'Normal' TSH ? LOW TSH and Heart Problems/ HIGH TSH and Heart Disease

[Rella48]

Dr. M L, I've read several messages where you've referred to studies that say low TSH (<.3) causes heart problems. Were these studies done on patients taking T4 only synthetic (Synthroid)? Were they hypO or Graves patients? I'm concerned so could you please tell me where I can find the reports on those studies? Following is a study-"Proper Treatment of Hypothyroidism Found to Prevent Heart Diseases":
  
http://www.medindia.net/News/View_news_main.asp?t=ru&x=5823

I've had untreated HypO for years but now I'm symptom-free. I've been on the same Armour dose 10 mos. My TSH is below .00 depending on when I took my last dose. I had 4 TSH tests done in a 6-hour period:

2.8 TSH at 8am-(17 hrs after last Armour dose),
.0001 TSH at 9am-(1 hr after 180mgs);
.018 TSH at 11am-(3 hrs after 180mg); and
1.02 TSH at 2pm-(6 hrs after 180mg and 1 hr before my 2nd dose of 180mgs).

I've had no hypER or hypO symptoms. In your opinion, am I at risk for heart damage, anyway? Should I decrease my dosage and risk hypO symptoms returning?

It's been reported that 1.0 TSH is normal for most people not taking thyroid replacement. Have any studies been done concerning a "normal" TSH # for those of us taking thyroid hormone? Because the hormone circulating in our blood causes the TSH result to vary so much as my tests show, aren't symptoms much more important than TSH #'s when it comes to dosage adjustment and heart damage? Are thyroid patients at risk for heart damage anyway? Shouldn't more studies be done?

Thank you in advance for your time and answers to my questions.

Rella

[Mark Lupo, M.D.]

Of course more data is needed on thyroid and heart disease - the risk of a low TSH and heart disease is increased with advanced age (typically greater than 65) - this is in population studies usually in patients not on thyroid hormone, but expert opinion is that a low TSH in a pt on thyroid is at risk as well (again, esp with advanced age).  The 6h study is interesting - shows the powerful TSH suppression of relatively high dose armour (ie 3grams).  Honestly, the studies have not specifically looked at this situation, so in absence of palpitations, chest pain, history of heart disease or risks for heart disease (diabetes, tobacco, high cholesterol, hypertension) it may not be dangerous in a young healthy person -- there is no "one size fits all" answer to the question.

Certainly, untreated hypothyroidism can worsen heart disease as well but currently treating to a TSH <0.3 (give or take) is not considered advisable by most international experts.

[mshypo]

I'm with you...with an undetectable TSH and absolutely no hyper symptoms..and in fact, still struggle a bit with hypo symptoms at times.  I don't know how the docs have confused a suppressed TSH from true hyperthyroidism with those with a suppressed TSH because of the normal HPT feedback loop being disrupted with oral thyroid hormone replacement.  

But thank goodness some docs are not confused.  I was just reading Dr. Starr's new book, Hypothyroidism Type 2...and like Dr. Hotze's new book, Hormones, Health, and Happiness...and both of them get it right. I wish all doctors would read these books...it would help so many.  These docs, like some other older thyroid docs, know that TSH only picks up a small portion of hypothyroidism...and they know that blood tests can be quite useless in treating hypothyroidism.  I have never quite figured out how a doctor can think a person is hyper when their temp is still low, their blood pressure and pulse are normal, and they are struggling to resolve lingering hypo symptoms...

[Chocobabe]

Rella, if you look at most studies that doctors cite which involve low TSH, they were either on patients who were on NO meds and were true hyperthyroid, OR they were on patients who were on T4-only meds! I belong to a group called Natural Thyroid Hormones on Yahoo, and it appears that the VAST majority have suppressed TSH's like yours.....and...they are NOT dosing by the TSH. They appear to be dosing by symptom elimnation first, and using the free T3 as a guide rather than the TSH. They have an EXCELLENT Files section to show why they do what they do, and some articles which refute what is being told to us---i.e. refutes dosing by the TSH, and definitely refutes taking T4-only meds. They also state that the real risk to our hearts is in REDUCING Armour simply to abide by the current "rule" that one must go by the TSH. Because when a person "reduces" their Armour to go by the TSH, they also "reduce" the thyroid hormones that puts them in a non-symptom state......and that reduction also increases risks from being chronically hypothyroid.......i.e. UNDERtreated. So in my mind, and in the minds of what appears to be thousands of folks like ourselves who have switched to Armour, going by SYMPTOMS is proving far superior than going by a fallible and changing TSH....in all due respect.

