Your doctor checked one number. Your thyroid runs on six. Here is what each one means, what 'optimal' actually looks like versus 'normal,' and the exact script for requesting the full panel.
Victor, I tried a similar script of asking for more than a TSH test from my endocrinologist (Stanford educated and trained). He said no. So I replied, “Well, perhaps you should justify YOUR rationale for only testing TSH” and I will quote from his written email response to me: “Many of the aspects of thyroid hormone metabolism that you commented on are not easily measurable in the individual person and can only be addressed in a research setting where tissue biopsies were obtained and analyzed. The measurement of the serum levels gives little information about T3 or T4 uptake into the cells or T4-T3 conversion within the nucleus.” He goes on to ask ME the following questions: “How would you use different combinations of results on serum measurements? Suppose the TSH is mid-normal. What type of treatment might you seek if your free T4 is high normal or mildly elevated in the setting of a mid normal T3, or a free T4 mid to high normal with a low normal free T3 or a higher than normal free T3 and a mid normal free T4?” He goes on to add: “I am not sure how you are linking glucose metabolism with your thyroid hormone levels and would need to better understand that to respond.” He ends his email to me with this: “I am open to your discussion so I challenge you to tell me how you would use the different combination of results I listed above.” Really. This email exchange took place in 2024. Because of your posts, I now feel equipped to answer his ridiculous gaslighting but because I can, I stopped being his patient after 30 years. This is the same endocrinologist who asked me if I wanted to go on Metformin when I told him I wanted to address my rising glucose. The same doctor who refused to order a fasting insulin. With every post, Victor, you give us, your readers, the power to turn away from these arrogant terrible doctors and reclaim our health. Also, I no longer have Hashimoto’s. I feel foolish that I went to this man for 30 years, but I also feel empowered that I no longer need to listen to him. Thank you.
I want to address the email he sent you because it's actually a useful teaching moment, not for you, but for anyone else reading this who might encounter the same dismissal.
His argument was essentially: serum levels don't tell you about intracellular uptake or nuclear conversion, so why bother measuring them. This sounds sophisticated. But it contains its own contradiction. If serum free T3 and free T4 are so uninformative, then by his own logic, serum TSH is also uninformative, because TSH is a serum measurement reflecting the pituitary's interpretation of what it thinks is happening peripherally. If he trusts TSH, he's already trusting a serum marker's ability to reflect something meaningful. He just chose the one marker that happens to align with the least amount of work.
The challenge questions he posed ("what would you do if free T4 is high-normal and free T3 is low-normal?") have actual clinical answers. A high-normal free T4 with a low-normal free T3 and a mid-normal TSH suggests a peripheral conversion problem: the raw material is available but T4 isn't being efficiently converted to the active T3 form. That's clinically actionable. It points toward evaluating selenium status, iron/ferritin, liver function, cortisol, and gut health, all of which affect the deiodinase enzymes responsible for T4-to-T3 conversion. The fact that he asked those questions as a gotcha rather than as a clinical discussion tells you everything about how he approached your care.
The glucose-thyroid link he claimed not to understand is equally established. Thyroid hormone directly regulates hepatic glucose output, insulin sensitivity, and mitochondrial metabolic rate. Hypothyroid states are associated with insulin resistance and impaired glucose clearance. This isn't fringe. It's in the endocrinology textbooks.
You went to him for 30 years. That's not foolish. That's loyalty to a system you trusted. The fact that you walked away when the information finally showed you what that trust was costing you is not something to feel foolish about. That's strength.
And the Hashimoto's remission tells its own story. When the right interventions finally reach the immune system and the thyroid, the body can sometimes do exactly what the old approach insisted it couldn't.
I wish I had known about your research-driven, engaging, and informative posts back in 2024, Victor. Instead, I remember feeling demoralized and intimidated. And angry. But maybe that anger was a good thing because it made me finally realize there was no white coat in shining armor coming to save me; I had to save myself. It was your posts about cortisol that had the most impact on me, a bio-marker I tested on my own that repeatedly was flagged as high, that finally led to my healing journey. I still have much to learn, but I am grateful every day for the insight, encouragement, and depth of knowledge you so willingly share with your readers … and the kindness with which you respond (in more detail!) to those of us searching for healing. Thank you!!!
This theory about serum measurement of t4&t3 levels is pervasive in NZ and labs will not test these unless the TSH is “outside of normal range”. It is used to save money on lab tests. I have to pay for my t4&3 tests if I want them. I have a new doctor who was supposedly interested in thyroid. I debated him for half an hour about this. His argument was that t3&4 levels were hugely changeable and results were not to be believed except in a macro way. He said levels varied as to what you eat for dinner the night before, how much sleep you had , how hydrated you were etc etc and that tissue biopsies were the only way to get good measurements. I’m sure there’s is some truth in this BUT those of us who monitor our levels know that how we feel does correlate with what the number says. I was hyper last year and on my way down (taking anti thyroid drugs) I reached a t4&3 level that I may never have been at before!! Optimal! I felt so energetic and cognitively sharp. It was wonderful. Sadly I wasn’t proactive enough to reduce the drugs quickly and was plunged into a tired hypo state ! Only private functional Doctors - will work outside this model!????
The argument your doctor made is structurally identical to one I addressed from a Stanford-trained endocrinologist in another comment, and the rebuttal is the same: if serum T3 and T4 are too variable to be trusted, then serum TSH is equally unreliable by the same logic, because TSH is also a serum measurement that fluctuates with circadian rhythm, stress, sleep, illness, and even the time of day the blood is drawn. They're selecting the one marker that requires the least work and then using variability as the reason to dismiss the others. That's not a scientific position. It's a workload management position.
Yes, free T3 and free T4 fluctuate. So does every biomarker in the body, including TSH. That's why you don't make clinical decisions on a single draw. You look at trends across multiple draws, taken at consistent times (ideally fasting, morning, before medication if applicable). Variation is a feature of biology, not a reason to stop measuring.
The experience you had during your Graves treatment is the most valuable data point in your entire medical history. You experienced optimal thyroid levels for what may have been the first time, and the difference in energy, cognition, and how you felt was unmistakable. That tells you exactly what your body is capable of when thyroid hormones are in the right range. The fact that you fell past that window into hypo because the medication wasn't adjusted quickly enough is a medication management issue, not evidence that the measurements were unreliable.
The NZ and Australian model of restricting T3/T4 testing to save lab costs is creating a population of undertreated thyroid patients who are told they're fine based on incomplete data. The cost savings on labs is being paid for in quality of life. You already know this because you lived it.
