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Hormone Testing

Understanding thyroid, sex hormones, and cortisol markers—the key players in energy, metabolism, and wellbeing.

📖 The Story​

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Lisa had been exhausted for years. Her hair was thinning, she was gaining weight despite eating well, and she was always cold. Multiple doctors ran TSH tests—always "normal" at 3.2-3.8 mIU/L.

Finally, a new doctor ran a complete thyroid panel: TSH, Free T4, Free T3, Reverse T3, and thyroid antibodies.

The results told a different story. Her TSH of 3.5 was "normal" by lab standards but not optimal. Her Free T4 was mid-range, but her Free T3 was at the bottom. She had elevated Reverse T3, suggesting poor conversion. And her TPO antibodies were elevated—indicating Hashimoto's thyroiditis.

"Your thyroid is struggling," the doctor explained. "TSH alone doesn't tell the whole story. You're making thyroid hormone but not converting it well, and your immune system is attacking your thyroid."

With targeted treatment and lifestyle changes addressing the conversion issue and autoimmune component, Lisa's energy returned, her hair stopped falling out, and she finally lost the stubborn weight.

"I spent years being told my thyroid was fine because one number was in range," Lisa reflects. "The full picture told a completely different story."

The lesson: Hormones are complex systems. Testing one marker often misses dysfunction. The full panel reveals what single tests can't.

🚶 The Journey​

The Hormone Testing Framework

Why Single Markers Aren't Enough:

Single MarkerWhat It Misses
TSH onlyConversion issues, autoimmunity, T3 levels
Total testosteroneFree testosterone, SHBG status
Morning cortisolDiurnal pattern, chronic dysregulation
Estrogen onlyProgesterone balance, metabolism

🧠 The Science​

Understanding Hormone Markers

Thyroid Hormones​

The Thyroid Cascade:

Hypothalamus → TRH
    ↓
Pituitary → TSH
    ↓
Thyroid → T4 (mostly) and T3
    ↓
Periphery → T4 converts to T3 (active) or Reverse T3 (inactive)
    ↓
Cells → T3 binds receptors, drives metabolism

Key Thyroid Markers:

MarkerWhat It MeasuresLab RangeOptimal
TSHPituitary signal to thyroid0.4-4.5 mIU/L1.0-2.5 mIU/L
Free T4Available storage hormone0.8-1.8 ng/dLMid-to-upper range
Free T3Active thyroid hormone2.3-4.2 pg/mLMid-to-upper range
Reverse T3Inactive metabolite9-24 ng/dLLower half
TPO AntibodiesAutoimmune marker<35 IU/mL<9 (negative)
Thyroglobulin AbAutoimmune marker<20 IU/mLNegative

What Different Patterns Mean:

TSHT4T3rT3Likely Issue
HighLowLow—Primary hypothyroidism
High-normalNormalLowHighConversion problem
NormalNormalLowHighChronic stress, illness
———Elevated antibodiesHashimoto's (autoimmune)

Sex Hormones​

Testosterone (Men and Women):

MarkerMen OptimalWomen Optimal
Total Testosterone500-900 ng/dL20-60 ng/dL
Free Testosterone15-25 pg/mL1-3 pg/mL
SHBG20-50 nmol/L30-100 nmol/L

Estrogen and Progesterone (Women):

MarkerFollicularOvulationLuteal
Estradiol30-120 pg/mL100-400 pg/mL30-180 pg/mL
Progesterone<1 ng/mL<1 ng/mL5-20 ng/mL
E2/P4 ratio——~1:100 (P4:E2)

DHEA-S:

  • Adrenal hormone, precursor to sex hormones
  • Declines with age
  • Optimal varies by age/sex
  • Low may indicate adrenal dysfunction

Cortisol​

Cortisol Patterns:

TimeNormal RangeNotes
Morning (8 AM)10-20 μg/dLShould be highest
Afternoon3-10 μg/dLDeclining
Evening2-4 μg/dLLowest
Night<2 μg/dLShould be low

Ideal Pattern:

  • Highest in morning (cortisol awakening response)
  • Declines through day
  • Lowest at night

Dysfunctional Patterns:

  • Flat (low all day) → Adrenal fatigue/HPA dysfunction
  • Inverted (high evening) → Sleep issues, chronic stress
  • Elevated all day → Chronic stress, Cushing's
## 👀 Signs & Signals

Signs Your Hormones May Need Testing​

Thyroid (Hypothyroid Symptoms):

  • Fatigue, low energy
  • Weight gain despite good diet
  • Cold intolerance
  • Hair loss
  • Dry skin
  • Brain fog
  • Depression
  • Constipation