[Chocobabe]

"I have never quite figured out how a doctor can think a person is hyper when their temp is still low, their blood pressure and pulse are normal, and they are struggling to resolve lingering hypo symptoms... "  Mshypo, you couldn't have said it better. Why doctors think that a TSH is the end-all to treatment in spite of and in lieu of obvious symptoms or lack of.....boggles the mind.

[Mark Lupo, M.D.]

The TSH debate continues....it is certainly not the end-all test and we all welcome the day when we have tests that reflect tissue level thyroid activity -- until then, in order to make general treatment recommendations we need to rely on studies that suggest a low tsh may be harmful in certain patients -- body temperature is not dependable to reflect thyroid function.  There are certainly other opinions that are well marketed and described -- however, in mainstream thyroidology we depend on studies and expert consensus -- again the individual patient evaluation supercedes any generalized statement that can be made.

[Chocobabe]

Dr. Mark, it is refreshing to read an Endocrinologist like yourself state that the TSH is not the end-all test, because AACE and so many of your colleagues are rigidly stating that fact ABOVE AND BEYOND the continuing symptoms of patients who are kept in that TSH range. And if a patient on Armour takes enough Armour to rid themselves of symptoms...and has a suppressed TSH...it's the Endocrinologists who are screaming bloody murder and insisting that the patient in now "hyper" and that the patient needs to decrease their Armour, even though there are NO symptoms of hyper and even though decreasing Armour to get the patient back "in range" also causes hypo symptoms to return!

But when you state that you have to rely on studies---those studies are based on patients who are either true hyper, or on patients on T4-only meds, and no studies are addressing those who are on Armour, which changes that feedback loop! So, because of inadequate "studies" (and because of the huge financial power of Abbott labs), patients are being told to decrease or dose according to a TSH and inadequate studies.

When did "studies" and "mainstream thyroidology" become more important than obvious symptoms, or more important than patients who are finally symptom-free, yet are told to decrease their meds so they can fall within an arbitrary range??
It's ludicrous.

But, you also stated that "the individual patient evaluation supercedes any generalized statement that can be made", and that is hopeful. Because there appear to be thousands upon thousands of us..of individuals..whose experiences with Armour and with dosing NOT by the TSH are DISPROVING those "studies" and that "mainstream thyroidology".

[NURSELPN]

Even though I am a nurse, I am certainally no expert on thyroid, but I have experienced hypothyroidism since the early 80's & then last year I was treated for hyperthyroidism due to Graves. Until the symptoms got so pronounced, that they almost stopped me in my tracks, it was hard for me to differentiate hypo from hyper.. Yes their are some suttle differences, but many symptoms are alike, i.e. generalized weakness, muscle aches, brain fog, breathlessness, hair loss, ridges on fingernails, palpitations, goiter, just to name a few. Also I had low blood pressure when I was hyper., not everyone has the same symptoms. Until my symptoms escalated into full blown hyperthyroidism I could not tell the difference. Then the other hyper. symptoms came into play & believe me you don't want to go there. My hyper status was documented first in my TSH long before my symptoms escalated. I also now know I was experiencing periods of extreme hyperactivity that would come & go for at least 3 yrs.prior to my diagnosis . But like hypo symptoms they come on so slowly you don't even realize they are there until they are out of control. If my hyper state would have been caught earlier my immune system may not have attacked my thyroid or my eyes & it may not have affected my health so much. My TSH was consistently <.03 for almost nine years before my diagnosis but seeing I wasn't having any hyper symptoms I was maintained on the same dosage of Synthroid & my Free T's weren't checked. But this was done that way because I was asymptomatic. The one thing I would like to advocate is that (Family Physican's) be educated to always check the free T-3 & free T-4 with the TSH. Especially if the TSH is low.  I feel you must combine the lab results including the TSH with the symptoms of the pt., as Dr. Mark has said.  But you can't just go by symptoms. TSH, free T-3 & free T-4 are important too..
I'm not saying that one med is any better than another, that too depends on an individuals reaction. I have taken both Synthroid pre-hyperthyroid & now Armour post-hyperthyroid treatment & have had good results with both of them.
I'd like to say thank you to Dr. Mark for making this disease so much easier for us to deal with & offering your knowledge so freely. I wished I could have been able to talk with you while I was undergoing treatment for my hyperthyroid state. I know I have gained alot of knowledge from you so far. It's great to have an Endocrinologist at our finger tips. Thanks again.