If private functional doctors are the only ones who will run the full panel, and you have access to one, that may be the price of getting the data you need. It shouldn't be, but until the policy changes, the alternative is flying blind on two-thirds of the picture.
To me, one of the greatest advancements in medicine over the past few years is that anyone can go online to Ulta or Walk-in Labs and order any test they want, stripping doctors of their gate-keeping powers.
I went ER 11 years ago with messed up thyroid and asked them to do thyroid bloodwork. They of course did only TSH.
The physician said - everything is ok. I asked to see the sheet. It read, TSH: 4.69. (My normal used to be 1.15). It's hard to describe the gut punch feeling you get when a medical authority figure keeps telling you you are ok but your own body is falling apart. Yet so many of us experience it.
After 8 years of that, I finally went to an ND. She ran the full thyroid panel, TSH was 2.3, other things were within "normal" limits, and she as well convinced me my thyroid needed no support.
Another 3 miserable years went by and I finally begged her to start me on a mini dose of thyroid. She finally agreed. Second day of taking it I felt like a new person, and I still do, 2 months after starting.
I do get angry, thinking of those 11 years of misery, depression, fatigue, anxiety --yet all responsibilities tended to, all the meals made, all the laundry folded, all the work completed, despite falling apart constantly--that 15mg (and then 30mg daily) of thyroid resolved in less then 48 hrs
I need to point something out about what you just wrote, because I don't think you see it clearly yet.
You listed everything you maintained for 11 years while falling apart: the responsibilities tended to, the meals made, the laundry folded, the work completed. You listed those as if they were minor details in the story. They're not. They're the entire story. You carried a full life on your back for over a decade while your body was running on a fraction of the thyroid hormone it needed, and you did it so completely that everyone around you, including your medical providers, concluded you were fine. Because you never stopped performing.
That performance is exactly why the system failed you. You didn't look like someone whose thyroid was destroying her quality of life. You looked like someone who was managing. And medicine has a terrible habit of confusing "managing" with "healthy."
Your TSH went from your personal baseline of 1.15 to 4.69 and they told you it was normal. That's a 4x increase in the signal your pituitary was sending to your thyroid, screaming for more hormone production, and it was dismissed because 4.69 falls within the conventional reference range of 0.4-4.5 (and many labs now extend it to 5.0). The range is built from population averages, not from your individual baseline. A TSH of 4.69 for someone whose normal is 1.15 is a completely different clinical picture than a TSH of 4.69 for someone who's always run at 3.5. Context got ignored. You paid for it with 11 years.
The fact that 15-30mg of thyroid medication resolved depression, fatigue, and anxiety in less than 48 hours tells you everything about what those 11 years were. They weren't a personal failing. They weren't aging. They weren't "stress." They were hypothyroid symptoms that responded immediately to the hormone that was missing. If it were anything else, a tiny dose of thyroid medication wouldn't have touched it.
Your anger is earned. Use it to make sure the next woman who walks into that ER with a TSH 4x her baseline doesn't get told she's fine.
Thank you Victor. Yes, I'm telling to whoever will listen. I also think some men too might benefit from being told about this thyroid business. And yes -- there is such a huge difference between "managing" and "healthy".
Passing it on is the best thing you can do with it. One reader who shares it with three people who share it with three more: that's how information reaches the women who need it most but would never have found it on their own. Thank you. 🙏
Interesting information and I will re-evaluate my test results. I don't see the endocrinologist until December, so I will probably have to do a pay out of pocket for now and have the other draw closer to my Dec appt. I can ask insurance about the extra markers and whether they pay or not. It doesn't matter who pays, the results are the my concern. Thank-you for all your research and sharing.
That last line is the one I'd frame. "It doesn't matter who pays, the results are my concern." That's the approach that changes outcomes. When you walk into December with two sets of data instead of one, you have a trajectory, not just a snapshot. And a trajectory tells you more than any single lab draw ever could. Bring both sets. Compare them yourself before the appointment so you know what questions to ask.
Started with a novella. The real stuff: great conversation w/ insurance nurse, names provided for new endocrinologist, and nurses vs Dr's as nurses typically have more time to spend with patient, don't look at just the one set of blood lab results, they look at trends, I don't need to be as stringent in my food choices as I have- can eat more normally ( but I will still continue to watch sodium and potassium levels), nurse will be able to taylor meal plan, insurance nurse will stay in the loop. A much more positive look than I was having. I do see a downward trend in some important markers that started after I had a 'stroke like' presentation at ER back in 8/2024. Got my charts ready. BTW, I was following your meal eating order and even with the overkill of limiting food choices, I wasn't starving and certainly had no problem sleeping through night. BRAVO:). A continued thank-you for your support.
The nurse is exactly the right person to have in your corner right now. You nailed the observation: nurses typically have more time, they look at trends rather than single snapshots, and they treat the whole patient rather than the single lab value in front of them. The fact that she's staying in the loop, providing endocrinologist referrals, and will tailor a meal plan means you finally have a continuous relationship with someone who's tracking your trajectory rather than seeing you once and moving on.
The permission to eat more normally is important. You were being more restrictive than you needed to be, and the meal eating order was giving you the metabolic benefits (blood sugar stability, satiety, better sleep) without requiring the extreme food limitations you'd imposed on yourself. Not starving and sleeping through the night while following the eating order is exactly how it's supposed to work. The framework is doing its job. Let it.
The downward trend in markers since the 8/2024 ER presentation is the data the endocrinologist needs to see. You have the charts. You have the timeline. When you sit with the new endocrinologist, you're walking in with a trend line, not a complaint. That changes the conversation completely.
This is what it looks like when the system starts working for you instead of against you. You pushed for it. You earned this progress. Keep going.
Thank you for sharing your knowledge so generously. I, after ten years (starting at age 22), finally found a doctor to give me a full thyroid panel. My TSH, T4 and T3 are “normal”. So I was dismissed. Now I’m looking at my lab results. TPO: 340 IU/mL. Thyroglobulin Antibody: 25.7.
I feel both empowered, seen and so sad I have been fighting with my body for so long. I knew something was wrong, each time at every appointment I would get the “just lose weight lecture” so I put myself on a GLP to help and even though I had painstakingly slow results, I lost some weight but still felt completely horrible.
I’m not sure what I’m here to say but solidarity to the women here in these comments. At 32 years old I finally feel like I have a few pieces of the puzzle. Thank you 🫶🏼
I need you to hear something clearly: you just got the diagnosis that ten years of doctors missed by refusing to run the right tests.
