July 8, 2025 • 23 mins
In this in-depth episode of Thyroid Shorts, Dr. Eric Balcavage addresses one of the most misunderstood aspects of thyroid physiology: T4 to T3 conversion problems.
What You'll Learn:
- Why conventional medicine ignores conversion issues and focuses only on TSH
- The critical difference between "broken" physiology vs. adaptive responses
- How deiodinase enzymes (D1, D2, D3) actually control thyroid hormone conversion
- Why your body might be intentionally reducing T4 to T3 conversion
- The real reasons behind elevated reverse T3 levels
- Why T3 medication often backfires and creates more problems
- Practical steps to naturally improve conversion through addressing root causes
Dr. Balcavage explains how reduced T4 to T3 conversion isn't a malfunction—it's often your body's intelligent response to cellular stress, inflammation, or danger signals. Instead of forcing conversion with medication, he advocates for identifying and addressing the underlying stressors through his Strategic Thyroid Solution approach.
Key Topics: Thyroid conversion, T4 to T3, functional medicine, reverse T3, deiodinase enzymes, cellular physiology, stress response, inflammation, homeostasis vs allostasis
Resources Mentioned:
- The Thyroid Debacle book
- Free discovery calls at DrEricBalcavage.com
- Thyroid Recovery Blueprint
Perfect for anyone struggling with hypothyroid symptoms despite "normal" labs or those on T3 medication without lasting results.
Mark as Played
Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Eric Balcavage (00:20):
Hey everybody, it's Dr Eric Balcavage. We're
back for another edition of thethyroid answers shorts. And this
episode of thyroid answersshorts is all about thyroid
conversion, the conversion of t4to t3 and what I like to do in
these thyroid answer shorts isjust kind of get rid kind of get
(00:41):
really deep on one particulartopic and then give you some
information so you can take thatand run with it, and take it and
use it. So today we really wantto talk about thyroid
conversion, because there's alot of different stories about
thyroid conversion, or aninability to convert t4 to t3
(01:03):
optimally. And I think a lot ofthese things create problems,
especially in the functionalmedicine world. So we're going
to get into this a bit. So thefirst thing we'll talk about is
the conventional view of thyroidconversion. If you go see a
medical physician, a classicallytrained endocrinologist, you're
(01:27):
probably not going to hear anydiscussion of conversion of t4
to t3 they're going to theirprimary focus is to determine,
are you in a state where you'vedeveloped a glandular thyroid
disorder that now requiresreplacement therapy, and
primarily that replacementtherapy is going to be t4 now,
(01:48):
for anybody who doesn't know andis new to listening to this
podcast, t4 is the inactivehormone or the less active
hormone. It is what your thyroidgland primarily makes, and the
active hormone is called t3 andyour peripheral tissues
primarily take t4 and convert itto t3 and then t3 supports the
(02:11):
Cellular Physiology. Intraditional medicine, their
assumption is that if youprovide enough t for the body,
will automatically convert it toappropriate levels of t3 and
this is not actually accurate.But because they don't look at
total t3 typically, or free t3or reverse t3 they the
(02:32):
assumption is that if I providet4 and it suppresses TSH, that
TSH into an is now within anormal range, so it must have
converted into t3 The problemis, is that there are many
reasons why t4 medication couldsuppress TSH, despite you having
lots of hypothyroid signs andsymptoms, which is caused by a
(02:55):
reduced conversion of t4 To t3in your peripheral cells and tissues.
Now in functional or integrativemedicine, we often look at more
comprehensive panels, and we dotend to look at total t3 and
free t3 and reverse t3 now thereis a trend in functional and
integrative medicine wherepractitioners are just running
(03:18):
free hormones because they thinkthat those are the only things
that matter. I don't agree withthat. I think you need to know
the total and the free value.And we'll do a podcast, maybe
know the thyroid answer shortson wine, but I've done many
thyroid Thursdays on why thefull panel is important. So go
(03:38):
check those things out. Butthere is a tendency in
integrative and functionalmedicine to be to look at a more
comprehensive panel, and morespecifically, to look at maybe
free t3 and reverse t3 and beconcerned about the conversion
of t4 to t3
The problem, however, in thespace a lot of times, is that
(04:00):
when clinicians see a reducedconversion of t4 to t3 the
assumption is, is that your bodyforgot how to do it, or can no
longer do it, or that it's adysfunction. Can't. Yeah, it
can't. It can't do it. So wemust help them. And what I want
practitioners to learn andunderstand, and I want you, the
(04:22):
individual person strugglingwith thyroid issues and chronic
hypothyroid signs and symptoms,despite what somebody might say
is appropriate or optimizedthyroid medication, is that your
body doesn't forget how toconvert t4 to t3 their body
adaptively decreases theconversion of t4 to t3 based on
(04:44):
the state. So when you when welook at labs, and we see that t4
is in a normal range and TSH iswhatever range it's at, but we
see that there's in. Increasedreverse t3 or and, or low t3
total t3 free t3 what weshouldn't be thinking is that
your body is broken and we mustgive you t3 what we should be
(05:06):
con considering as physicians isthe body is adaptively
decreasing the conversion of t4to t3 and increasing the
conversion of t4 to thedeactivated form called reverse
t3 and we need to understandthat this is oftentimes an
adaptive response to some typeof excessive stress response,
(05:27):
and that instead of adding t3and assuming that the body's
broken or forgot How to do it?That we should be asking better
questions. And that betterquestion would be, why is the
body behaving in this way? Andhow do I support the physiology
to reduce the stress load so thebody converts t4 to t3 in a more
(05:50):
optimal fashion, and I almosthate to say optimal fashion,
because the yes, the physiologymay be working optimally if
there is a cell stress responsegoing on, if there's a threat at
the cellular level that'sreducing the conversion of t4 to
t3 that is likely an optimalfunction. That's optimal
(06:12):
physiology, given that state andyour individual condition. It's
not broken physiology. So weshouldn't assume that the
optimal optimization is to givemore t3 that doesn't necessarily
optimize the physiology. It maychange the blood value that the
doctor cares about. It maychange your symptoms
(06:33):
temporarily, but it doesn'tnecessarily optimize your
thyroid physiology. That term isis probably thrown around too
much and used inappropriately.We often have to consider that
what's going on the cells andtissues is the optimal
physiology given your state. Areyou operating from this low
(06:55):
stress state we callhomeostasis, or are you
operating from an excessivestress state we call Allostatic
regulation or cell dangerphysiology. Okay, so in
conventional medicine, theyreally don't look at the
conversion of t4 to t3 you'rerarely have total t3 or free t3
or reverse t3 run because notrelevant to what they're trying
(07:19):
to do. They're trying to just torestore TSH into a lab range.
