When The Thyroid Labs Look Fine And The Patient Is Not

Most of the patients I see have already been told their thyroid is fine. A TSH in range, a free T4 in range, and a conversation that stops there. My argument in this session is that in chronic illness those two numbers are the least informative part of the panel, because they tell you about signalling and circulating supply rather than about what is getting into the cell and being used.

So I go through what I look at instead. Free T3 rather than free T4 alone. The relationship between free T3 and reverse T3, because a rising reverse T3 changes the picture even when everything else reads as acceptable. And clinical signs that are not on the panel at all: basal metabolic rate, body temperature, and the relaxation phase of a reflex, which is old fashioned and, to my eye, still underused. None of this is a replacement for the standard tests. It is what I think has to sit alongside them before you tell a sick patient there is nothing wrong.

The second half is about why I pair that with immune modulation. In the chronically ill patient you tend to see the immune system shifted in one direction and stuck, and my view is that treating the thyroid without addressing that shift leaves you fighting the same problem twice. This is where peptides come in, and the mechanical distinction is the part worth holding onto. A hormone goes into the nucleus and changes protein synthesis, which makes it slow to come on and slow to come off. Peptides mostly act at the cell surface and work through a cascade of secondary messengers, so they come on and off faster and tend to have several effects at once rather than a single one. That is why I describe hormones as the blunt instrument and peptides as the finer one, and it is also why I am careful about stacking them without knowing what each is doing.

I walk through the classes I use and what they are being studied for: thymic peptides for immune balance, pineal peptides and bioregulators in the longevity and sleep space, nootropic peptides for cognitive and brain injury work, mitochondrial peptides, and the melanocortin family. I go through a lot of published work quickly, and I want to be plain about what that evidence is. A large part of it is animal work, small trials, and research from outside the United States. Several of the compounds I name are not approved by the FDA for the uses discussed, and some are not available as prescribed medicines at all. I share the mechanisms because I think clinicians should know them, not because the case is closed.

This session was recorded for a clinical audience and it includes my own interpretation of the literature and my own clinical approach, neither of which is a standard of care. It is not medical advice, no dosing guidance from it should be applied to yourself, and nothing here is a reason to change or stop a prescribed medication. If any of it is relevant to you, take it to the clinician who is actually looking after you.

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About the Host:

Dr. Kent Holtorf, MD, is the medical director of Holtorf Medical Group and the founder of Integrative Peptides. He is also a founder and director of the non profit National Academy of Hypothyroidism, which exists to get evidence based information on the diagnosis and treatment of hypothyroidism to doctors and patients.

His clinical focus is the patient nobody has been able to help: tick borne illness, chronic fatigue syndrome, fibromyalgia, CIRS, MCAS, long COVID, traumatic brain injury and neurodegenerative disease, alongside hormone optimization and longevity medicine. He works at the mechanism level, and he is candid that much of what he discusses sits ahead of where mainstream guidelines currently are.

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Social Handles:

Holtorf Medical Group: holtorfmed.com

National Academy of Hypothyroidism: nahypothyroidism.org

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