Why am I gaining weight even though I’m eating less and exercising more?
Today we’re diving into a question I hear from so many women: “Why am I gaining weight even though I’m eating less and exercising more?” If you have thyroid issues—especially hypothyroidism or Hashimoto’s—this can feel incredibly frustrating and unfair. You’re doing all the “right” things, yet the scale keeps creeping up or refuses to budge.
We’re approaching this through holistic and functional medicine lenses—focusing on root causes instead of just pushing harder with more restriction or workouts
The Thyroid-Metabolism Connection
Your thyroid gland produces hormones that act like the body’s metabolic thermostat. When it’s underactive, your metabolism slows down significantly. Even if you cut calories and ramp up exercise, your body simply burns fewer calories at rest.
Early weight gain in hypothyroidism is often mostly fluid and salt retention—called myxedema—caused by glycosaminoglycans pulling water into tissues. This can add 5–10 pounds or more and often improves once thyroid levels are better balanced.
But the ongoing issues are deeper: a true slowdown in basal metabolic rate (BMR). Studies show BMR can drop 15–40% in hypothyroidism. You burn fewer calories just existing—breathing, circulating blood, maintaining temperature. Plus, lower energy often reduces NEAT (non-exercise activity thermogenesis)—all that fidgeting and daily movement you don’t even notice.
On top of that, you can’t break down fat well so that you are more prone to fat storage, and thermogenesis (heat production) decreases. So even with a calorie deficit on paper, your body can shift into conservation mode, especially if you’re under-eating or over-exercising without support.
The Conversion Problem: T4 to Active T3
Most thyroid medication is T4 (storage form, like levothyroxine), but your body must convert it to active T3 for metabolism to fire properly. Poor conversion is incredibly common and leaves many women with “normal” TSH and T4 labs but low cellular thyroid activity.
Why does conversion fail?
Chronic stress and high cortisol push production toward inactive reverse T3 (rT3), which blocks T3 receptors—like slamming the brakes on metabolism. This is a survival mechanism in times of stress or perceived famine.
Inflammation from Hashimoto’s, gut issues, or infections downregulates the deiodinase enzymes needed for conversion.
Nutrient deficiencies: Selenium and zinc are critical cofactors. Low iron (ferritin), vitamin D, and B vitamins also impair the process. Many women are deficient due to poor absorption.
Liver and gut health: Conversion happens mostly in the liver and intestines. Sluggish liver function, fatty liver, toxins, or gut dysbiosis/leaky gut disrupt it.
Other triggers: Caloric restriction itself, insulin resistance, heavy metals, plastics (BPA), certain medications, and genetic variations (like DIO2 polymorphisms).
Functional testing looks at Free T3, Reverse T3, and their ratio—not just TSH.
Insulin Resistance and Leptin Resistance – The Vicious Cycles
Low thyroid function promotes insulin resistance: your cells become less responsive to insulin. Insulin’s job is to move glucose into cells. When cells resist, your pancreas makes more insulin, which drives fat storage—especially around the middle—and makes weight loss much harder. This creates energy crashes, cravings, and that stubborn belly fat many women notice.
Thyroid issues also contribute to leptin resistance. Leptin is the “satiety hormone” from fat cells that tells your brain you have enough energy. Weight gain raises leptin, but in thyroid dysfunction the signaling gets blunted. The brain thinks you’re starving despite extra fat stores, so it slows metabolism further, increases fat conservation, and worsens thyroid conversion and insulin issues. It’s a frustrating loop: low thyroid → weight gain → hormone resistance → more weight gain.
Functional and Holistic Solutions – Addressing Roots
Instead of doubling down on restriction (which can raise cortisol and worsen the problem), focus on support:
1. Comprehensive Testing
Ask for a full thyroid panel: TSH (optimal often under 2.0–2.5), Free T4, Free T3, Reverse T3, and antibodies (TPO, TG) for autoimmunity. Also check ferritin, vitamin D, selenium, zinc, B12, fasting insulin, HbA1c, and inflammatory markers. Many feel best with Free T3 in the upper range.