TPO antibodies at 340 IU/mL is massively elevated. Normal is typically below 35. Thyroglobulin antibodies at 25.7 are also elevated. These two results together tell you definitively that your immune system has been attacking your thyroid gland, probably for years. That's Hashimoto's thyroiditis. Your TSH, T4, and T3 being "normal" right now means the thyroid hasn't failed yet. It's under siege, but it's still producing. That's why you were dismissed at every appointment: the function tests looked fine, so nobody looked deeper. But the antibodies show the fire that's burning underneath the "normal" numbers, and eventually, if it's not addressed, the function will decline.
Every "just lose weight" lecture you received for a decade was a doctor looking at a symptom and ignoring the mechanism. Hashimoto's directly affects metabolism, energy expenditure, and body composition. Telling someone with autoimmune thyroid disease to just lose weight without investigating the thyroid is like telling someone with a broken leg to just walk faster.
What matters now: you have data. You have a diagnosis. The next step is finding a provider who will actually monitor the antibodies, track thyroid function over time, and implement the interventions that can slow the autoimmune process. Selenium (200mcg daily of selenomethionine) has the strongest evidence for reducing TPO antibodies. Optimizing vitamin D, iron, and gut health are all part of the Hashimoto's management picture. Some women with Hashimoto's benefit significantly from removing gluten, because there's a molecular mimicry mechanism where gliadin peptides resemble thyroid tissue and can sustain the autoimmune attack.
You're 32. You caught this before the thyroid failed completely. That's not too late. That's early. And the fact that you kept pushing for 10 years until someone finally ran the right tests tells me everything about who you are.
You are not the person those doctors told you you were. 🫶🏼
I keep a spreadsheet of every blood test I've had since 2014, including columns for what it's testing for, normal range, and now (thanks to you!) optimal range. Your articles are helping me to be able to use this data to better interpret how I've been feeling for the last few years, as well as see patterns.
I had TSH and Free T4 run 2 months ago, and 14 months before that. Prior to that, my doc only ran TSH. From 2014-2025, it ranged from 0.88 to 2.17. In March of last year, it was 1.36, well within my normal range. This May, it had jumped to 3.98. My Free T4 scores on those draws were virtually identical at .94 and .96 respectively.
I've been unable to sleep properly since having Covid 3 years ago, and am chronically exhausted. As part of my May labs, I tested Ferritin (37), serum Mag (2.2), Vit B-12 (408), Vit D-25 (48.1), ESR (11), and Morning Cortisol (37). I also had a 90-point drop in my Total Cholesterol (70 of it in LDL) despite no changes whatsoever to diet, exercise, or meds (I'm on none for lipids). The only thing that got a reaction from my now-former PCP was the Cortisol ("see an endocrinologist," which I plan to do).
I am gradually implementing your Cortisol protocol, having added Ashwaganda and L-theanine (I've been on Mag Glycinate for years), and have just added iron, Vit C, Vit K, and Vit B-12. I'm being conscientious about adequate protein, carbs, and calories (in spite of gaining 45 lb in 6 years). I plan to rerun all these labs once I'm established with an endocrinologist. In the meantime, any additional advice and/or observations? (I'm 71 and on Tamoxifen for breast cancer, BTW.) As always, I really appreciate your sharing your knowledge!
You're doing something most patients don't, and I want to acknowledge it before I get into the specifics: keeping a longitudinal spreadsheet of your labs since 2014 means you have trend data that your doctors can see at a glance instead of pulling up fragmented records across systems. That's powerful. When you walk into the endocrinologist, you're not showing up with a complaint. You're showing up with a decade of data. Use that.
Now let me walk through what stands out.
TSH jump from 1.36 to 3.98 in 14 months with stable Free T4. This is the most important finding in your labs right now. A TSH nearly tripling while Free T4 barely moves suggests the pituitary is sensing inadequate thyroid hormone at the tissue level, even though circulating T4 hasn't dropped. There are a few things that could drive this pattern, and one of them is directly relevant to your situation: Tamoxifen increases thyroid-binding globulin (TBG) production in the liver. More TBG means more T4 gets bound in the blood, leaving less free hormone available. The Free T4 on your lab result measures unbound hormone, and if it's sitting at .94-.96, it's in the lower half of most reference ranges. Your pituitary may be responding to functionally low free hormone availability even though the number looks "normal." Ask the endocrinologist to check thyroid antibodies (TPO and thyroglobulin) to rule out autoimmune thyroid disease, and to evaluate whether the Tamoxifen-TBG relationship is affecting your effective thyroid hormone levels. Also request Free T3, because if peripheral conversion is being impaired (and your ferritin at 37 would contribute to that), Free T3 is where it will show up.
Ferritin at 37. Suboptimal. Iron is a required component of thyroid peroxidase, the enzyme that synthesizes thyroid hormone, and it's needed for the deiodinase enzymes that convert T4 to active T3. Below 50, thyroid conversion is measurably impaired. You've started iron, which is the right move. Take it with vitamin C (which you're doing) on an empty stomach or with a light meal, and separate it from your other supplements by at least 2 hours. Target a ferritin above 50, ideally 50-70.
B12 at 408. Functional range wants this above 500. At 408 it's not critically low, but it's not providing optimal neurological and metabolic support. Your supplementation should move this up. Methylcobalamin or hydroxocobalamin are the better-absorbed forms.
Vitamin D at 48.1. Good but not quite optimal. The 50-80 ng/mL range is where most of the evidence for bone, immune, and metabolic benefits concentrates. A small increase in your D3 dose could push you into that range.
Morning Cortisol at 37. Your doctor's reaction (see an endocrinologist) tells you this was flagged as significantly elevated. Depending on the unit, this is well above the normal morning range. The endocrinologist will likely want to rule out Cushing's syndrome (24-hour urine cortisol, late-night salivary cortisol, dexamethasone suppression test). If Cushing's is ruled out, this likely reflects chronic HPA axis dysregulation, and three years of post-COVID insomnia is exactly the kind of persistent stressor that can drive sustained cortisol elevation. Elevated cortisol contributes to insulin resistance, visceral fat accumulation, bone loss, and immune dysregulation, so addressing this is central to everything else.