And they assume that if theyprovide enough t4 that restores
TSH to a lab reference range,that you are converting it
optimally. However, if you'restruggling with chronic
hypothyroid signs and symptoms,you're not converting that t4 to
(07:41):
t3 optimally, right in it,you're not converting it as if
you're in homeostasis, or youwouldn't have hypothyroid signs
and symptoms. From a functionalor integrative standpoint,
functional medicinepractitioners do look at t3
levels, sometimes reverse t3levels, and they are aware that
(08:02):
there's reduced conversion to oft4 to t3 and an increased
conversion of t4 to reverse t3however, they just assume it's
broken physiology and these andthe treatment is to provide
medication, versus saying, Hey,this is likely an adaptive
response, and we need to figureout why. So the next thing
(08:24):
that's really important tounderstand is what happens that
the body adaptively decreasesthe conversion of t4 to t3 and
increases the conversion of t4to reverse t3 we in your while
your thyroid gland makes thyroidhormone t4 mostly a little bit
of t3 this the cells, theindividual cells and tissues,
(08:46):
actually determine what happensto that thyroid hormone. Is it
going to be converted to t3because the cells and tissues
are need more energy. They needto ramp up their metabolism.
They need to make more stuff. Ordoes the cell saying, hey, if we
want to slow down the metabolismbased on what we're perceiving,
(09:09):
lack of nutrition, other formsof stress or danger, and
infection as an example. And sowe have with these, these
enzymes inside our cells thatare called de iodinase enzymes,
and the D en de idenate enzymescan either convert t4 to t3 or
they can deactivate t4 toreverse t3 they can deactivate
(09:31):
t3 to t2 and then they can alsometabolize t3 reverse t3, t2 out
of the system. So the D ID nasesreally have the local control
inside your cells and tissues.What's in your bloodstream may
not necessarily correlate withwhat's happening inside the
cells and tissues, all the cellsand tissues at the same time. So
(09:54):
just because we see a normallevel of teeth T. Or t3 in the
bloodstream doesn't mean we haveoptimal levels of t3 inside all
the cells and tissues. The bodyhas this beautiful design that
allows it to increase ordecrease different tissues
metabolism at the same exacttime. This is ultimately gives
(10:16):
us optimal control of ourmetabolism and our thyroid physiology.
So these there's enzymes insidethe cells that are called de
iodinase enzymes. And these deidinase Enzymes either convert
t4 to t3 or deactivate t4 and t3now the primary enzyme that
(10:37):
converts t4 to t3 is calleddeiodinase 2.
And when we have what we callhomeostatic, low stress
physiology going on and the bodywants to increase its
metabolism, it needs to burn offfat, it needs to make more
energy, it needs to make moreenzymes or tissues or proteins,
(10:57):
it's going to increase yourmetabolism, increase the
conversion of t4 to t3 and itdoes this by increasing
deodinace Two activity. There isanother enzyme that can convert
t4 to t3 and that is deodinaceone. It does a small amount of
the conversion of t4 to t3 atone point we thought that
(11:18):
deodinace One converted a you'llhear things people say, 80% of
the t4 to t3 conversion is bydeodinace One deliver, and
that's been shown in the mostrecent literature not to be the
case, not to be true. Theprimary action of deodinace one
is actually to metabolize, getrid of reverse t3 the
(11:40):
deactivated form. And so theprimary hormone that converts t4
to t3 is de iodinase Two.Deodinace one can do it because
it a small amount, but hisprimary role is metabolizing
reverse t3 to get it out of thesystem. And there's one more de
idinase enzyme, and that'scalled deodinace Three. And that
(12:02):
that enzyme, its primary job isto deactivate t4 to reverse t3
and deactivate t3 to t2 nowdon't go looking on your lab
report for t2 don't ask yourmedical doctor to run t2 because
they just don't do it. It's notavailable in traditional labs,
and most people wouldn't knownecessarily what to do with a
(12:25):
high or low t2 result, but theiodine ace threes primary role
is to slow down the metabolism.So when, in general, when there
is increased levels ofinflammatory chemicals, which
are danger signals incirculation, impacting the
cells, impacting the tissues,there's going to be a net
(12:46):
decreased conversion of t4, tot3 a net D, drop in t4, to t3
conversion and a net increasedconvert, deactivation of both t4
and t3 t4 deactivated to reverset3 which, if your doctor runs
reverse t3 we can see And theother enzyme, t2 is not done a
traditional labs. So if somebodyhas this cell stress,
(13:08):
inflammatory mechanism going on,the body is saying, hey, there's
threat, there's theseinflammatory signals, there's
danger. And I we need to slowdown our metabolism. And so what
we have is an up regulation of Dinase Three, that adaptively
decreases the conversion of t4to t3 increases the conversion
(13:31):
of t4 to reverse t3 this is notbroken physiology. Matt, it is
often a response to thisinflammatory process, and it's
not broken. And the literaturetalks about this now more than
ever, that this is anappropriate adaptive response to
some type of threat. And so whenyour doctor says your body
(13:52):
forgot how to do it, or youcan't do it anymore, or this you
have a dysfunction or amalfunction, that is not true.