2. Support Conversion and Thyroid Function
Prioritize nutrients: selenium, zinc, iron (if low), vitamin D.
Anti-inflammatory, nutrient-dense diet: plenty of protein, healthy fats, non-starchy vegetables. Many with Hashimoto’s feel better identifying food triggers like gluten or dairy through elimination.
Heal the gut: Address dysbiosis or leaky gut for better absorption and reduced inflammation.
3. Lifestyle Foundations
Manage stress: Sleep 7–9 hours, gentle movement like walking, yoga, or strength training (which builds muscle and boosts metabolism better than endless cardio when thyroid is low).
Avoid extreme calorie cuts. Focus on nutrient density so your body feels safe.
Reduce toxins: Limit plastics, heavy metals, pesticides.
4. Medication and Professional Guidance
Thyroid medication (T4, T3, or desiccated) can be life-changing for restoring energy and metabolism when needed. But in functional medicine, we pair it with root-cause work—nutrition, gut healing, stress reduction—so you get the best response and potentially lower doses over time. Work with a functional or integrative practitioner who looks at the whole system.
Ladies, you are not failing at willpower. Your body is sending a loud signal that it needs different support. When we address nutrient gaps, inflammation, stress, gut health, and conversion issues, many women see improvements in energy, easier weight management, and overall well-being. Progress takes time and consistency—be patient and kind to yourself.
If this resonates, share it with a friend who’s struggling, and leave a review if you found it helpful. Consult your healthcare provider before making changes, especially with thyroid conditions. Get the right testing and personalized care.
How to Lower Thyroid Antibodies Naturally: What Actually Worked for My Clients
Wondering if you can lower TPO or Tg antibodies with Hashimoto’s? Learn realistic, root-cause strategies from a nutritionist who reduced her own antibodies — plus what’s helped dozens of women feel better.
One of the most common questions I hear: “Can nutrition actually lower my thyroid antibodies?”
The honest answer: Yes — for many women, targeted changes do help bring antibodies down. It’s not a cure (Hashimoto’s needs ongoing management), and results vary, but I’ve seen it happen in my own journey and with clients when we address the roots: inflammation, gut health, nutrient gaps, and stress.
Here’s what tends to move the needle — based on both research and real-world experience.
Why Antibodies Matter (and Why “Normal” Labs Aren’t Enough) High TPO or Tg antibodies show your immune system is still attacking your thyroid. Lowering them often correlates with fewer symptoms and more stable energy.
Standard care focuses on medication to replace hormones, which is important. Nutrition complements that by calming the immune response upstream.
4 Evidence-Based Strategies That Help Many Women
Focus on anti-inflammatory, nutrient-dense eating Key takeaway: Prioritizing whole foods rich in antioxidants, omega-3s, and fiber reduces overall body inflammation that fuels autoimmunity.
Think colorful vegetables, berries, quality proteins, and healthy fats. Studies link higher fruit/vegetable intake with lower oxidative stress in Hashimoto’s.
Support key nutrients — especially selenium and zinc Key takeaway: Selenium (from 1–2 Brazil nuts daily or food sources) has been shown in research to reduce antibodies in some women with Hashimoto’s. Zinc supports immune balance and thyroid conversion.
We test levels when needed and adjust — never guessing with high-dose supplements.
Heal the gut Key takeaway: A large percentage of your immune system lives in your gut. Addressing bloating, constipation, or leaky gut often calms systemic inflammation and antibody activity.
Simple steps: more fiber from tolerated veggies, fermented foods if okay, and identifying personal food triggers.
Manage stress and sleep Key takeaway: Chronic stress raises cortisol, which can worsen autoimmune flares. Consistent sleep and gentle stress tools (walking, breathing, boundaries) make a bigger difference than most expect.
What I’ve Seen Work in Practice
One client lowered her TPO antibodies significantly after a 3-month personalized plan focused on gluten/dairy exploration, selenium-rich foods, and gut repair. Her energy returned and she stopped needing daily naps.
