T3. Thus, both hormones might be high or above optimal but the T3 will be found to the left of T4 on the scale. (e.g. TSH 0.8, FT4 1.65, FT3 352)
In cases of chronic adrenal fatigue, the body (actually the adrenals) can only handle a low amount of metabolic energy, so the TSH will usually be below optimal. This is an example of the body 'down-regulating' the thyroid energy. With this low level of thyroid stimulation, we find the T4 and T3 below optimal approximately at the same place on the scale. (e.g. TSH 0.9, FT4 0.95, FT3 282)
If we give adrenal support, as the adrenals get stronger and can handle more energy, the early response is a shift of T3 to the right (high T4 to T3 conversion) followed by a shift of T4 slightly to the left as the T4 reservoir gets used up quickly to make T3. Meanwhile, the TSH stays the same because the brain is not yet convinced that this improvement is permanent. It therefore will not unnecessarily build up the thyroid glad (for higher T4 production) for what might be a temporary improvement. (e.g. TSH 0.9, FT4 0.89, FT3 290)
Thyroid Scale™: Extracting New Meaning from Labs
The Thyroid Scale™ is a powerful tool that provides us an idea of what our lab data actually means by simply plugging in some thyroid lab values (TSH, TT4, and TT3). As stated earlier, this data can be critical in determining the cause of low metabolic energy. Therefore, as your adrenals and thyroid receive the needed support, revisit this tool as your lab values change.
NOTE: This is a powerful tool originally intended for health care practitioners trained at my seminars. Please work with your health care practitioner in reviewing your lab values to ensure an appropriate treatment protocol. - Bruce Rind, M.D.
Diagnostic Tool Coming Soon
We will be adding a Thyroid Scale™ Diagnostic Tool to this website to give you feedback on your own lab values. It will provide you with confirmation on how to interpret your Thyroid Scale™ Diagram. Please register to this website, and you will be notified when this feature is added.