Your body didn't forget. Youdon't have a dysfunction. You
don't have a malfunction. Thisreduced conversion of t4 to t3
this increased conversion of t4to reverse t3 is an adaptive
(14:14):
response. Now it may cause youto not feel good, you may be
more tired, you may be morefatigued, you may have more
sluggish metabolism. But that'snot broken physiology, and that
part is really important,because if the if the doctor
thinks you are broken, then theywill think the appropriate
(14:36):
treatment is to give you t3 ifthey think this is an
appropriate adaptive response,then they will likely won't want
to give you t3 not becausethey're mean, not because they
are they don't want you to feelbetter, but because they're
trying to work with yourphysiology, not against your
(14:58):
physiology. So what things mightcause your body to adaptively
decrease the conversion of t4 tot3 and increase the conversion
to reverse t3 this deactivatedform. So. Lack of proper sleep,
emotional stress, poor habits,poor diet, lots of alcohol,
fasting excessively so low heavycaloric restriction, bacteria,
(15:21):
viruses, toxins in yourenvironment that things that are
create damage or inflammation toyour tissues, things that create
real or perceived stress on yourphysiology are going to increase
deodinace Three, increasing thedeactivation of t4 to reverse t3
increase the deactivation of t3to t2 and cause your hypothyroid
(15:44):
symptoms, again, not broken, butin an appropriate response to
this adaptive physiology. Sosome people might ask, Well, if
the reduced conversion of t4 tot3 is going on? If this is an
adaptive response, and I don'tfeel good, I'm tired, I'm
fatigued, why wouldn't I justgive t3 why? Why wouldn't I want
(16:07):
to just feel better? And theanswer is, is that there's a
couple, there's, well, there's acouple answers. One, is taking
t3 medication can temporarilymake you feel better, because
you're providing a hormone thatyour body is not converting and
some of that's going to get intothe cells and tissues, and it
(16:30):
often does make some people feelbetter, at least initially. The
problem is, is that once you getthat t3 into the system, the
body now has to work harder toactually decrease the to get rid
of that t3 medication you'retaking and too much t3,
medication in it, in this whenyou have this inflammatory
(16:52):
process going on, can actuallycreate more tissue damage, more
oxidative stress, moreinflammatory mechanisms, so it
can perpetuate this immune andinflammatory process. It is not
unusual that almost every week Ihave somebody contacting me who
has been prescribed t3medication. They initially felt
(17:14):
better, and they thought, wow,this is the right strategy that
medical doctor wasn't providingit, this integrated
practitioner, is, I feel better,but then it doesn't last, and so
then they wind up on a strongerdose. So they go from five
micrograms to 10 micrograms to15 micrograms to 20 micrograms,
(17:36):
and it starts to not only notlast and require greater amounts
of t3 but it also createsalterations in their thyroid
labs that many times theclinician doesn't understand or
doesn't know how to interpretappropriately, and they say,
Hey, we're just not going to payattention to that TSH, because
(17:58):
we expect it to go really low.It can result in suppression,
further suppression of thethyroid gland more than maybe
you were it was suppressedbefore and result in either
dramatic rise in t3 medicationjust to feel half decent, or the
addition of t4 medication as well.
But the key piece is, eventhough it can temporarily make
(18:22):
you feel better, it's notaddressing the real issue. It's
not addressing what's causingthe self stress response, and
you're working against thebody's natural adaptive changes
as a result of some type ofexcessive stress response. So
yes, taking t3 medication canchange your t3 values on your
(18:44):
labs. Can it change yoursymptoms at least temporarily?
Yes, but more often than not, itwinds up people starting to feel
better and then chasing thatfeel good with higher and higher
doses of thyroid medication. AndI have many clients that wind up
on higher doses of medication,have severe anxiousness,
(19:06):
anxiety, irritability, and arereally struggling with chronic
with chronic symptoms of bothhypo and hyper thyroid
physiology because of thesuccessive use of t3 medication.
Now, I don't think medicfunctional or integrative
practitioners that are providingit have bad intent. I think
(19:27):
they're trying to help out. Ijust think in many cases, they
don't fully understand what'sgoing on with thyroid
physiology. They assume it'sbroken and that the solution is
the same as the medicalprofessional believes, is that
the system's broken, thephysiology is broken. You lost
(19:47):
the ability to make hormone andconvert hormone, and therefore
the answer is to manage yourblood levels with medication.
And it is a management strategy,but I think it rarely leads to
somebody recovering from athyroid condition.
So other thing I want to talkabout is, how can you can
(20:08):
increase the conversion of t4 tot3? How can you feel and
function better? Because peoplelook at that low t3 and low,
free t3 and elevated, reverse t3as the actual problem. And when
they see it, they're like, oh, Ineed to change this. I need to
add t3 to fix it. If I fix thelabs, it'll I'll feel better.
(20:31):
The reality is, when we seelabs, we have to interpret them.
So if we see that somebody hasreduced conversion of t4 to t3
if they have an increasedconversion of t4 to reverse t3
we need to just ask a betterquestion, what's creating
excessive stress on yourphysiology that's causing your
(20:53):
body to adaptively decrease theconversion of t4 to t3 and
increase the deactivation Toreverse t3 if we ask that
question and we startinvestigating what's doing that
that's the best way to improvet4, to t3 conversion, identify
the stressors and reduce orremove those stressors. And do
(21:15):
it for a period of time, thedanger physiology goes away, and
now the body can start toconvert t4, to t3 naturally,
adaptively, optimally, and soyou'll see conversion go up as
you address these things. Thethere is some discussion that
there's many things likeSelenium and other
(21:36):
micronutrients that are reallyimportant for improved
conversion of t4, to t3 and thatis true, but I don't think the
primary issue for the vastmajority of people is they just
don't have enough micronutrientsto support the conversion.
Matter of fact, if somebody hasreduced conversion of t4 to t3
(21:58):
and has a higher level ofdeactivation of t4 to reverse t3
then obviously they have enoughmicronutrients to support the
iodinase, three, thedeactivation. So it's not a lack
of micronutrients. It is anadaptive response by the body.
And this is really the bestanswer. I know. It's not what,
really what everybody wants tohear. Everybody primarily wants
(22:22):
to know. Just tell me what I cantake and this makes it better.