Another saw steady drops alongside better labs when we added consistent protein and omega-3s while reducing processed foods.
Results take consistency — usually 3–6 months for measurable antibody shifts — but many feel symptom improvements much sooner.
Important Caveats
Not every woman sees big antibody drops. That’s okay — feeling better is the real goal.
Work with your doctor for medication and monitoring. Nutrition supports, it doesn’t replace.
Extreme diets (very low calorie or overly restrictive) can backfire and stress the body more.
Your Next Step Start small: Pick one area (e.g., add selenium-rich foods or track one potential trigger) and observe for 2–4 weeks.
If you’re tired of guessing, that’s exactly why I offer personalized Hashimoto’s support. We review your full history, labs (using tighter optimal ranges), and build a plan that fits you — no dogma, no million supplements.
Ready to move the needle on your Hashimoto’s? Grab my free 7 Tips to Manage Hashimoto’s guide to begin today by signing up for my newsletter.
Or schedule your free clarity call — let’s connect the dots together and get you feeling more like yourself.
By Stephanie Ewals, Licensed Nutritionist specializing in Hashimoto’s for women
7 Foods That Quiet Hashimoto’s Inflammation
Struggling with Hashimoto’s fatigue, brain fog, or stubborn symptoms? Discover 7 anti-inflammatory foods that many women with Hashimoto’s find helpful — plus practical tips on what to watch out for. Personalized guidance from a nutritionist who’s been there.
If you have Hashimoto’s, you already know inflammation is at the heart of it. Your immune system is overactive, attacking your thyroid and leaving you exhausted, foggy, and frustrated — even when labs look “normal.”
The good news? Food can be one of your most powerful tools to calm that inflammation. There’s no single “Hashimoto’s diet” that works for everyone (what helped me lower my own antibodies may not be perfect for you), but focusing on nutrient-dense, anti-inflammatory whole foods often brings noticeable shifts in energy, digestion, and how you feel day to day.
Here are 7 foods that many women with Hashimoto’s report feeling better with, plus 3 common ones to approach thoughtfully. These aren’t extreme restrictions — they’re about adding what supports your body while listening to your unique triggers.
1. Berries (Blueberries, raspberries, strawberries) Key takeaway: Berries are packed with antioxidants that help fight oxidative stress, a driver of autoimmune inflammation.
Add a handful to breakfast or snacks. Studies show higher fruit and vegetable intake (especially colorful ones like berries) correlates with lower markers of inflammation in Hashimoto’s. They’re gentle on blood sugar and delicious — no need to go overboard.
2. Leafy greens and non-starchy vegetables (Spinach, kale, zucchini, broccoli, asparagus) Key takeaway: These deliver fiber, vitamins, and minerals that support gut health — crucial because gut imbalances often fuel Hashimoto’s flares.
Aim for half your plate as colorful veggies. Cooked greens are often easier to digest than raw for sensitive systems. They provide folate, magnesium, and other nutrients that help thyroid function indirectly.
3. Fatty fish or omega-3 sources (Salmon, sardines, or algae oil if plant-based) Key takeaway: Omega-3 fats help lower inflammatory markers like CRP, which can be elevated in Hashimoto’s.
Even 2–3 servings per week can make a difference. If fish isn’t your thing, talk with me about quality supplements — but food-first is usually gentler.
4. Brazil nuts (for selenium)
Key takeaway: Just 1–2 Brazil nuts a day can provide the selenium many women with Hashimoto’s are low in. Research shows selenium supplementation (around 200 mcg) has helped reduce TPO antibodies in some studies.
Selenium supports the conversion of T4 to active T3 and protects thyroid tissue. Don’t overdo it — too much can cause issues.
5. Healthy fats (Avocado, olive oil, coconut oil in moderation) Key takeaway: These fats help absorb fat-soluble vitamins and keep you satisfied so you’re less likely to reach for inflammatory processed foods.