[NURSELPN]

The prior post was to Chocobabe & you.  Thanks

[Ussie]

My TSH has been suppressed to under 0.01, you could say nonexistant. When my Ft4 and Ft3 are not in the upper 1/3 of the range, I have depression, anxiety,low body temperatures.

I did have RAI for Graves disease.

[mshypo]

Yes, the TSH debate continues..as every test to check thyroid function has been debated...and eventually discarded.  Haven't they all had problems and haven't they all been discontinued eventually?  I do not understand how the medical establishment has gotten away from what worked - diagnosing hypothyroidism from the patient's medical history, symptoms, and physical findings.  

As for stating "body temperature is not dependable to reflect thyroid function", I believe it might well be true that is is more dependable than the TSH lab test as lowering of body temperature is an extremely prevalent symptom of hypothyroidism.  True, hypo is not the only problem that may lower the patient's temperature, but it is definitely the most common reason...and this is being ignored by the vast majority of doctors. My own experience is that I had a lowered temperature for over a decade before my TSH rose high enough to get a hypo diagnosis.  My life would had been entirely different if docs had looked at low body temperature and symptoms instead of saying "normal" because of a faulty TSH test.

As for those tests regarding a low TSH that you refer too, investigation reveals those tests are all about true hyperthyroidism and not for those on oral thyroid hormone replacement.  In fact, it would appear that the real threat to a hypo person's health is remaining hypo due to undertreatment due to dosing by the TSH.  

[MinnieM]

I want to ditto Nurse's comments.  Where is Dr. Mark located?  Wish he was here in Houston. He has been very helpful.  I am on 3 Grams of Armour and thanks to Dr. Mark I am taking 1/2 in AM and 1/2 in PM.  I have had bouts of Tach and A-bib.  I most likely will switch to Synthroid very soon.

[nelsonchatham]

Dr. Mark's web address is on the thyroid home page.  
I think you meant 3 GRAINS of Armour...which is an average dosage according to some studies and slightly less than a full replacement dosage according to some docs.  Although palps are not uncommon at all when someone is raising their dosage (the heart has to adjust..and btw A-Fib can be a hypo symptom too), I am wondering how long you were untreated (which could have caused heart problems...and does mean extreme caution in dosing with desiccated thyroid extract since it does push the heart to normalcy) and if your adrenal function is normal (which could cause those problems) since many hypos have adrenal dysfunction as well.  There are a lot of thing to consider in a patient before jumping to conclusions.  Low Ferritin is another lab to check...The Broda Barnes Foundation recommends it be 100 to avoid problems with the thyroid hormone.

Good luck on the Synthroid though...although all I've ever heard are tales of years of misery and worsening hypothyroidism on T4 medications.  Maybe you'll be an exception?

[Chocobabe]

You make a good point that it was the TSH that showed your hyper state long before the symptoms did. But you are also SO on target to advocate that physicians check the free T3 and free T4 as well! Good for you! The tragedy of the current thyroid "methodology" of doctors is that they tend to use the outdated "thyroid panel" and only test the total T4, TSH and sometimes the uptake------and those can MISS what is really going on! A patient who uses the thyroid panel could have a total T4 and a TSH in a normal range, yet their free T3 was low in range, and symptoms, of course, persist!

My point about the TSH concerns the problem of rigidly--keeping a patient in an arbitrary range when the patient's symptoms scream hypo while in that range. When I was put on Armour and was slowly being raised, my TSH got down to the bottom of the TSH range........yet I STILL had symptoms. Granted, my symptoms improved, but they were not totally gone. I kept raising my Armour a bit more...and when my symptoms were totally gone, I was below range! And if you talk to folks who are on Armour and symptom-free, you discover that MOST are below the TSH range...with NO hyper symptoms.