That'll make my t3 better andmake me feel better. But life is
not that simple. When I amtrying to help somebody
understand what's causing thereduced conversion of t4 to t3
that's where I go back and lookat what I call the fitness
(22:42):
factors, their dietary fitness,their habits, their mindset,
their emotional stressors, theirdistress from relationships,
work stress, financial stress.How do they sleeping? Do they
have chronic infections, like,what is creating the excessive
stress on the individual? Andhow do I start to reduce or
(23:02):
eliminate those things? We canuse diet, diet modification. We
can use short term strategicsupplementation strategies. But
ultimately, the thing that hasbeen most effective, and I've
been doing this for 30 years atthis point, the thing that's
been most effective at helpingsomebody improve their t4 to t3
(23:23):
conversion is helping themidentify what's contributing to
their excessive stress load andstart reducing and eliminating
those things. It hasn't beenlots and lots and lots of
supplements. Supplements are agreat tool, but they are not the
tool.
There is no magic supplementthat's going to probably convert
(23:44):
increase your conversion of t4to t3, long term, we
usesupplementation strategicallyto help shift somebody from this
cell stress physiology back tohomeostatic physiology, once we
identify what those triggersare. But the most important
thing that you can do to improveyour t4 to t3 conversion is not
(24:05):
take t3 medication. It is to behonest with yourself, and it's
to it is to work with afunctional medicine or
integrated practitioner, to say,what is creating excessive
stress on my physiology that Ican start to reduce or eliminate.
If you start to do that, and youreally start to address the
(24:26):
overall stress load, more thanlikely you're going to see
improved conversion of t4 to t3on your own. The The one caveat
to that, and is that? Is thisthat many times excessive
thyroid medication is one of thebig stressors on your
physiology. It's not unusualthat somebody comes to see me.
(24:48):
They're on 3040, 6080,micrograms of t3, because t4
men. Medication on its owndidn't work. They tried NP,
thyroid or armor, and thatworked temporarily, but then
they couldn't find the dose, andthen they found somebody who
does t3 only therapy, and theystarted t3 therapy, and that
(25:10):
created some more positivechange, but it's led them to be
having to take 80 micrograms ormore on a daily regular basis,
and they still have hypo andhyper thyroid symptoms. And
while they feel better than theydid without thyroid medication
or maybe on the t4 alone,they're still chasing the
(25:32):
ultimate answer of, how do Iimprove my thyroid physiology?
How do I recover from a thyroidcondition, how do I feel better
and not have this kind of wiredand tired feeling that often
happens as people add t3medications? So what can you do
if you're one of those peoplewho's been on t4 medication and
(25:55):
you still don't feel and function?
Well, reach out to me or anotherfunctional or integrated
practitioner and get acomprehensive thyroid panel
done. Have see if you're eventhough your TSH may you may be
told your TSH is normal and yourt4 or free t4 is normal. Look at
the t3 levels and the free t3levels are they reduced. Look at
(26:19):
the reverse t3 is that elevated,and it what is the free to free
t3, to free t4, ratio? If thatis reduced, or any of those
things I said are, are aproblem. You have reduced
conversion. You're in this cellstress, inflammatory mechanism.
Your body is not converting t4to t3 optimally, or as it as in
(26:41):
a in a form that would make youfeel awesome. And it's not
because you're broken. It'sbecause you're operating from
this danger physiology yourbody's adaptively decreasing the
conversion of t4 to t3 and it'sprobably the same danger
physiology that triggered thethyroiditis and the loss of
(27:03):
gland function to begin with. Soget a more complete panel done.
The other thing you can do alongwith that is you can look at
inflammatory markers on yourblood work. If you run a uric
acid, a fibrinogen, a ferritin,a homocysteine, a CRP, or a host
of other inflammatory markers,and any of them are elevated,
(27:25):
you're now have confirmationthat you're not broken. You now
have confirmation that you havean inflammatory process going
on, and the reduced conversionof t4 to t3 is the adaptive
response and not brokenphysiology. More thyroid
hormone, regardless of whetherit's t4 or t3 will not fix this
(27:47):
situation. It can changesymptoms, it can change labs,
but it's not going to restoreyour thyroid physiology. Why?
Because it's not broken. Whatyou need to do is look at what's
contributing to the excessivecell stress response. And if you
need more help and more guidanceon this, you can pick up my
(28:08):
book, The thyroid debacle, wherewe talk about what some of these
fitness factors are. You can goto my website. Dr Balcavage,
www.dr, Eric balcavage.com, andyou can request a complimentary
discovery call, and we can talkabout what's going on and maybe
what the best options are foryou. But stop trying to fix the
(28:32):
t3 level. Stop trying to fix theconversion issue with more
thyroid hormone it's not theright strategy. If it was, you
would probably not be listeningto this podcast. You wouldn't be
struggling with chronichypothyroid symptoms and
sometimes hyper and hypothyroidsymptoms at the same time, and
(28:53):
you wouldn't be doing constantDr Google searches for how do I
feel better? How do I recover mythyroid physiology.
So if you need help thyroid andgo to my website, request a
discovery call, pick up my book,The thyroid DeMarco, and check
out some of those things, someof the suggestions in the book
(29:14):
that can help you, but don'tchase or spend too much time
trying to optimize your t3levels if you have this cell
stress, inflammatory processgoing on. The last comment I'll
make is, some people say, Well,if my thyroid gland is totally
destroyed, shouldn't I be onsome type of thyroid medication?
(29:35):
And I would agree, yes, you'regoing to be on some type of
thyroid medication, and itprobably should be t4 and my
suggestion would be a separatemedication of t3 I'm not a huge
fan of armor and NP thyroid forthe vast majority of people. I
think if we're going to providet4 and t3 it probably should be
(29:55):
done. Separately, so that we canincrease or decrease t4, and t3
separately. If you're takingarmor, np thyroid, if you
increase t, the NP thyroid orarmor, you're increasing both t4
and t3 if you need, if you're ifyou need to drop t3 you can't
drop it separately. You have todecrease the armor or the MP
(30:16):
thyroid, which means you'regoing to decrease t4 and t3 so
the best bet, in my opinion, isseparate t4 and t3 and the t3
probably taken in a split doseto maintain more flu, more
balance of your t3 levelsthrough the day. And we probably
shouldn't be providing morethyroid medication, in most
(30:36):
cases, than a healthy thyroidgland would have made in the
first place. And from a t3perspective, that may be five to
10 micrograms of t3 is maybewhat a healthy thyroid gland
would have made. Most of the t3is not made by your thyroid
gland. It's made by theperipheral tissues that are in a
(30:56):
homeostatic low stress state.Converting t4 to t3 that's what
maintains a higher level of t3free t3 and a lower level of
reverse t3 so I hope this hashelped. If you have any
challenges, questions, problems,you can reach out to me at my
office info at Dr Ericbalcallcavage.com, and you can
put your comments or questionsbelow wherever you watch this
(31:20):
video or listen to this podcast,and you can always reach out to
me on Instagram and send me adirect message with your
questions. All right, hopefullythis helps and stay tuned for
more thyroid answers and thyroidshorts episodes in the future.