The 90-point cholesterol drop. This one likely has a straightforward explanation: Tamoxifen. Tamoxifen acts as a weak estrogen agonist in the liver, which increases LDL receptor expression and accelerates LDL clearance from the blood. A 70-point drop in LDL is a well-documented Tamoxifen effect. If the Tamoxifen was started or the dose was adjusted in the period between your two cholesterol measurements, that's almost certainly the cause. This is actually one of Tamoxifen's known metabolic effects and isn't typically a concern. Mention it to the endocrinologist for confirmation, but I wouldn't expect it to be unexplained once the Tamoxifen effect is accounted for.
One critical note on your supplements. You're on Tamoxifen for breast cancer. This means any supplement that has estrogenic activity or that affects the CYP2D6 enzyme pathway (which is how Tamoxifen is metabolized to its active form, endoxifen) needs to be confirmed safe by your oncologist. Most of what you're taking (magnesium, iron, B12, vitamin C, vitamin K, L-theanine) should be fine. Ashwagandha is generally considered safe alongside Tamoxifen, but since it can modulate immune function and has some effects on thyroid hormone levels, it's worth confirming with your oncology team. And avoid any supplements with phytoestrogenic activity (red clover, black cohosh, concentrated soy isoflavones) since they could interfere with Tamoxifen's mechanism.
You're approaching this with exactly the right combination of diligence and proactivity. The endocrinologist appointment is the key next step, and you'll be one of the most prepared patients they see. Bring the spreadsheet.
Thank you for this! When I looked at the Lipid results, I asked a friend who's a retired cardiologist for his take; he suggested possible lab error. I also reached out to my then-PCP, pointing out that I had years of consistent numbers, and asking if I should be concerned. Her response was a terse “no concerns with this lab.” Did she know about this Tamoxifen side effect? I'll never know. But after reading your response, I looked it up and found a meta study, which I sent to my friend. We both found it quite interesting that the same drug protects me from cancer, bone loss, and cardiovascular disease.
This is exactly how this is supposed to work. You had an unexplained lab finding. Your cardiologist friend's first instinct was lab error, which is a reasonable clinical reflex when numbers move that dramatically. Your PCP dismissed it without explanation. And then you found the mechanism yourself, confirmed it with a meta-study, and educated both yourself and your cardiologist friend in the process.
The triple protection from Tamoxifen (anti-cancer through estrogen receptor blockade in breast tissue, bone preservation through estrogen agonist activity in bone, and cardiovascular protection through LDL receptor upregulation in the liver) is genuinely remarkable pharmacology. It's one drug acting as an antagonist in one tissue and an agonist in others simultaneously. That's the SERM mechanism, and it's why Tamoxifen has survived as a frontline treatment for decades despite newer drugs entering the market.
Your former PCP's "no concerns" without explaining the why is another example of what I keep writing about: the answer existed, but the explanation didn't follow the answer. You deserved to know why your cholesterol dropped 90 points. Not just that it wasn't concerning, but what caused it. That gap between answer and explanation is the space these articles live in.
Glad the cardiologist friend found the meta-study interesting. Now he knows too.
This article helps so much, and yes, I need to print out. I also messaged you today. After reading this, tomorrow’s appointment with my MD will probably just function as my medicare checkup, and little else.
Even if the appointment is just a checkup, bring your questions. A Medicare visit is still a face-to-face interaction with a doctor who can order labs and refer you to specialists. Don't let it be a passive experience. Walk in with a list: the labs you want run, the markers you want checked, the questions this article raised for you. The doctor may not volunteer those tests on their own, but if you ask clearly and specifically, most will order them. The appointment is yours, not theirs. Use it. And I'll look for your message.
OMG so interesting, story of my life, was thinking of writing about and I will. TSI testing all the time but more expensive test. It is genetic in my family. Started with Graves-Basedow (highest results the lab ever saw), now Hashimoto. Honoustly I only believe in medicine but will read anyway. Had strumazol and elthyroxine and both combined too.
Graves flipping to Hashimoto's is a well-documented pattern in autoimmune thyroid disease. The underlying driver, the immune system targeting thyroid tissue, is the same in both. What changes is which antibodies dominate: stimulating antibodies (TSI) in Graves cause overproduction, blocking and destructive antibodies (TPO, TgAb) in Hashimoto's cause underproduction. The fact that it's genetic in your family means the autoimmune susceptibility is wired in, and the expression just shifted form.
Believing in medicine and reading this aren't in conflict. Everything I write is based on the same peer-reviewed research your doctors use. I'm not trying to replace your medical team. I'm trying to make sure you walk into those appointments understanding the mechanisms well enough to have better conversations. Read with that lens and take what's useful.
Thanks, like I said I will read tomorrow ( after the semi finale)😉, and what you wrote is what the doctors predicted me 30 years ago. So I knew this was coming all the way. The thing which is difficult is living with the side effects: eye problems, intensity of not feeling hungry at all and being extremely hungry...sweating....But my thyroid values are now in the 'middle' so much better. My friend's thyroid doesn't function anymore at all which is more of a problem.
Enjoy the semi-final first. The article will still be here. 😉
The side effects you're describing are all consistent with the thyroid system trying to find its new equilibrium. The hunger swings (not hungry at all, then extremely hungry) are thyroid-driven metabolic oscillation. When T3 and T4 fluctuate, your body's energy regulation swings with them. Ghrelin and leptin signaling get jerky because the metabolic rate isn't stable enough for those hormones to calibrate against. As your values settle into the middle and stay there, those swings should dampen over time.
The sweating is the same mechanism: your thermoregulatory system is responding to fluctuating thyroid output. When T3 is higher in the cycle, heat production goes up. When it dips, it comes down. Once the values stabilize, thermoregulation smooths out.
The eye issues: if this is Graves-related (thyroid eye disease/Graves' ophthalmopathy), that's a separate autoimmune process that can persist or worsen even as thyroid values normalize, because the antibodies targeting the orbital tissue behind the eyes are distinct from the ones affecting the thyroid itself. If you're noticing changes in your eyes (bulging, dryness, pressure, vision changes), keep your ophthalmologist in the loop. That deserves its own monitoring track.
Your friend whose thyroid no longer functions at all is on full replacement, which creates a different challenge: getting the medication dose precisely right to replicate what a functioning gland would do dynamically. It's doable, but it requires more frequent lab monitoring and dose adjustments than most doctors provide.
You knew this was coming for 30 years. That doesn't make living through it easier, but it does mean you're not caught off guard. That's an advantage most people don't get.