I think I can definitely say that one med is better than another! I noticed a huge difference between being on T4-only meds and being on Armour, and apparently thousands upon thousands of folks are noticing the same. So again, it's the ridigity of docs that concern me--dosing a patient solely by the TSH range, and using Synthroid as a first line of defense.

(By the way, did you have antibodies? Is there a possibility that you were swinging to the hyper end because Synthroid wasn't doing the job of treating your thyroid, and thus, your antibodies were doing a number on you? Just curious.)

[MinnieM]

Yes, I did mean 3 Grams....And it is A-FIB and not A-BIB.  I need spell check...LOL

I never had a ferritin level checked in my 55 years and asked for one this summer.  It was 16.  I asked for a repeat...It was 14.  I asked for another repeat and it was 12.  All done by Quest Labs.  The docs were not concerend.  And, now I have adenoma on the Rt. Thyroid.  I am a mess.  And on top of this..heart disease. I really feel that the Thyroid has been the culprit to my problems and I feel like *&%^%^%*8!!! I even have problems breathing.  I am finally other seeing an Endo next week,  The other 2 Endo's I saw a few years back should be put to pasture.  My GP has been very good but now he is stumped.

[Chocobabe]

I used to have a Ferritin as low as yours, and it was miserable--hair loss, depression, achiness, palps, weakness in my arms and legs...plus I was unable to raise my Armour at a certain point without having problems. I finally got wise about it--had it tested. Started on iron--had to take quite a lot--and now I keep my Ferritin between 70 - 90. Made a huge difference, plus I was able to once again raise my Armour and get the full benefit. And by the way, it appears that MANY hypos have low Ferritin, and we're not sure why. I also had to stop seeing Endos--they didn't seem to have ANY knowledge about Armour or it's benefit...or how to dose it. And I KNEW first hand that Armour was working far better for me than Levothyroxine, which I used to be on.

[ancientmariner]

Minnie,

I would be willing to bet that you're right - thyroid has caused ALL your problems. But I'd also be willing to bet that you feel so bad because of your very low ferritin. If you could get the ferritin up to about 80, I'd bet you feel lots better. If you're interested, there's a natural thryoid hormones group on yahoo that I belong to - there's a lot of information there on Armour and thyroid in general.

[NURSELPN]

I would be interested to know what my antiboties are too but no my antiboties have never been tested. It may be an afterthought now but I asked my opthamologist about it & he said right now the important thing is to get my thyroid back in control to see if it helps my eye disease. I have recently been increased to 3 grains of Armour ( do I understand you to say that is full replacement ?) hopefully that will bring my free T's back into line. It has been since May when my TSH plumbted to 89 & hopefully I will feel better soon. I also have B-12 deficiency so that does not help my symptoms. My family physican is having a hard time bringing my B-12 up over 344 even though I'm on injectable B-12 @ 1cc twice weekly since May also. It was in the low 80's when first checked.I must be resistant or something. I've had my CBC checked (normal) & I know that would reflect anemia but I'm not sure whether that would show any possible problems with my ferritin. I wonder if should ask my F.P. if he could check that too.  Maybe Dr Mark could give us some insight into these questions.
As to your question about the Synthroid, I'm not sure exactly what caused the immune system attack, but I do not think the Synthroid had anything to do with it. Remember I took Synthroid for twenty years & was asymptomatic for the majority if them. The reason I requested Armour after my treatment is that I'm almost bald due to hair loss ( I have to wear a wig) & I understand that one of Synthroid's side effects is hair loss. I wanted to give my hair every oppurtunity to come back, so I requested Armour.

[NURSELPN]

Sorry, kind of dumb for a nurse but what are the symptoms of low ferritin anyway?

[Chocobabe]

Did you know that you can have "normal" CBC labs and STILL have low Ferritin? That is exactly what happened to me. My symptoms were fairly benign at the beginning with my low Ferritin, but due to an abnormally long menstrual flow, I then plummeted with symptoms--my arms tired quickly when I would wash my hair, extreme hair loss, achiness, and depression. And...I was unable to raise my Armour. That's when I discovered my Ferritin to be in the low teens. I got on iron, and managed to raise it to about 58. Got off, and DOWN my Ferritin went. Very strange. I now keep it between 70 - 90.