Take care you
Hey everybody, it's Dr Eric Balcavage. We're
back for another edition of thethyroid answers shorts. And this
episode of thyroid answersshorts is all about thyroid
conversion, the conversion of t4to t3 and what I like to do in
these thyroid answer shorts isjust kind of get rid kind of get
(00:41):
really deep on one particulartopic and then give you some
information so you can take thatand run with it, and take it and
use it. So today we really wantto talk about thyroid
conversion, because there's alot of different stories about
thyroid conversion, or aninability to convert t4 to t3
(01:03):
optimally. And I think a lot ofthese things create problems,
especially in the functionalmedicine world. So we're going
to get into this a bit. So thefirst thing we'll talk about is
the conventional view of thyroidconversion. If you go see a
medical physician, a classicallytrained endocrinologist, you're
(01:27):
probably not going to hear anydiscussion of conversion of t4
to t3 they're going to theirprimary focus is to determine,
are you in a state where you'vedeveloped a glandular thyroid
disorder that now requiresreplacement therapy, and
primarily that replacementtherapy is going to be t4 now,
(01:48):
for anybody who doesn't know andis new to listening to this
podcast, t4 is the inactivehormone or the less active
hormone. It is what your thyroidgland primarily makes, and the
active hormone is called t3 andyour peripheral tissues
primarily take t4 and convert itto t3 and then t3 supports the
(02:11):
Cellular Physiology. Intraditional medicine, their
assumption is that if youprovide enough t for the body,
will automatically convert it toappropriate levels of t3 and
this is not actually accurate.But because they don't look at
total t3 typically, or free t3or reverse t3 they the
(02:32):
assumption is that if I providet4 and it suppresses TSH, that
TSH into an is now within anormal range, so it must have
converted into t3 The problemis, is that there are many
reasons why t4 medication couldsuppress TSH, despite you having
lots of hypothyroid signs andsymptoms, which is caused by a
(02:55):
reduced conversion of t4 To t3in your peripheral cells and tissues.
Now in functional or integrativemedicine, we often look at more
comprehensive panels, and we dotend to look at total t3 and
free t3 and reverse t3 now thereis a trend in functional and
integrative medicine wherepractitioners are just running
(03:18):
free hormones because they thinkthat those are the only things
that matter. I don't agree withthat. I think you need to know
the total and the free value.And we'll do a podcast, maybe
know the thyroid answer shortson wine, but I've done many
thyroid Thursdays on why thefull panel is important. So go
(03:38):
check those things out. Butthere is a tendency in
integrative and functionalmedicine to be to look at a more
comprehensive panel, and morespecifically, to look at maybe
free t3 and reverse t3 and beconcerned about the conversion
of t4 to t3
The problem, however, in thespace a lot of times, is that
(04:00):
when clinicians see a reducedconversion of t4 to t3 the
assumption is, is that your bodyforgot how to do it, or can no
longer do it, or that it's adysfunction. Can't. Yeah, it
can't. It can't do it. So wemust help them. And what I want
practitioners to learn andunderstand, and I want you, the
(04:22):
individual person strugglingwith thyroid issues and chronic
hypothyroid signs and symptoms,despite what somebody might say
is appropriate or optimizedthyroid medication, is that your
body doesn't forget how toconvert t4 to t3 their body
adaptively decreases theconversion of t4 to t3 based on
(04:44):
the state. So when you when welook at labs, and we see that t4
is in a normal range and TSH iswhatever range it's at, but we
see that there's in. Increasedreverse t3 or and, or low t3
total t3 free t3 what weshouldn't be thinking is that
your body is broken and we mustgive you t3 what we should be
(05:06):
con considering as physicians isthe body is adaptively
decreasing the conversion of t4to t3 and increasing the
conversion of t4 to thedeactivated form called reverse
t3 and we need to understandthat this is oftentimes an
adaptive response to some typeof excessive stress response,
(05:27):
and that instead of adding t3and assuming that the body's
broken or forgot How to do it?That we should be asking better
questions. And that betterquestion would be, why is the
body behaving in this way? Andhow do I support the physiology
to reduce the stress load so thebody converts t4 to t3 in a more
(05:50):
optimal fashion, and I almosthate to say optimal fashion,
because the yes, the physiologymay be working optimally if
there is a cell stress responsegoing on, if there's a threat at
the cellular level that'sreducing the conversion of t4 to
t3 that is likely an optimalfunction. That's optimal
(06:12):
physiology, given that state andyour individual condition. It's
not broken physiology. So weshouldn't assume that the
optimal optimization is to givemore t3 that doesn't necessarily
optimize the physiology. It maychange the blood value that the
doctor cares about. It maychange your symptoms
(06:33):
temporarily, but it doesn'tnecessarily optimize your
thyroid physiology. That term isis probably thrown around too
much and used inappropriately.We often have to consider that
what's going on the cells andtissues is the optimal
physiology given your state. Areyou operating from this low
(06:55):
stress state we callhomeostasis, or are you
operating from an excessivestress state we call Allostatic
regulation or cell dangerphysiology. Okay, so in
conventional medicine, theyreally don't look at the
conversion of t4 to t3 you'rerarely have total t3 or free t3
or reverse t3 run because notrelevant to what they're trying
(07:19):
to do. They're trying to just torestore TSH into a lab range.