Drizzle olive oil on veggies or add half an avocado to meals. They support hormone balance, which is extra important if you’re also navigating perimenopause.
6. Pumpkin seeds and other zinc-rich foods Key takeaway: Zinc is another mineral often low in autoimmune conditions and needed for immune regulation and thyroid hormone production.
A small handful of pumpkin seeds makes an easy snack. Pair with protein for better absorption.
7. Bone broth or collagen-rich foods (if tolerated) Key takeaway: These provide glycine and other compounds that support gut lining repair — a common root-area issue in Hashimoto’s.
Start slow if dairy or nightshades are triggers for you.
How to Make This Practical
Start with adding 2–3 of the “yes” foods this week instead of overhauling everything. Track how you feel in a simple journal — energy, digestion, mood. That’s exactly what we do in sessions: personalize based on your responses, not a generic list.
Many clients notice steadier energy and fewer flares within weeks when we combine these shifts with gut support and stress management.
Ready to quiet the inflammation for good? Sign up for my newsletter and download my free 7 Tips to Manage Hashimoto’s guide for more simple swaps and recipes.
Or book a free clarity call — we’ll review your labs and symptoms and build a plan that actually fits your life.
Stephanie Ewals, Licensed Nutritionist & CNS I’ve walked this road with Hashimoto’s myself. Let’s get you feeling like yourself again — one nourishing meal at a time.
Nutrition for Every Stage of Life.
Nutrition needs change as we go through different stages of life, but one big idea stays the same: everyone is different. This is called bio-individuality. What your body needs depends on things like your health, if you're a man or woman, your weight, and how active you are. Even at the same age, people can need different amounts of nutrients.
Adulthood: The Long Middle Years
Adulthood is the longest part of life. Your body isn't growing quickly anymore like when you were a kid or teen. Instead, life is full of big things like building a career, finding love, starting a family, or raising kids.
In your 30s, you might be chasing goals at work, settling down, or having kids. Your energy and nutrient needs stay pretty steady unless something special is going on, like training for sports, being pregnant, or dealing with health issues.
In your 40s and 50s, many people juggle jobs and family. Some become part of the "sandwich generation," caring for their own kids and aging parents at the same time. This is also when some long-term health problems can start showing up.
Calorie needs don't go up for growth anymore. They depend mostly on your activity level and personal factors. To figure out the right balance of carbs, proteins, and fats (called macronutrients), try keeping a food journal. Pay attention to how you feel—your energy, mood, and if you're full after eating—and adjust from there.
The big focus in adulthood shifts to preventive nutrition. The foods you choose now can help protect your health for many years. Good eating habits build up over time and lower the chance of diseases like heart problems or diabetes.
Here are some key nutrients to think about during adulthood:
Omega-3 fatty acids- these healthy fats found in fish like salmon, walnuts, and flaxseeds can help keep your heart strong and protect your brain as you get older.
Vitamins B6, B12, and folate - they help break down a substance called homocysteine that can raise heart disease risk.
Calcium - important for strong bones to prevent weak bones later in life
Fiber - helps keep a healthy weight, good digestion, and steady blood sugar.
Phytochemicals and antioxidants - these come from colorful plants and fight harmful free radicals in your body.
Aim for 2-3 liters of total water each day. This includes plain water, other drinks, and water in foods like fruits and veggies. Your exact need changes based on your size, activity, weather, and health.
Older Adults: Age 65 and Beyond
People are living longer thanks to better medicine, so more folks are over 65. As we age, the body changes. Cells don’t repair as fast, and it gets harder to absorb nutrients. Digestion slows down, and the immune system can act differently, sometimes causing more inflammation.
Energy needs drop about 5% every 10 years because of less activity, a slower metabolism, and hormone changes. You might need fewer calories, but you still need plenty of vitamins and minerals.
Focus on nutrient packed foods:
Eat lots of fruits and veggies for antioxidants, fiber, and key nutrients.