I didn't say it, but it is my understanding that 3-5 grains is a full replacement dose. I do know a few gals who are on much more, but they seem to have some kind of thyroid hormone resistance.

When you mentioned that a side effect of Synthroid is hair loss--doesnt' surprise me a bit. It's T4 only, and I note that T4-only users have continuing hypo symptoms--and hair loss is one of those. And low Ferritin doesn't help either. When I was on Levothyroxine, my hair kept getting thinner and thinner. I thought it was due to nearing peri-meno, but I was wrong. After I switched to Armour and was allowed to get my free T3 at the top of the range, slowly but surely my hair thickness has come back! I hope that turns out to be true for you! :o)

[nelsonchatham]

just curious - but you say antibodies have never been checked?  then how do you know you have graves?  
the reason for asking is this:...even though your TSH was suppressed...all your symptoms are ones that can be hypo...and were you just on a higher dosage of synthroid that suppressed your TSH?  Or are you really Hashi's who just went hyper for a while?  i guess i'm wondering if they treated you for hyper (what did they do?  RAI?) when you were just still hypo and undertreated on a T4 med.  I especially wonder this because of the hair loss.  True, TED (thyroid eye disease) is more common to Graves than it is to Hashimoto's...but it can happen with both.  sorry for being nosy..but you wouldn't be the first Hashi's person to get RAI for a hyper phase.

[Mark Lupo, M.D.]

A FEW POINTS:

Antibodies aren't necessary to clench to diagnosis of Graves

Pharmacologically 3-5 grains of armour would usually be considered a high dose while 1-3 grains may be normal full replacement based on pharmacodynamic models of thyroid hormone physiology in humans.  Studies are still lacking on the exact answer here.

Until we have studies of armour patients followed over years for heart disease (based on TSH levels, etc) I would hesitate in broadcasting statements that Armour does not cause heart problems in the same way endogenous hyperthyroidism does.

Low Ferritin is an early sign of iron deficiency - in LPN's case would check for celiac sprue (anti gliadin & anti endomysial antibodies) and for pernicious anemia (anti-IF and anti-parietal cell antibodies).

In the case of Minnie - I am concerned that 3g of armour may have over-stimulated the heart and aggravated the a-fib - even though dosed 1/2 bid as stated - in that case I would convert to synthroid or levoxyl to see if the a-fib improves (and make sure the TSH is 0.5-2.0).

I believe that people should be cautious in making broad statements about treating thyroid problems - particularly when it comes to TSH and high dose armour -- there are many individual considerations that a clinician should use in making these decisions and such broad statements may be dangerous to an individual who may then try to titrate their own armour dose -- I have personally seen patients in atrial fib and heart failure in such situations.

[nelsonchatham]

I did not intend to make any broad statements, but I think it sufficient to say that I and others have obviously  looked at older studies which current endocrinology ignores and disputes.  Broda Barnes' info from his "case studies" are excellent...and I believe the NEJOM says case studies are just as good as other studies.  His info on thyroid hormone and heart cases should be a must read for all docs.  But I will not argue the points.  It is interesting to note, however, that Armour makes a five grain tab...supposedly a full replacement dosage.

[NURSELPN]

I was diagnosed with Graves disease by an endocrinologist after she looked at my test results which included multiple labs, thyroid ultrasound, I-123 scan w/ 70% uptake & positive S/S (not just hypo.) of Extreme fatigue,sweaty palms, heat intolerance,increased sweating, 60# Weight loss,nervousness, muscle tremors,insomnia, breathlessness, chest pain & palpitations, frequent stools, muscle weakness, numbness of hands & feet, hair loss, enlarged thyroid gland, vision changes, depression,irratic behavior, poor memory, shortened attention span & diff. concentrating. I also had panic attacks & agoraphobia. Which I do not have now. I thought I was going to die @ times & was so shakey I felt as if I was going explode. My TSH was undetectable & free t-4 3x's normal when off from all thyroid meds.. I was a basket case & needed help. I had an I-131 treatment in Feb.of this year & seen an endocrinologist for the first time 3 days afterward due to the post dumping syndrome. That's when I was told that I have Graves. Prior to that time I had been seeing an internist, my family physican, and all I knew is that I had hyperthyroidism. Mind you I wasn't in very good shape. Being a nurse & a woman I dismissed alot of these symptoms as something else & just kept going until I could no longer function. I was having alot of diff. concentrating or even thinking straight.  At first he thought I was just taking too much Synthoid and slowly titrated me down then realized I was truly hyper. after he stopped all thyroid meds.. Then began ordering tests. Approx. 6 mos. after my initial visit I was treated with I-131. Due to the severity of my symptoms I still have not returned to work. I'm now hypo taking Armour & back with my family physican who is trying to get my labs back to normal. I feel better but still not well & far from normal. Your not being noisy & I probably more than answered your question. Sorry for such a long response.