And they assume that if theyprovide enough t4 that restores
TSH to a lab reference range,that you are converting it
optimally. However, if you'restruggling with chronic
hypothyroid signs and symptoms,you're not converting that t4 to
(07:41):
t3 optimally, right in it,you're not converting it as if
you're in homeostasis, or youwouldn't have hypothyroid signs
and symptoms. From a functionalor integrative standpoint,
functional medicinepractitioners do look at t3
levels, sometimes reverse t3levels, and they are aware that
(08:02):
there's reduced conversion to oft4 to t3 and an increased
conversion of t4 to reverse t3however, they just assume it's
broken physiology and these andthe treatment is to provide
medication, versus saying, Hey,this is likely an adaptive
response, and we need to figureout why. So the next thing
(08:24):
that's really important tounderstand is what happens that
the body adaptively decreasesthe conversion of t4 to t3 and
increases the conversion of t4to reverse t3 we in your while
your thyroid gland makes thyroidhormone t4 mostly a little bit
of t3 this the cells, theindividual cells and tissues,
(08:46):
actually determine what happensto that thyroid hormone. Is it
going to be converted to t3because the cells and tissues
are need more energy. They needto ramp up their metabolism.
They need to make more stuff. Ordoes the cell saying, hey, if we
want to slow down the metabolismbased on what we're perceiving,
(09:09):
lack of nutrition, other formsof stress or danger, and
infection as an example. And sowe have with these, these
enzymes inside our cells thatare called de iodinase enzymes,
and the D en de idenate enzymescan either convert t4 to t3 or
they can deactivate t4 toreverse t3 they can deactivate
(09:31):
t3 to t2 and then they can alsometabolize t3 reverse t3, t2 out
of the system. So the D ID nasesreally have the local control
inside your cells and tissues.What's in your bloodstream may
not necessarily correlate withwhat's happening inside the
cells and tissues, all the cellsand tissues at the same time. So
(09:54):
just because we see a normallevel of teeth T. Or t3 in the
bloodstream doesn't mean we haveoptimal levels of t3 inside all
the cells and tissues. The bodyhas this beautiful design that
allows it to increase ordecrease different tissues
metabolism at the same exacttime. This is ultimately gives
(10:16):
us optimal control of ourmetabolism and our thyroid physiology.
So these there's enzymes insidethe cells that are called de
iodinase enzymes. And these deidinase Enzymes either convert
t4 to t3 or deactivate t4 and t3now the primary enzyme that
(10:37):
converts t4 to t3 is calleddeiodinase 2.
And when we have what we callhomeostatic, low stress
physiology going on and the bodywants to increase its
metabolism, it needs to burn offfat, it needs to make more
energy, it needs to make moreenzymes or tissues or proteins,
(10:57):
it's going to increase yourmetabolism, increase the
conversion of t4 to t3 and itdoes this by increasing
deodinace Two activity. There isanother enzyme that can convert
t4 to t3 and that is deodinaceone. It does a small amount of
the conversion of t4 to t3 atone point we thought that
(11:18):
deodinace One converted a you'llhear things people say, 80% of
the t4 to t3 conversion is bydeodinace One deliver, and
that's been shown in the mostrecent literature not to be the
case, not to be true. Theprimary action of deodinace one
is actually to metabolize, getrid of reverse t3 the
(11:40):
deactivated form. And so theprimary hormone that converts t4
to t3 is de iodinase Two.Deodinace one can do it because
it a small amount, but hisprimary role is metabolizing
reverse t3 to get it out of thesystem. And there's one more de
idinase enzyme, and that'scalled deodinace Three. And that
(12:02):
that enzyme, its primary job isto deactivate t4 to reverse t3
and deactivate t3 to t2 nowdon't go looking on your lab
report for t2 don't ask yourmedical doctor to run t2 because
they just don't do it. It's notavailable in traditional labs,
and most people wouldn't knownecessarily what to do with a
(12:25):
high or low t2 result, but theiodine ace threes primary role
is to slow down the metabolism.So when, in general, when there
is increased levels ofinflammatory chemicals, which
are danger signals incirculation, impacting the
cells, impacting the tissues,there's going to be a net
(12:46):
decreased conversion of t4, tot3 a net D, drop in t4, to t3
conversion and a net increasedconvert, deactivation of both t4
and t3 t4 deactivated to reverset3 which, if your doctor runs
reverse t3 we can see And theother enzyme, t2 is not done a
traditional labs. So if somebodyhas this cell stress,
(13:08):
inflammatory mechanism going on,the body is saying, hey, there's
threat, there's theseinflammatory signals, there's
danger. And I we need to slowdown our metabolism. And so what
we have is an up regulation of Dinase Three, that adaptively
decreases the conversion of t4to t3 increases the conversion
(13:31):
of t4 to reverse t3 this is notbroken physiology. Matt, it is
often a response to thisinflammatory process, and it's
not broken. And the literaturetalks about this now more than
ever, that this is anappropriate adaptive response to
some type of threat. And so whenyour doctor says your body
(13:52):
forgot how to do it, or youcan't do it anymore, or this you
have a dysfunction or amalfunction, that is not true.