Thyroid (Hyperthyroid Symptoms):

  • Anxiety, nervousness
  • Unintentional weight loss
  • Rapid heart rate
  • Heat intolerance
  • Tremor
  • Insomnia

Low Testosterone (Men):

  • Low energy, fatigue
  • Decreased libido
  • Erectile dysfunction
  • Muscle loss
  • Weight gain (especially abdominal)
  • Depression, mood changes
  • Brain fog

Hormone Imbalance (Women):

  • Irregular periods
  • Heavy or painful periods
  • PMS symptoms
  • Low libido
  • Fatigue
  • Mood swings
  • Weight changes
  • Hot flashes, night sweats

Cortisol Dysfunction:

  • Chronic fatigue
  • Difficulty waking
  • Second wind at night
  • Wired but tired
  • Anxiety
  • Poor stress tolerance
  • Sleep problems

🎯 Practical Application​

Testing and Optimizing Hormones

Complete Thyroid Testing​

Minimum Panel:

  • TSH
  • Free T4
  • Free T3
  • TPO antibodies

Comprehensive Panel (Add):

  • Reverse T3
  • Thyroglobulin antibodies
  • Total T4, Total T3

When to Test:

  • Symptoms of thyroid dysfunction
  • Family history of thyroid disease
  • Other autoimmune conditions
  • Unexplained fatigue, weight changes

Optimizing Thyroid Function:

Nutrients:

  • Iodine (seaweed, iodized salt—don't overdo)
  • Selenium (Brazil nuts, seafood—important for conversion)
  • Zinc (supports thyroid function)
  • Iron (needed for thyroid hormone synthesis)

Lifestyle:

  • Stress management (stress increases rT3)
  • Sleep (impacts thyroid function)
  • Reduce goitrogens if hypothyroid (raw cruciferous in excess)
  • Address gut health (conversion happens partly in gut)

If Hypothyroid:

  • Work with provider on medication options
  • T4-only (Synthroid) vs. T4/T3 combination
  • Monitor and adjust based on Free T3 levels
  • Address root causes (autoimmune, conversion issues)
## 📸 What It Looks Like

Sample Thyroid Panel Interpretation​

Results:

  • TSH: 3.5 mIU/L (normal but not optimal)
  • Free T4: 1.1 ng/dL (mid-range)
  • Free T3: 2.4 pg/mL (low-normal) ⚠️
  • Reverse T3: 22 ng/dL (upper range) ⚠️
  • TPO Antibodies: 250 IU/mL (elevated) ⚠️

Interpretation:

  • TSH "normal" by lab standards but body is asking for more
  • T4 being made adequately
  • T3 (active hormone) is low
  • Reverse T3 is high = poor T4→T3 conversion
  • Elevated antibodies = Hashimoto's thyroiditis

This person is functionally hypothyroid despite "normal" TSH.

Tracking Hormone Changes​

MarkerBaseline3 Months6 MonthsGoal
TSH3.52.82.01.0-2.5
Free T32.42.93.3Mid-upper
rT3221814Lower half
TPO Ab250180120Minimize
## 🚀 Getting Started

Step 1: Identify Symptoms​

  • Note symptoms that might be hormone-related
  • Track patterns (time of day, cycle timing)
  • Note impact on quality of life

Step 2: Request Appropriate Testing​

  • Thyroid: Full panel, not just TSH
  • Sex hormones: Multiple markers + SHBG
  • Cortisol: Consider 4-point saliva or DUTCH
  • Time tests appropriately (morning, cycle day)

Step 3: Review Results​

  • Compare to optimal ranges (not just lab ranges)
  • Look for patterns
  • Consider symptoms alongside numbers
  • Identify root causes

Step 4: Optimize​

  • Address lifestyle factors first
  • Target specific deficiencies
  • Work with provider for medication if needed
  • Retest to monitor progress
## 🔧 Troubleshooting

Common Hormone Testing Challenges​

"My doctor won't run a full thyroid panel"

  • Explain your symptoms and family history
  • Offer to pay for additional tests
  • Use direct-to-consumer labs
  • Find integrative provider

"My thyroid is 'normal' but I have symptoms"

  • TSH alone isn't sufficient
  • Request Free T3, Reverse T3, antibodies
  • Optimal ranges differ from lab ranges
  • Conversion issues are common

"My testosterone is 'normal' but I feel low"

  • Check free testosterone, not just total
  • Consider SHBG (high SHBG lowers free T)
  • Optimal for men is mid-to-upper range
  • Test in morning

"My results vary between tests"

  • Hormones fluctuate (especially cortisol, female hormones)
  • Test at consistent times
  • Multiple tests may be needed
  • Look at patterns, not single values

"I don't know when in my cycle to test"

  • Day 3: FSH, LH, Estradiol
  • Days 19-22: Progesterone (confirms ovulation)
  • Day 1 = first day of period
## 🤖 For Mo

AI Coach Guidance​

Assessment Questions:

  1. "What symptoms are you experiencing?"
  2. "What hormone tests have you had?"
  3. "Was it a full panel or just one marker?"
  4. "Where in the reference range are your results?"
  5. "How do you feel, regardless of what numbers say?"