Choose complex carbs like beans, lentils, and whole grains for steady energy and fiber.
Include lean proteins every day, but watch saturated fats if heart health is a concern.
Special nutrients for seniors:
Calcium, vitamin d, and vitamin K - to keep bones strong and slow bone loss
Antioxidants like vitamins C and E, plus carotenoids from colorful produce to help eyesight
B vitamins (especially B12 and folate) - for brain health and thinking clearly. B12 absorption drops with age, so it might need extra attention.
Omega 3’s - can help the brain, ease joint pain, and improve movement.
Fiber - keeps bowels working well.
Dehydration is a real risk for older adults. Thirst signals get weaker, and it can be hard to get up for a drink. Make water easy to reach, and include hydrating foods like soups, juice fruits, and veggies.
Everyone’s needs are unique, so listen to your body. Eating well at any age helps you feel your best and stay healthy for the long run.
Should I be on T4 only, or do I need T3 too?
No, not everyone with Hashimoto’s and hypothyroidism needs T3 in addition to T4—but many women feel dramatically better when they do, especially once root causes are addressed.
From a functional medicine or holistic lens, the goal isn’t just normalizing TSH on your labs. It’s restoring energy, mood, metabolism, brain function, and overall vitality by supporting your body’s natural hormone production and conversion while healing the underlying drivers of autoimmunity and poor thyroid performance.
Why T4-Only Meds like Levothyroxine Are the Default—but Often Falls Short in Hashimoto’s
Conventional medicine starts (and usually stays) with synthetic T4 (levothyroxine/Synthroid/etc.) because your thyroid normally makes mostly T4, which your body converts to active T3. This is the hormone that actually powers your cells. The assumption is “your body will handle the rest.”
In Hashimoto’s, that conversion frequently breaks down. Chronic inflammation from the autoimmune attack, plus common co-factors like stress, gut issues, and nutrient deficiencies, down-regulates the enzymes (deiodinases) that turn T4 → T3. That means the enzymes don’t work as well.
The result?
You can have “normal” TSH and free T4 while your free T3 is low and reverse T3 (the inactive “brake”) is high—leaving you with fatigue, brain fog, depression, weight gain, cold hands/feet, hair loss, and other symptoms that T4 alone never fully fixes.
I see this pattern a lot. Many clients report they only started feeling like themselves again after adding T3 or switching to natural desiccated thyroid (NDT/Armour, Nature-Throid, etc.), which contains both T4 and T3 in a ratio closer to what a healthy thyroid produces (roughly 4:1 or 80/20).
Surveys of thousands of Hashimoto’s patients show ~60% feel better on T4+T3 or NDT versus T4-only.
The Root Cause Priority: Fix Conversion First, Then Decide on Medication
Instead of jumping straight to “add T3,” a holistic approach asks: Why is conversion impaired? Address these root drivers and you often need less medication—or a lower dose of T3—while feeling dramatically better.
Common conversion blockers in Hashimoto’s (and how to support them):
Nutrient deficiencies — Selenium, zinc, iron/ferritin, and vitamin A are required for the conversion enzymes. Low ferritin (<50–70 ng/mL) is especially common in women and tanks T4 → T3.
Gut dysfunction — 20% of conversion happens in the intestines. Leaky gut, dysbiosis, or inflammation (very common in Hashimoto’s) blocks it. Many women improve conversion simply by going gluten- and dairy-free and healing the gut through an anti-inflammatory diet and possibly some supplementation. When you have Hashimoto’s, you likely need regular gut healing rather than just a one time protocol. Gut healing includes removing things that are negatively affecting your gut whether it is infections, foods, etc. Then you need to make sure you are digesting food well. You might need some prebiotics or a specific probiotic for gut healing. Then you need to give your gut nutrients it needs to heal.