Your body didn't forget. Youdon't have a dysfunction. You
don't have a malfunction. Thisreduced conversion of t4 to t3
this increased conversion of t4to reverse t3 is an adaptive
(14:14):
response. Now it may cause youto not feel good, you may be
more tired, you may be morefatigued, you may have more
sluggish metabolism. But that'snot broken physiology, and that
part is really important,because if the if the doctor
thinks you are broken, then theywill think the appropriate
(14:36):
treatment is to give you t3 ifthey think this is an
appropriate adaptive response,then they will likely won't want
to give you t3 not becausethey're mean, not because they
are they don't want you to feelbetter, but because they're
trying to work with yourphysiology, not against your
(14:58):
physiology. So what things mightcause your body to adaptively
decrease the conversion of t4 tot3 and increase the conversion
to reverse t3 this deactivatedform. So. Lack of proper sleep,
emotional stress, poor habits,poor diet, lots of alcohol,
fasting excessively so low heavycaloric restriction, bacteria,
(15:21):
viruses, toxins in yourenvironment that things that are
create damage or inflammation toyour tissues, things that create
real or perceived stress on yourphysiology are going to increase
deodinace Three, increasing thedeactivation of t4 to reverse t3
increase the deactivation of t3to t2 and cause your hypothyroid
(15:44):
symptoms, again, not broken, butin an appropriate response to
this adaptive physiology. Sosome people might ask, Well, if
the reduced conversion of t4 tot3 is going on? If this is an
adaptive response, and I don'tfeel good, I'm tired, I'm
fatigued, why wouldn't I justgive t3 why? Why wouldn't I want
(16:07):
to just feel better? And theanswer is, is that there's a
couple, there's, well, there's acouple answers. One, is taking
t3 medication can temporarilymake you feel better, because
you're providing a hormone thatyour body is not converting and
some of that's going to get intothe cells and tissues, and it
(16:30):
often does make some people feelbetter, at least initially. The
problem is, is that once you getthat t3 into the system, the
body now has to work harder toactually decrease the to get rid
of that t3 medication you'retaking and too much t3,
medication in it, in this whenyou have this inflammatory
(16:52):
process going on, can actuallycreate more tissue damage, more
oxidative stress, moreinflammatory mechanisms, so it
can perpetuate this immune andinflammatory process. It is not
unusual that almost every week Ihave somebody contacting me who
has been prescribed t3medication. They initially felt
(17:14):
better, and they thought, wow,this is the right strategy that
medical doctor wasn't providingit, this integrated
practitioner, is, I feel better,but then it doesn't last, and so
then they wind up on a strongerdose. So they go from five
micrograms to 10 micrograms to15 micrograms to 20 micrograms,
(17:36):
and it starts to not only notlast and require greater amounts
of t3 but it also createsalterations in their thyroid
labs that many times theclinician doesn't understand or
doesn't know how to interpretappropriately, and they say,
Hey, we're just not going to payattention to that TSH, because
(17:58):
we expect it to go really low.It can result in suppression,
further suppression of thethyroid gland more than maybe
you were it was suppressedbefore and result in either
dramatic rise in t3 medicationjust to feel half decent, or the
addition of t4 medication as well.
But the key piece is, eventhough it can temporarily make
(18:22):
you feel better, it's notaddressing the real issue. It's
not addressing what's causingthe self stress response, and
you're working against thebody's natural adaptive changes
as a result of some type ofexcessive stress response. So
yes, taking t3 medication canchange your t3 values on your
(18:44):
labs. Can it change yoursymptoms at least temporarily?
Yes, but more often than not, itwinds up people starting to feel
better and then chasing thatfeel good with higher and higher
doses of thyroid medication. AndI have many clients that wind up
on higher doses of medication,have severe anxiousness,
(19:06):
anxiety, irritability, and arereally struggling with chronic
with chronic symptoms of bothhypo and hyper thyroid
physiology because of thesuccessive use of t3 medication.
Now, I don't think medicfunctional or integrative
practitioners that are providingit have bad intent. I think
(19:27):
they're trying to help out. Ijust think in many cases, they
don't fully understand what'sgoing on with thyroid
physiology. They assume it'sbroken and that the solution is
the same as the medicalprofessional believes, is that
the system's broken, thephysiology is broken. You lost
(19:47):
the ability to make hormone andconvert hormone, and therefore
the answer is to manage yourblood levels with medication.
And it is a management strategy,but I think it rarely leads to
somebody recovering from athyroid condition.
So other thing I want to talkabout is, how can you can
(20:08):
increase the conversion of t4 tot3? How can you feel and
function better? Because peoplelook at that low t3 and low,
free t3 and elevated, reverse t3as the actual problem. And when
they see it, they're like, oh, Ineed to change this. I need to
add t3 to fix it. If I fix thelabs, it'll I'll feel better.
(20:31):
The reality is, when we seelabs, we have to interpret them.
So if we see that somebody hasreduced conversion of t4 to t3
if they have an increasedconversion of t4 to reverse t3
we need to just ask a betterquestion, what's creating
excessive stress on yourphysiology that's causing your
(20:53):
body to adaptively decrease theconversion of t4 to t3 and
increase the deactivation Toreverse t3 if we ask that
question and we startinvestigating what's doing that
that's the best way to improvet4, to t3 conversion, identify
the stressors and reduce orremove those stressors. And do
(21:15):
it for a period of time, thedanger physiology goes away, and
now the body can start toconvert t4, to t3 naturally,
adaptively, optimally, and soyou'll see conversion go up as
you address these things. Thethere is some discussion that
there's many things likeSelenium and other
(21:36):
micronutrients that are reallyimportant for improved
conversion of t4, to t3 and thatis true, but I don't think the
primary issue for the vastmajority of people is they just
don't have enough micronutrientsto support the conversion.
Matter of fact, if somebody hasreduced conversion of t4 to t3
(21:58):
and has a higher level ofdeactivation of t4 to reverse t3
then obviously they have enoughmicronutrients to support the
iodinase, three, thedeactivation. So it's not a lack
of micronutrients. It is anadaptive response by the body.
And this is really the bestanswer. I know. It's not what,
really what everybody wants tohear. Everybody primarily wants
(22:22):
to know. Just tell me what I cantake and this makes it better.
That'll make my t3 better andmake me feel better. But life is
not that simple. When I amtrying to help somebody
understand what's causing thereduced conversion of t4 to t3
that's where I go back and lookat what I call the fitness
(22:42):
factors, their dietary fitness,their habits, their mindset,
their emotional stressors, theirdistress from relationships,
work stress, financial stress.How do they sleeping? Do they
have chronic infections, like,what is creating the excessive
stress on the individual? Andhow do I start to reduce or
(23:02):
eliminate those things? We canuse diet, diet modification. We
can use short term strategicsupplementation strategies. But
ultimately, the thing that hasbeen most effective, and I've
been doing this for 30 years atthis point, the thing that's
been most effective at helpingsomebody improve their t4 to t3
(23:23):
conversion is helping themidentify what's contributing to
their excessive stress load andstart reducing and eliminating
those things. It hasn't beenlots and lots and lots of
supplements. Supplements are agreat tool, but they are not the
tool.