Key Coaching Points:

  • Full panels more informative than single markers
  • Optimal differs from normal
  • Symptoms matter alongside numbers
  • Lifestyle impacts hormones significantly
  • Work with knowledgeable provider

Important Boundaries:

  • Cannot diagnose hormone disorders
  • Cannot recommend hormone therapy
  • Refer to appropriate specialists
  • Education about testing, not treatment

Example Scenarios:

  1. "My TSH is 3.5—is that normal?":

    • Lab normal but not optimal
    • Optimal is 1.0-2.5 mIU/L
    • Need full panel (Free T4, Free T3, antibodies)
    • Symptoms matter
    • Discuss with provider

  2. "I think my testosterone is low":

    • Need blood test to confirm
    • Test in morning, fasting
    • Total AND free testosterone
    • Many lifestyle factors affect it
    • If low, work with provider

  3. "I'm always tired—could it be my thyroid?":

    • Common thyroid symptom
    • Request full thyroid panel
    • Also consider iron, B12, vitamin D
    • Sleep and stress matter too
    • See provider for evaluation
## ❓ Common Questions

Q: Why won't my doctor run a full thyroid panel? A: Standard care often only tests TSH for screening. Additional tests are often considered "unnecessary" if TSH is normal. But TSH alone misses conversion issues and autoimmunity. You can request additional tests, offer to pay, or use direct-to-consumer labs.

Q: What time of day should I test hormones? A: Testosterone and cortisol should be tested in the morning (7-10 AM) when they're highest and most consistent. Thyroid can be tested any time but consistency helps with comparison.

Q: Can I optimize hormones without medication? A: Often yes, especially if levels are suboptimal but not severely deficient. Sleep, nutrition, exercise, stress management, and targeted supplements can significantly impact hormone levels. Severe deficiencies may need medication.

Q: Are saliva hormone tests accurate? A: Saliva tests are valuable for cortisol (showing diurnal pattern) and some research uses saliva for other hormones. Blood is standard for most hormone testing. Each has pros and cons—context matters.

Q: How often should I retest hormones? A: Depends on whether you're actively optimizing. If making changes or on treatment, every 2-3 months initially. Once stable, every 6-12 months. Thyroid typically every 6-8 weeks when adjusting medication.

## ✅ Quick Reference

Key Hormone Markers​

MarkerLab RangeOptimalTest When
TSH0.4-4.51.0-2.5Any time
Free T32.3-4.2 pg/mLMid-upperAny time
Free T40.8-1.8 ng/dLMid-upperAny time
Total T (men)300-1000 ng/dL500-900Morning
Free T (men)8-25 pg/mL15-25Morning
Morning cortisol10-20 μg/dL15-208 AM
DHEA-SAge-dependentUpper halfAny time

Testing Checklist​

PanelMarkers to Include
ThyroidTSH, Free T4, Free T3, TPO Ab
Male hormonesTotal T, Free T, SHBG, Estradiol
Female hormonesFSH, LH, E2, Progesterone (timed)
Cortisol4-point saliva or DUTCH

💡 Key Takeaways​

Essential Insights
  1. Full panels reveal what single tests miss—TSH alone isn't enough
  2. Optimal differs from normal—lab ranges aren't health goals
  3. Symptoms matter—don't dismiss symptoms because numbers are "normal"
  4. Timing matters—test testosterone and cortisol in morning
  5. Lifestyle impacts hormones—sleep, stress, nutrition are foundational
  6. Conversion issues are common—T4 to T3 can be impaired
  7. Work with knowledgeable providers—hormone optimization is nuanced
## 📚 Sources
  • American Thyroid Association Guidelines Tier A
  • Endocrine Society Testosterone Guidelines Tier A
  • Thyroid Conversion and Reverse T3 Research Tier A
  • HPA Axis Dysfunction Research Tier B
  • DUTCH Test Clinical Applications Tier B

🔗 Connections​