Chronic stress/high cortisol — This shunts T4 into reverse T3 instead of active T3. In this case Adrenal support, meditation, yoga, or ashwagandha can literally raise free T3. Ashwagandha will improve T4 to T3 conversion so you need to be really careful with it. Adrenal support can include managing stress and ensuring good sleep but you may also need to do something like a pinch of salt in your water or maybe you need licorice root. Reading a simple CBC - looking at sodium and potassium can tell us if you have issues with cortisol.
Liver sluggishness — Most conversion occurs here so if the liver is congested this won’t happen. This idea of sluggish liver is talked about in whole person care or holistic care and it just means your liver isn’t operating at its peak even when your labs might say your liver is fine. The lab ranges I go by are much smaller so I might pick up something that is off sooner than your doctor.
It’s common for women with Hashimoto’s and hypothyroidism to have issues here because the thyroid depends heavily on the liver and hypothyroidism slows down liver function, creating a vicious cycle.
Most of the conversion of T4 to T3 happens in the liver and T3 is actually what makes your metabolism run. More conversion happens in the gut- so if you have a messed up gut and a liver that is sluggish- you have got some issues.
In addition, the liver clears out thyroid hormone and excess estrogen. If the liver isn’t doing that, you get excess estrogen which causes free thyroid hormones to get bound up so they don’t reach your cells. You can have normal TSH and normal Free T4 on labs - often all that is checked by your doctor and you will still have hypothyroid symptoms.
Hypothyroidism also slows the production of bile and makes your gallbladder sluggish- clogging the liver detox pathways. You can end up with a fatty, inflamed, or congested liver and have less T4 to T3 conversion.
Add a high refined carb diet to the mix, environmental toxins, chronic stress, estrogen dominance, and nutrient deficiencies. What do you think is going to happen?
Signs your liver might be sluggish:
bloating after eating fatty meals. constipation, pale stools, floating stools
stubborn weight gain, belly fat, high cholesterol/triglycerides
acne, eczema, psoriasis, rashes, itchy skin, heavy/clotted periods
chemical sensitivity, bad breath, easy bruising, headaches
fatigue, brain fog, depression, feeling toxic.
I do not believe in aggressive detox protocols. It’s dangerous and can displace toxins to other areas of the body leading to more problems. An aggressive detox program can also make hashimoto’s flare.
Gentle liver support would include eating lots of liver loving foods. Bitter, fiber rich foods. Dandelion greens, arugula, radicchio, artichoke, beets, carrots, cruciferous veggies, garlic, onions, turmeric, berries, dark leafy greens. Aim for 30 or more grams of fiber per day. Reduce sugar, refined carbs, alcohol, processed foods.
Milk thistle tea protects liver cells. You might need some bile support too. Just depends.
Inflammation from Hashimoto’s itself — Think of inflammation in the body- the kind you can’t see or feel necessarily as your body being mad and not telling you- all the while it is just stewing about something creating damage unknown to you.
It is one of the biggest things that can sabotage your ability to get well. It’s attacking your thyroid gland, it disrupts how your body uses thyroid hormone at the cell too. This is why many of you feel terrible when your TSH is normal and your on T4 only meds. At the core, inflammation is interfering with the T4 to T3 conversion and promotes the conversion to reverse T3 which is the body’s way of trying to protect you and you end up with hypo symptoms.
You get in this vicious cycle where inflammation is causing more inflammation. Having low T3 levels worsen inflammation because thyroid hormones naturally stop the damage.
Lowering antibodies through diet, LDN (low-dose naltrexone), or treating triggers (infections, toxins, stress) improves conversion naturally.
Other factors — things that don’t show up on standard labs but they keep your body feeling hypothyroid even when your medication dose looks perfect.
Low calorie dieting or chronic under eating- We are wired for survival so when calories drop below what you need- less than 1,800-2,000 for most women, maybe more if you are really active or an athlete. When we don’t eat enough our body thinks ‘famine’ and conversion of T4 to T3 stops, you get more reverse T3 to conserve energy. Your body literally slows you down thinking you are in a state of famine. This causes more inflammation too. If you have plateaued at weight loss despite the perfect diet, you feel cold, you are losing hair, your period is off, you have extreme fatigue after meals, or labs show low T3, even within the range you may not be eating enough.