Victor, I tried a similar script of asking for more than a TSH test from my endocrinologist (Stanford educated and trained). He said no. So I replied, “Well, perhaps you should justify YOUR rationale for only testing TSH” and I will quote from his written email response to me: “Many of the aspects of thyroid hormone metabolism that you commented on are not easily measurable in the individual person and can only be addressed in a research setting where tissue biopsies were obtained and analyzed. The measurement of the serum levels gives little information about T3 or T4 uptake into the cells or T4-T3 conversion within the nucleus.” He goes on to ask ME the following questions: “How would you use different combinations of results on serum measurements? Suppose the TSH is mid-normal. What type of treatment might you seek if your free T4 is high normal or mildly elevated in the setting of a mid normal T3, or a free T4 mid to high normal with a low normal free T3 or a higher than normal free T3 and a mid normal free T4?” He goes on to add: “I am not sure how you are linking glucose metabolism with your thyroid hormone levels and would need to better understand that to respond.” He ends his email to me with this: “I am open to your discussion so I challenge you to tell me how you would use the different combination of results I listed above.” Really. This email exchange took place in 2024. Because of your posts, I now feel equipped to answer his ridiculous gaslighting but because I can, I stopped being his patient after 30 years. This is the same endocrinologist who asked me if I wanted to go on Metformin when I told him I wanted to address my rising glucose. The same doctor who refused to order a fasting insulin. With every post, Victor, you give us, your readers, the power to turn away from these arrogant terrible doctors and reclaim our health. Also, I no longer have Hashimoto’s. I feel foolish that I went to this man for 30 years, but I also feel empowered that I no longer need to listen to him. Thank you.
I want to address the email he sent you because it's actually a useful teaching moment, not for you, but for anyone else reading this who might encounter the same dismissal.
His argument was essentially: serum levels don't tell you about intracellular uptake or nuclear conversion, so why bother measuring them. This sounds sophisticated. But it contains its own contradiction. If serum free T3 and free T4 are so uninformative, then by his own logic, serum TSH is also uninformative, because TSH is a serum measurement reflecting the pituitary's interpretation of what it thinks is happening peripherally. If he trusts TSH, he's already trusting a serum marker's ability to reflect something meaningful. He just chose the one marker that happens to align with the least amount of work.
The challenge questions he posed ("what would you do if free T4 is high-normal and free T3 is low-normal?") have actual clinical answers. A high-normal free T4 with a low-normal free T3 and a mid-normal TSH suggests a peripheral conversion problem: the raw material is available but T4 isn't being efficiently converted to the active T3 form. That's clinically actionable. It points toward evaluating selenium status, iron/ferritin, liver function, cortisol, and gut health, all of which affect the deiodinase enzymes responsible for T4-to-T3 conversion. The fact that he asked those questions as a gotcha rather than as a clinical discussion tells you everything about how he approached your care.
The glucose-thyroid link he claimed not to understand is equally established. Thyroid hormone directly regulates hepatic glucose output, insulin sensitivity, and mitochondrial metabolic rate. Hypothyroid states are associated with insulin resistance and impaired glucose clearance. This isn't fringe. It's in the endocrinology textbooks.
You went to him for 30 years. That's not foolish. That's loyalty to a system you trusted. The fact that you walked away when the information finally showed you what that trust was costing you is not something to feel foolish about. That's strength.
And the Hashimoto's remission tells its own story. When the right interventions finally reach the immune system and the thyroid, the body can sometimes do exactly what the old approach insisted it couldn't.
I wish I had known about your research-driven, engaging, and informative posts back in 2024, Victor. Instead, I remember feeling demoralized and intimidated. And angry. But maybe that anger was a good thing because it made me finally realize there was no white coat in shining armor coming to save me; I had to save myself. It was your posts about cortisol that had the most impact on me, a bio-marker I tested on my own that repeatedly was flagged as high, that finally led to my healing journey. I still have much to learn, but I am grateful every day for the insight, encouragement, and depth of knowledge you so willingly share with your readers … and the kindness with which you respond (in more detail!) to those of us searching for healing. Thank you!!!
I was so looking forward to your rational reply to this shameful gaslighting of a (loyal) patient. Teaching moment indeed!
This theory about serum measurement of t4&t3 levels is pervasive in NZ and labs will not test these unless the TSH is “outside of normal range”. It is used to save money on lab tests. I have to pay for my t4&3 tests if I want them. I have a new doctor who was supposedly interested in thyroid. I debated him for half an hour about this. His argument was that t3&4 levels were hugely changeable and results were not to be believed except in a macro way. He said levels varied as to what you eat for dinner the night before, how much sleep you had , how hydrated you were etc etc and that tissue biopsies were the only way to get good measurements. I’m sure there’s is some truth in this BUT those of us who monitor our levels know that how we feel does correlate with what the number says. I was hyper last year and on my way down (taking anti thyroid drugs) I reached a t4&3 level that I may never have been at before!! Optimal! I felt so energetic and cognitively sharp. It was wonderful. Sadly I wasn’t proactive enough to reduce the drugs quickly and was plunged into a tired hypo state ! Only private functional Doctors - will work outside this model!????
The argument your doctor made is structurally identical to one I addressed from a Stanford-trained endocrinologist in another comment, and the rebuttal is the same: if serum T3 and T4 are too variable to be trusted, then serum TSH is equally unreliable by the same logic, because TSH is also a serum measurement that fluctuates with circadian rhythm, stress, sleep, illness, and even the time of day the blood is drawn. They're selecting the one marker that requires the least work and then using variability as the reason to dismiss the others. That's not a scientific position. It's a workload management position.
Yes, free T3 and free T4 fluctuate. So does every biomarker in the body, including TSH. That's why you don't make clinical decisions on a single draw. You look at trends across multiple draws, taken at consistent times (ideally fasting, morning, before medication if applicable). Variation is a feature of biology, not a reason to stop measuring.
The experience you had during your Graves treatment is the most valuable data point in your entire medical history. You experienced optimal thyroid levels for what may have been the first time, and the difference in energy, cognition, and how you felt was unmistakable. That tells you exactly what your body is capable of when thyroid hormones are in the right range. The fact that you fell past that window into hypo because the medication wasn't adjusted quickly enough is a medication management issue, not evidence that the measurements were unreliable.
The NZ and Australian model of restricting T3/T4 testing to save lab costs is creating a population of undertreated thyroid patients who are told they're fine based on incomplete data. The cost savings on labs is being paid for in quality of life. You already know this because you lived it.
If private functional doctors are the only ones who will run the full panel, and you have access to one, that may be the price of getting the data you need. It shouldn't be, but until the policy changes, the alternative is flying blind on two-thirds of the picture.