There is no magic supplementthat's going to probably convert
(23:44):
increase your conversion of t4to t3, long term, we
usesupplementation strategicallyto help shift somebody from this
cell stress physiology back tohomeostatic physiology, once we
identify what those triggersare. But the most important
thing that you can do to improveyour t4 to t3 conversion is not
(24:05):
take t3 medication. It is to behonest with yourself, and it's
to it is to work with afunctional medicine or
integrated practitioner, to say,what is creating excessive
stress on my physiology that Ican start to reduce or eliminate.
If you start to do that, and youreally start to address the
(24:26):
overall stress load, more thanlikely you're going to see
improved conversion of t4 to t3on your own. The The one caveat
to that, and is that? Is thisthat many times excessive
thyroid medication is one of thebig stressors on your
physiology. It's not unusualthat somebody comes to see me.
(24:48):
They're on 3040, 6080,micrograms of t3, because t4
men. Medication on its owndidn't work. They tried NP,
thyroid or armor, and thatworked temporarily, but then
they couldn't find the dose, andthen they found somebody who
does t3 only therapy, and theystarted t3 therapy, and that
(25:10):
created some more positivechange, but it's led them to be
having to take 80 micrograms ormore on a daily regular basis,
and they still have hypo andhyper thyroid symptoms. And
while they feel better than theydid without thyroid medication
or maybe on the t4 alone,they're still chasing the
(25:32):
ultimate answer of, how do Iimprove my thyroid physiology?
How do I recover from a thyroidcondition, how do I feel better
and not have this kind of wiredand tired feeling that often
happens as people add t3medications? So what can you do
if you're one of those peoplewho's been on t4 medication and
(25:55):
you still don't feel and function?
Well, reach out to me or anotherfunctional or integrated
practitioner and get acomprehensive thyroid panel
done. Have see if you're eventhough your TSH may you may be
told your TSH is normal and yourt4 or free t4 is normal. Look at
the t3 levels and the free t3levels are they reduced. Look at
(26:19):
the reverse t3 is that elevated,and it what is the free to free
t3, to free t4, ratio? If thatis reduced, or any of those
things I said are, are aproblem. You have reduced
conversion. You're in this cellstress, inflammatory mechanism.
Your body is not converting t4to t3 optimally, or as it as in
(26:41):
a in a form that would make youfeel awesome. And it's not
because you're broken. It'sbecause you're operating from
this danger physiology yourbody's adaptively decreasing the
conversion of t4 to t3 and it'sprobably the same danger
physiology that triggered thethyroiditis and the loss of
(27:03):
gland function to begin with. Soget a more complete panel done.
The other thing you can do alongwith that is you can look at
inflammatory markers on yourblood work. If you run a uric
acid, a fibrinogen, a ferritin,a homocysteine, a CRP, or a host
of other inflammatory markers,and any of them are elevated,
(27:25):
you're now have confirmationthat you're not broken. You now
have confirmation that you havean inflammatory process going
on, and the reduced conversionof t4 to t3 is the adaptive
response and not brokenphysiology. More thyroid
hormone, regardless of whetherit's t4 or t3 will not fix this
(27:47):
situation. It can changesymptoms, it can change labs,
but it's not going to restoreyour thyroid physiology. Why?
Because it's not broken. Whatyou need to do is look at what's
contributing to the excessivecell stress response. And if you
need more help and more guidanceon this, you can pick up my
(28:08):
book, The thyroid debacle, wherewe talk about what some of these
fitness factors are. You can goto my website. Dr Balcavage,
www.dr, Eric balcavage.com, andyou can request a complimentary
discovery call, and we can talkabout what's going on and maybe
what the best options are foryou. But stop trying to fix the
(28:32):
t3 level. Stop trying to fix theconversion issue with more
thyroid hormone it's not theright strategy. If it was, you
would probably not be listeningto this podcast. You wouldn't be
struggling with chronichypothyroid symptoms and
sometimes hyper and hypothyroidsymptoms at the same time, and
(28:53):
you wouldn't be doing constantDr Google searches for how do I
feel better? How do I recover mythyroid physiology.
So if you need help thyroid andgo to my website, request a
discovery call, pick up my book,The thyroid DeMarco, and check
out some of those things, someof the suggestions in the book
(29:14):
that can help you, but don'tchase or spend too much time
trying to optimize your t3levels if you have this cell
stress, inflammatory processgoing on. The last comment I'll
make is, some people say, Well,if my thyroid gland is totally
destroyed, shouldn't I be onsome type of thyroid medication?
(29:35):
And I would agree, yes, you'regoing to be on some type of
thyroid medication, and itprobably should be t4 and my
suggestion would be a separatemedication of t3 I'm not a huge
fan of armor and NP thyroid forthe vast majority of people. I
think if we're going to providet4 and t3 it probably should be
(29:55):
done. Separately, so that we canincrease or decrease t4, and t3
separately. If you're takingarmor, np thyroid, if you
increase t, the NP thyroid orarmor, you're increasing both t4
and t3 if you need, if you're ifyou need to drop t3 you can't
drop it separately. You have todecrease the armor or the MP
(30:16):
thyroid, which means you'regoing to decrease t4 and t3 so
the best bet, in my opinion, isseparate t4 and t3 and the t3
probably taken in a split doseto maintain more flu, more
balance of your t3 levelsthrough the day. And we probably
shouldn't be providing morethyroid medication, in most
(30:36):
cases, than a healthy thyroidgland would have made in the
first place. And from a t3perspective, that may be five to
10 micrograms of t3 is maybewhat a healthy thyroid gland
would have made. Most of the t3is not made by your thyroid
gland. It's made by theperipheral tissues that are in a
(30:56):
homeostatic low stress state.Converting t4 to t3 that's what
maintains a higher level of t3free t3 and a lower level of
reverse t3 so I hope this hashelped. If you have any
challenges, questions, problems,you can reach out to me at my
office info at Dr Ericbalcallcavage.com, and you can
put your comments or questionsbelow wherever you watch this
(31:20):
video or listen to this podcast,and you can always reach out to
me on Instagram and send me adirect message with your
questions. All right, hopefullythis helps and stay tuned for
more thyroid answers and thyroidshorts episodes in the future.
Take care you
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