Make sure you are getting enough protein- a good start is one gram protein per one pound of body weight. That’s a pretty general recommendation but still a very good place to start. If this seems overwhelming, start with breakfast and then lunch and then dinner. Remember a palm size of meat is about 25-30g of protein. You can get it in if you are intentional about it.
Stop restricting so many foods. If you are sensitive to a lot of foods, you probably have leaky gut and rather than avoiding 25 foods, you need to bring down inflammation and heal your gut.
Heavy Metals and Environmental Toxins
Mercury from dental fillings, fish and even vaccines can be triggers along with lead, cadmium, arsenic, and fluoride. These bind selenium making it unavailable to convert T4 to T3. They create oxidative stress which is like rust on your cells and this damages liver and thyroid cells. It can make autoimmune attacks worse, especially mercury with TPO.
These things accumulate in the body because of sluggish detox pathways and an inflamed thyroid so the body can’t clear them. This is also one big reason why you should not start with a detox. If you can’t clear these and you do a calorie deficit detox you are risking making yourself worse.
If you are on any of the following medications, they interfere with thyroid conversion or the message coming from the brain.
Beta blockers block conversion from T4 to T3
Steroids suppress conversion
Lithium, SSRIs, anticonvulsants, and high dose biotin can interrupt thyroid function
Birth control pills or HRT raise thyroid binding globulin, lowering the amount of hormone that gets to your cells and can also worsen estrogen dominance that burdens the liver.
Some people have a genetic polymorphism to the gene that codes for the enzymes that convert T4 to T3 inside the cells making the process less efficient. If you are doing everything right and your labs still show T4 is fine but T3 is low, or you have normal TSH and Free T4 but you have massive brain fog, depression, fatigue, and poor response to T4 only meds this might be an issue for you. This issue can make you more sensitive to inflammation.
These things rarely exist in isolation but you are likely dealing with many of these factors which is why we have to peel back layers of the onion so to speak. Fix one issue and then work on the next until all things are resolved and you are feeling better.
Here is what I recommend:
Comprehensive labs (not just TSH): free T3, free T4, reverse T3, TPO/TG antibodies, ferritin, vitamin D, selenium, zinc, B12, and a full gut/inflammation panel.
Anti-inflammatory, nutrient-dense diet (gluten-free and often dairy-free for 3–6 months is a game-changer for many).
Targeted supplements specific to what your body needs.
Stress and sleep optimization.
Gut healing protocol.
Once these are in place, retest. If free T3 is still low, reverse T3 high, or symptoms linger despite optimal labs, that’s when adding T3 becomes logical.
Medication Options Through a Functional Lens
T4-only — Works beautifully for some women once root causes are fixed. Clean versions like Tirosint (gel cap or liquid) avoid fillers that can trigger Hashimoto’s.
T4 + T3 combo — Synthetic (levothyroxine + liothyronine/Cytomel) or compounded. Allows precise dosing. Many start low (e.g., 5–10 mcg T3) and titrate based on symptoms and labs.
Natural desiccated thyroid (NDT) — Contains T4, T3, and trace T1/T2. Often preferred because it mimics human thyroid tissue more closely. Some women swear by it for energy and weight loss; others do better on synthetic combo if they react to the porcine proteins.
The evidence is mixed in large studies (some show no average benefit, others show patients with persistent symptoms or Hashimoto’s specifically prefer and do better on T3-containing therapies). I honor your individual response: if you feel better and labs improve, that’s what matters. Roughly half of patients in preference studies choose combo therapy over T4-only.
Bottom Line
You don’t have to be on T3, but you also don’t have to suffer on T4-only if your body isn’t converting it well. I look at your full story—labs, symptoms, diet, stress, gut health, and life circumstances—and partner with you to find the right balance. Many women end up on a lower total dose of thyroid hormone (or even reduce medication over time) once the root causes are found and dealt with.