Wow...this is shocking, when seen so clearly typed down. Gaslighting indeed. Good that you stopped seeing him.
To me, one of the greatest advancements in medicine over the past few years is that anyone can go online to Ulta or Walk-in Labs and order any test they want, stripping doctors of their gate-keeping powers.
I went ER 11 years ago with messed up thyroid and asked them to do thyroid bloodwork. They of course did only TSH.
The physician said - everything is ok. I asked to see the sheet. It read, TSH: 4.69. (My normal used to be 1.15). It's hard to describe the gut punch feeling you get when a medical authority figure keeps telling you you are ok but your own body is falling apart. Yet so many of us experience it.
After 8 years of that, I finally went to an ND. She ran the full thyroid panel, TSH was 2.3, other things were within "normal" limits, and she as well convinced me my thyroid needed no support.
Another 3 miserable years went by and I finally begged her to start me on a mini dose of thyroid. She finally agreed. Second day of taking it I felt like a new person, and I still do, 2 months after starting.
I do get angry, thinking of those 11 years of misery, depression, fatigue, anxiety --yet all responsibilities tended to, all the meals made, all the laundry folded, all the work completed, despite falling apart constantly--that 15mg (and then 30mg daily) of thyroid resolved in less then 48 hrs
I need to point something out about what you just wrote, because I don't think you see it clearly yet.
You listed everything you maintained for 11 years while falling apart: the responsibilities tended to, the meals made, the laundry folded, the work completed. You listed those as if they were minor details in the story. They're not. They're the entire story. You carried a full life on your back for over a decade while your body was running on a fraction of the thyroid hormone it needed, and you did it so completely that everyone around you, including your medical providers, concluded you were fine. Because you never stopped performing.
That performance is exactly why the system failed you. You didn't look like someone whose thyroid was destroying her quality of life. You looked like someone who was managing. And medicine has a terrible habit of confusing "managing" with "healthy."
Your TSH went from your personal baseline of 1.15 to 4.69 and they told you it was normal. That's a 4x increase in the signal your pituitary was sending to your thyroid, screaming for more hormone production, and it was dismissed because 4.69 falls within the conventional reference range of 0.4-4.5 (and many labs now extend it to 5.0). The range is built from population averages, not from your individual baseline. A TSH of 4.69 for someone whose normal is 1.15 is a completely different clinical picture than a TSH of 4.69 for someone who's always run at 3.5. Context got ignored. You paid for it with 11 years.
The fact that 15-30mg of thyroid medication resolved depression, fatigue, and anxiety in less than 48 hours tells you everything about what those 11 years were. They weren't a personal failing. They weren't aging. They weren't "stress." They were hypothyroid symptoms that responded immediately to the hormone that was missing. If it were anything else, a tiny dose of thyroid medication wouldn't have touched it.
Your anger is earned. Use it to make sure the next woman who walks into that ER with a TSH 4x her baseline doesn't get told she's fine.
Thank you Victor. Yes, I'm telling to whoever will listen. I also think some men too might benefit from being told about this thyroid business. And yes -- there is such a huge difference between "managing" and "healthy".
This is a wealth of information all in one place! Thank you so much for this comprehensive explanation 🙏 I’ve archived to pass on to as many as I can.
Passing it on is the best thing you can do with it. One reader who shares it with three people who share it with three more: that's how information reaches the women who need it most but would never have found it on their own. Thank you. 🙏
Interesting information and I will re-evaluate my test results. I don't see the endocrinologist until December, so I will probably have to do a pay out of pocket for now and have the other draw closer to my Dec appt. I can ask insurance about the extra markers and whether they pay or not. It doesn't matter who pays, the results are the my concern. Thank-you for all your research and sharing.
That last line is the one I'd frame. "It doesn't matter who pays, the results are my concern." That's the approach that changes outcomes. When you walk into December with two sets of data instead of one, you have a trajectory, not just a snapshot. And a trajectory tells you more than any single lab draw ever could. Bring both sets. Compare them yourself before the appointment so you know what questions to ask.
Started with a novella. The real stuff: great conversation w/ insurance nurse, names provided for new endocrinologist, and nurses vs Dr's as nurses typically have more time to spend with patient, don't look at just the one set of blood lab results, they look at trends, I don't need to be as stringent in my food choices as I have- can eat more normally ( but I will still continue to watch sodium and potassium levels), nurse will be able to taylor meal plan, insurance nurse will stay in the loop. A much more positive look than I was having. I do see a downward trend in some important markers that started after I had a 'stroke like' presentation at ER back in 8/2024. Got my charts ready. BTW, I was following your meal eating order and even with the overkill of limiting food choices, I wasn't starving and certainly had no problem sleeping through night. BRAVO:). A continued thank-you for your support.
Stormy, THIS is the update I was hoping for.
The nurse is exactly the right person to have in your corner right now. You nailed the observation: nurses typically have more time, they look at trends rather than single snapshots, and they treat the whole patient rather than the single lab value in front of them. The fact that she's staying in the loop, providing endocrinologist referrals, and will tailor a meal plan means you finally have a continuous relationship with someone who's tracking your trajectory rather than seeing you once and moving on.
The permission to eat more normally is important. You were being more restrictive than you needed to be, and the meal eating order was giving you the metabolic benefits (blood sugar stability, satiety, better sleep) without requiring the extreme food limitations you'd imposed on yourself. Not starving and sleeping through the night while following the eating order is exactly how it's supposed to work. The framework is doing its job. Let it.
The downward trend in markers since the 8/2024 ER presentation is the data the endocrinologist needs to see. You have the charts. You have the timeline. When you sit with the new endocrinologist, you're walking in with a trend line, not a complaint. That changes the conversation completely.
This is what it looks like when the system starts working for you instead of against you. You pushed for it. You earned this progress. Keep going.
Thank you for sharing your knowledge so generously. I, after ten years (starting at age 22), finally found a doctor to give me a full thyroid panel. My TSH, T4 and T3 are “normal”. So I was dismissed. Now I’m looking at my lab results. TPO: 340 IU/mL. Thyroglobulin Antibody: 25.7.
I feel both empowered, seen and so sad I have been fighting with my body for so long. I knew something was wrong, each time at every appointment I would get the “just lose weight lecture” so I put myself on a GLP to help and even though I had painstakingly slow results, I lost some weight but still felt completely horrible.
