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Low TSH w/ hot nodule... no treatment?
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Questions in the Thyroid forum are answered by Mark Lupo, MD. Topics covered include Goiter, Graves Disease, Hyperthyroid, Parathyroid/Calcium Problems, Thyroid Cancer, Thyroid Nodules/Cysts, Thyroiditis, Thyroid & Pregnancy, Thyroid Stimulating Hormone (TSH), Thyroid Tests, and Thyroid Surgery.

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Low TSH w/ hot nodule... no treatment?

Thanks ahead of time for reading and responding to this post.

First of.. I am 33 year old female, I have been having daily headaches for over 1 yr now which brought me finally to see various docs and last but not least an endo. Loooong story short, my recent blood work show this, unfortunately I wasn't given all the lab ranges, nor were my Free T's checked.

TSH: 0.02
Tup: 1.06
T4 :  7.9    ( 5.1 - 10.8 )
T3 : 110    ( 75 - 170 )
TSI: 85     ( <125 )

Also I had a radioactive iodine scan, which showed a 2cm hot nodule in right lobe, during my endo's physical exam he said both sides of my thyroid felt swollen/enlarged, and there might be an onset of a goiter.  The RAI scan did not show this so my endo seemed surprised by it, he also sounded surprised by my thyroid hormone levels because they are in the middle of normal ranges, I think he may have expected something else.  He doesn't feel my thyroids are causing any symptoms and that I am just a "normal" low, and feels treatment is not needed.  I should have another blood test in 3 months and see endo again in 6 months.  I must say, I do not have many symptoms headaches are the main problem, am always tired and can't sleep well, slight tremor in hands, pulse can be a tad high, my blood pressure on the other hand is great and always the same 110/70.  I am very confused though... TSH 0.02 + 2cm hot nodule + enlarged thyroid = normal?  What is your opinion? Should I have more tests? Which ones? Could this be a pituitary problem? Or is this all normal?

Thank you for your time and assistance,
Jen
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Your labs show subclinical hyperthyroidism -- ie low TSH and normal T4/T3 -- the normal TSI suggests against Graves and the "hot" nodule suggests it's an autonomous ("toxic") nodule that is causing the problem -- if this was not c/w palpation, then US should be done to make sure this all fits.

With your symptoms, would consider a low dose methimazole (5-10mg) and see if normalizing the TSH helps out -- if so, then definitive treatment with surgery or I-131 to knock out the hot nodule would make sense.

good luck.
2 Comments
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Thank you for your reply,
I shall ask and talk to my endo about this again in 6 months. I know when I saw him last month he said the an US was not necessary and a FNB was out of the question because it is only a hot nodule (toxic adenoma).  I will definately ask about the methimazole though when I see him again.  For now I guess I'll just have to wait and see what my labs show in 3 months and what endo has to say in 6 months.
Thanks again for your input, it is appreciated.
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Mark Lupo, M.D.Blank
Thyroid & Endocrine Center of Florida
Sarasota, FL
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