[nelsonchatham]

Thx nurse, for that informative post.  i'm a hypo person so I don't know much about Graves and how it is diagnosed.  I was, however, struck again by how similar hyper symptoms can be to hypo symptoms.  For example, I experienced many of those symptoms when undiagnosed hypo.  I also find it fascinating that you went from a long hypo stage to a diagnosis of Graves.  I would think that was an unusual presentation...and would appreciate it is Dr. Mark might comment on that.  Also, since he said antibodies weren't the clencher for a Graves diagnosis, I would appreciate his comments on what is.  
Thx again, nurse, for sharing your experience.

[MinnieM]

Thank you again, Dr.  I saw the Endo today and printed off your most informative information on Armour and my heart condition.  This female Endo either had a long night and or was Hypo herself and was moving at a smail's pace but she did agree that I should not be on Armour as the T3 is not regulated. She is also doing Cortisol testing, i.e. 24 hour Urine and blood and a host of other thyroid blood work.  She felt the nodules and saw a driver's license picture taken 2 1/2 years ago and compare it to one taken 6 years earlier. (this is about the time I started Armour)   The latter one had wide bulging eyes.  She said the eyes were indicative of TOO MUCH thyroid. (3 Gr. of Armour) She also asked when I had my heartattack and I told her I do not know. She was surprised when I told her my old TSH numbers and that some of the docs I had seen were satisfied with those numbers. She noted that my Free T3 that was taken 3 months ago was too high. She also told me that the Ferritin being low was due to either bleeding from the colon or upper digestive area and not from the Plavix.  I told her all Iron and CBC blood tests were normal though.  She wants me to see a gastro doc ASAP. As soon as the blood work comes back, I will be switched to Synthroid ans a teeny bit of Cytomel to be taken around 2:00PM.   I had no idea that I must wait 2 hours after eating to take my thyroid or an hour before eating.  

Thanks again Dr. Mark for all your help.

Minnie the Mouse.

[MarlanaD]

hey everyone i have been on armour for almost a year now levoxyl worked for a while but then started not to. I had a my thyroid totally removed almost 3 years ago. I'm at the point now where I take 90mg 0f armour a day I just got my blood work back stating that my TSH was 0.26 T4 was 0.8 (low end) and T3 was normal high end. I am concerned about the T4 number. My doc suggests I Lower my armour and see how it goes I don't understand why my T4 is low if I am hyper.

[ancientmariner]

What makes you say you're hyper? The TSH? Several studies say that when you're on thyroid hormone replacement, the TSH cannot be relied on, but the Free T3 and Free T4 should be used. The way I understand it, and it makes sense to me, is that there's a feedback loop where the thyroid produces hormone based on teh TSH from the pituitary. The pituitary checks how much is available and increases the TSH if your thyroid need sto produce more. But, when you're taking thryoid replacement, you dump all that thyroid into the system in the morning. Your pituitary senses that and decides that it'll tell your thyroid not to produce so much, so your TSH goes down.

If you don't have hyper symptoms, you're probably NOT hyper. IMO there's entirely too much attention paid to labs and too little attention paid to how we FEEL! If your T4 is low, I don't see how it can possibly go up if you reduce your thyroid dose and your own thyroid isn't there to produce anything.

Also, I have seen studies that say that a normal thyroid produces the equivalent of 180 - 300 mg of Armour daily, so the amout you're taking would seem very low.

I belong to the yahoo Natural Thyroid Hormones group - most everybody there is on Armour - you might be interested in joining.

[brushart]

A related discussion, TSH # was started.