I’m not sure what I’m here to say but solidarity to the women here in these comments. At 32 years old I finally feel like I have a few pieces of the puzzle. Thank you 🫶🏼
I need you to hear something clearly: you just got the diagnosis that ten years of doctors missed by refusing to run the right tests.
TPO antibodies at 340 IU/mL is massively elevated. Normal is typically below 35. Thyroglobulin antibodies at 25.7 are also elevated. These two results together tell you definitively that your immune system has been attacking your thyroid gland, probably for years. That's Hashimoto's thyroiditis. Your TSH, T4, and T3 being "normal" right now means the thyroid hasn't failed yet. It's under siege, but it's still producing. That's why you were dismissed at every appointment: the function tests looked fine, so nobody looked deeper. But the antibodies show the fire that's burning underneath the "normal" numbers, and eventually, if it's not addressed, the function will decline.
Every "just lose weight" lecture you received for a decade was a doctor looking at a symptom and ignoring the mechanism. Hashimoto's directly affects metabolism, energy expenditure, and body composition. Telling someone with autoimmune thyroid disease to just lose weight without investigating the thyroid is like telling someone with a broken leg to just walk faster.
What matters now: you have data. You have a diagnosis. The next step is finding a provider who will actually monitor the antibodies, track thyroid function over time, and implement the interventions that can slow the autoimmune process. Selenium (200mcg daily of selenomethionine) has the strongest evidence for reducing TPO antibodies. Optimizing vitamin D, iron, and gut health are all part of the Hashimoto's management picture. Some women with Hashimoto's benefit significantly from removing gluten, because there's a molecular mimicry mechanism where gliadin peptides resemble thyroid tissue and can sustain the autoimmune attack.
You're 32. You caught this before the thyroid failed completely. That's not too late. That's early. And the fact that you kept pushing for 10 years until someone finally ran the right tests tells me everything about who you are.
You are not the person those doctors told you you were. 🫶🏼
I keep a spreadsheet of every blood test I've had since 2014, including columns for what it's testing for, normal range, and now (thanks to you!) optimal range. Your articles are helping me to be able to use this data to better interpret how I've been feeling for the last few years, as well as see patterns.
I had TSH and Free T4 run 2 months ago, and 14 months before that. Prior to that, my doc only ran TSH. From 2014-2025, it ranged from 0.88 to 2.17. In March of last year, it was 1.36, well within my normal range. This May, it had jumped to 3.98. My Free T4 scores on those draws were virtually identical at .94 and .96 respectively.
I've been unable to sleep properly since having Covid 3 years ago, and am chronically exhausted. As part of my May labs, I tested Ferritin (37), serum Mag (2.2), Vit B-12 (408), Vit D-25 (48.1), ESR (11), and Morning Cortisol (37). I also had a 90-point drop in my Total Cholesterol (70 of it in LDL) despite no changes whatsoever to diet, exercise, or meds (I'm on none for lipids). The only thing that got a reaction from my now-former PCP was the Cortisol ("see an endocrinologist," which I plan to do).
I am gradually implementing your Cortisol protocol, having added Ashwaganda and L-theanine (I've been on Mag Glycinate for years), and have just added iron, Vit C, Vit K, and Vit B-12. I'm being conscientious about adequate protein, carbs, and calories (in spite of gaining 45 lb in 6 years). I plan to rerun all these labs once I'm established with an endocrinologist. In the meantime, any additional advice and/or observations? (I'm 71 and on Tamoxifen for breast cancer, BTW.) As always, I really appreciate your sharing your knowledge!
You're doing something most patients don't, and I want to acknowledge it before I get into the specifics: keeping a longitudinal spreadsheet of your labs since 2014 means you have trend data that your doctors can see at a glance instead of pulling up fragmented records across systems. That's powerful. When you walk into the endocrinologist, you're not showing up with a complaint. You're showing up with a decade of data. Use that.
Now let me walk through what stands out.
TSH jump from 1.36 to 3.98 in 14 months with stable Free T4. This is the most important finding in your labs right now. A TSH nearly tripling while Free T4 barely moves suggests the pituitary is sensing inadequate thyroid hormone at the tissue level, even though circulating T4 hasn't dropped. There are a few things that could drive this pattern, and one of them is directly relevant to your situation: Tamoxifen increases thyroid-binding globulin (TBG) production in the liver. More TBG means more T4 gets bound in the blood, leaving less free hormone available. The Free T4 on your lab result measures unbound hormone, and if it's sitting at .94-.96, it's in the lower half of most reference ranges. Your pituitary may be responding to functionally low free hormone availability even though the number looks "normal." Ask the endocrinologist to check thyroid antibodies (TPO and thyroglobulin) to rule out autoimmune thyroid disease, and to evaluate whether the Tamoxifen-TBG relationship is affecting your effective thyroid hormone levels. Also request Free T3, because if peripheral conversion is being impaired (and your ferritin at 37 would contribute to that), Free T3 is where it will show up.
Ferritin at 37. Suboptimal. Iron is a required component of thyroid peroxidase, the enzyme that synthesizes thyroid hormone, and it's needed for the deiodinase enzymes that convert T4 to active T3. Below 50, thyroid conversion is measurably impaired. You've started iron, which is the right move. Take it with vitamin C (which you're doing) on an empty stomach or with a light meal, and separate it from your other supplements by at least 2 hours. Target a ferritin above 50, ideally 50-70.
B12 at 408. Functional range wants this above 500. At 408 it's not critically low, but it's not providing optimal neurological and metabolic support. Your supplementation should move this up. Methylcobalamin or hydroxocobalamin are the better-absorbed forms.
Vitamin D at 48.1. Good but not quite optimal. The 50-80 ng/mL range is where most of the evidence for bone, immune, and metabolic benefits concentrates. A small increase in your D3 dose could push you into that range.
Morning Cortisol at 37. Your doctor's reaction (see an endocrinologist) tells you this was flagged as significantly elevated. Depending on the unit, this is well above the normal morning range. The endocrinologist will likely want to rule out Cushing's syndrome (24-hour urine cortisol, late-night salivary cortisol, dexamethasone suppression test). If Cushing's is ruled out, this likely reflects chronic HPA axis dysregulation, and three years of post-COVID insomnia is exactly the kind of persistent stressor that can drive sustained cortisol elevation. Elevated cortisol contributes to insulin resistance, visceral fat accumulation, bone loss, and immune dysregulation, so addressing this is central to everything else.
The 90-point cholesterol drop. This one likely has a straightforward explanation: Tamoxifen. Tamoxifen acts as a weak estrogen agonist in the liver, which increases LDL receptor expression and accelerates LDL clearance from the blood. A 70-point drop in LDL is a well-documented Tamoxifen effect. If the Tamoxifen was started or the dose was adjusted in the period between your two cholesterol measurements, that's almost certainly the cause. This is actually one of Tamoxifen's known metabolic effects and isn't typically a concern. Mention it to the endocrinologist for confirmation, but I wouldn't expect it to be unexplained once the Tamoxifen effect is accounted for.
One critical note on your supplements. You're on Tamoxifen for breast cancer. This means any supplement that has estrogenic activity or that affects the CYP2D6 enzyme pathway (which is how Tamoxifen is metabolized to its active form, endoxifen) needs to be confirmed safe by your oncologist. Most of what you're taking (magnesium, iron, B12, vitamin C, vitamin K, L-theanine) should be fine. Ashwagandha is generally considered safe alongside Tamoxifen, but since it can modulate immune function and has some effects on thyroid hormone levels, it's worth confirming with your oncology team. And avoid any supplements with phytoestrogenic activity (red clover, black cohosh, concentrated soy isoflavones) since they could interfere with Tamoxifen's mechanism.
You're approaching this with exactly the right combination of diligence and proactivity. The endocrinologist appointment is the key next step, and you'll be one of the most prepared patients they see. Bring the spreadsheet.
Thank you for this! When I looked at the Lipid results, I asked a friend who's a retired cardiologist for his take; he suggested possible lab error. I also reached out to my then-PCP, pointing out that I had years of consistent numbers, and asking if I should be concerned. Her response was a terse “no concerns with this lab.” Did she know about this Tamoxifen side effect? I'll never know. But after reading your response, I looked it up and found a meta study, which I sent to my friend. We both found it quite interesting that the same drug protects me from cancer, bone loss, and cardiovascular disease.
This is exactly how this is supposed to work. You had an unexplained lab finding. Your cardiologist friend's first instinct was lab error, which is a reasonable clinical reflex when numbers move that dramatically. Your PCP dismissed it without explanation. And then you found the mechanism yourself, confirmed it with a meta-study, and educated both yourself and your cardiologist friend in the process.
The triple protection from Tamoxifen (anti-cancer through estrogen receptor blockade in breast tissue, bone preservation through estrogen agonist activity in bone, and cardiovascular protection through LDL receptor upregulation in the liver) is genuinely remarkable pharmacology. It's one drug acting as an antagonist in one tissue and an agonist in others simultaneously. That's the SERM mechanism, and it's why Tamoxifen has survived as a frontline treatment for decades despite newer drugs entering the market.
Your former PCP's "no concerns" without explaining the why is another example of what I keep writing about: the answer existed, but the explanation didn't follow the answer. You deserved to know why your cholesterol dropped 90 points. Not just that it wasn't concerning, but what caused it. That gap between answer and explanation is the space these articles live in.
Glad the cardiologist friend found the meta-study interesting. Now he knows too.
This article helps so much, and yes, I need to print out. I also messaged you today. After reading this, tomorrow’s appointment with my MD will probably just function as my medicare checkup, and little else.
Even if the appointment is just a checkup, bring your questions. A Medicare visit is still a face-to-face interaction with a doctor who can order labs and refer you to specialists. Don't let it be a passive experience. Walk in with a list: the labs you want run, the markers you want checked, the questions this article raised for you. The doctor may not volunteer those tests on their own, but if you ask clearly and specifically, most will order them. The appointment is yours, not theirs. Use it. And I'll look for your message.
Great read!
Thank you. Glad it was useful.
OMG so interesting, story of my life, was thinking of writing about and I will. TSI testing all the time but more expensive test. It is genetic in my family. Started with Graves-Basedow (highest results the lab ever saw), now Hashimoto. Honoustly I only believe in medicine but will read anyway. Had strumazol and elthyroxine and both combined too.
Graves flipping to Hashimoto's is a well-documented pattern in autoimmune thyroid disease. The underlying driver, the immune system targeting thyroid tissue, is the same in both. What changes is which antibodies dominate: stimulating antibodies (TSI) in Graves cause overproduction, blocking and destructive antibodies (TPO, TgAb) in Hashimoto's cause underproduction. The fact that it's genetic in your family means the autoimmune susceptibility is wired in, and the expression just shifted form.
Believing in medicine and reading this aren't in conflict. Everything I write is based on the same peer-reviewed research your doctors use. I'm not trying to replace your medical team. I'm trying to make sure you walk into those appointments understanding the mechanisms well enough to have better conversations. Read with that lens and take what's useful.
Thanks, like I said I will read tomorrow ( after the semi finale)😉, and what you wrote is what the doctors predicted me 30 years ago. So I knew this was coming all the way. The thing which is difficult is living with the side effects: eye problems, intensity of not feeling hungry at all and being extremely hungry...sweating....But my thyroid values are now in the 'middle' so much better. My friend's thyroid doesn't function anymore at all which is more of a problem.
Enjoy the semi-final first. The article will still be here. 😉
The side effects you're describing are all consistent with the thyroid system trying to find its new equilibrium. The hunger swings (not hungry at all, then extremely hungry) are thyroid-driven metabolic oscillation. When T3 and T4 fluctuate, your body's energy regulation swings with them. Ghrelin and leptin signaling get jerky because the metabolic rate isn't stable enough for those hormones to calibrate against. As your values settle into the middle and stay there, those swings should dampen over time.
The sweating is the same mechanism: your thermoregulatory system is responding to fluctuating thyroid output. When T3 is higher in the cycle, heat production goes up. When it dips, it comes down. Once the values stabilize, thermoregulation smooths out.
The eye issues: if this is Graves-related (thyroid eye disease/Graves' ophthalmopathy), that's a separate autoimmune process that can persist or worsen even as thyroid values normalize, because the antibodies targeting the orbital tissue behind the eyes are distinct from the ones affecting the thyroid itself. If you're noticing changes in your eyes (bulging, dryness, pressure, vision changes), keep your ophthalmologist in the loop. That deserves its own monitoring track.
Your friend whose thyroid no longer functions at all is on full replacement, which creates a different challenge: getting the medication dose precisely right to replicate what a functioning gland would do dynamically. It's doable, but it requires more frequent lab monitoring and dose adjustments than most doctors provide.
You knew this was coming for 30 years. That doesn't make living through it easier, but it does mean you're not caught off guard. That's an advantage most people don't get.