Normal TSH with low T4

[Josleas]

I am 41, female, diagnosed with coeliac disease Jan 2005, two of my children, a brother and nephew have type 1 diabetes, mother has autoimmune hypothyroidism. I had hair loss, sleepiness (falling asleep in day, sleeping 10-12 hours), fatigue, aching joints, low libido, poor mental function. Periods irregular varying between 30-45 days and painful with clots.

Sept 2005
TSH 2.3 (0.35 – 3.5)
FT4 7 (8-21)

Put on 25mg Levothyroxine, then 50mg 2 months later as symptoms persisted.

Symptoms now gone apart from occasional fatigue. Periods vary between 25 & 29 days, less painful and no clots. The last symptoms went over last two weeks. I cannot eat more than 1400 calories per day. I have no hyper symptoms.

March 2006
TSH 0.02 (0.35-3.5)
FT4 14 (8-21)
Thyroid antibody normal

My 14yo daughter, type 1 diabetes 7 yrs, has similar results. Her symptoms are tired all the time, feeling cold, poor concentration, blurred vision when reading and feeling down. Over the last few weeks, she has complained of nausea, headaches (always middle of forehead just above eye level), and loss of appetite.

March 2006
Ferritin 17 (20-200)
Hb normal
Celiac normal
TSH 1.67 (0.35-3.5)
FT4 7 (8-21)

The normal TSH and low FT4 confuses us. I believe that this can happen with pituitary problems but this is quite rare so it seems unlikely that both of us have developed a pituitary problem independently.

Are there genetic causes of pituitary problems?
Can I have autoimmune hypoT without antibodies?
Is this common?
Can it be just hypothyroidism with these TSH results?
Do you recommend any further tests?

[Mark Lupo, M.D.]

There are genetic pituitary problems -- very rare -- your labs do NOT suggest reason to be concerned about pituitary but perhaps the levothyroxine dose may need a slight decrese (ie to 37.5mcg) as the TSH is too low.

Yes, you can have autoimmune hypoT without ab's -- thyroid ultrasound may help identify it.  10% of hashi may be ab neg.

My guess is your daughter has normal thyroid function but may want to repeat with antibodies in 2 months to make sure.  Also repeat the CBC (hgb) as the low ferritin may be worrisome for iron deficiency/anemia.

[Josleas]

Thanks for your reply. I had a FT3 taken a couple of weeks after starting Levothyroxine because my coeliac consultant didn't think I should be on thyroxine. Luckily, my GP didn't take any notice. My levels then were:

TSH = 0.76 (0.35 – 3.5)
FT4 = 9 (8-21)
FT3 = 3.9 (3.8-6)
(after taking 25mg Levothyroxine for 2 weeks)

I am sure I am hypothyroid because of the resolution of symptoms. I'm more concerned that there may be a problem with the pituitary gland as this can obviously cause other problems and we should be monitored for these. I'm wondering if there is any way to establish the cause of the hypothyroidism for sure or tests that can be carried out to check the pituitary. If it is a pituitary problem, I think it is normal to treat to the T4 level and ignore the TSH because the pituitary is not producing TSH correctly. My daughter and I would then avoid the problem of other doctors saying we should not be taking thyroxine because our TSH falls within the normal range (normal or low TSH combined with low T4 indicates secondary hypothyroidism).

My daughter is on iron for the low ferritin and is on 25mg Levothyroxine. I ran out of space for the question or I would have included this. I've been unable to find out for sure if low iron stores cause symptoms. Some places say yes, some say no. Our doctor doesn't think the symptoms are caused by the low iron stores as the full blood count Hb was OK.

Thanks again for your reply it is much appreciated.

[Josleas]

Thanks for the feedback. I was originally reassured by your replies until I read this:

http://bmj.bmjjournals.com/cgi/content/full/321/7271/1275

" A 43 year old man was having the results of his thyroid tests checked to investigate possible causes of hypercholesterolaemia. On testing, his TSH concentration was 2.42 mU/l and free thyroxine was 7 pmol/l, suggesting central hypothyroidism."

My TSH was 2.3 and FT4 was 7; almost identical and my daughter's are similar. There are several cases detailed with similar TSH & T4 results and these results were considered to suggest central hypothyroidism. Not sure where to go from here. I would be interested to know why ML believes that my results do not suggest a pituitary problem. Maybe if he had given a reason I would see that this is consistent with the linked page in some way. However, with the information I have I cannot see a difference. Rare doesn't mean it never happens. I'm not convinced that we do have a pituitary problem (because of it's rareness and lack of other symptoms) but I would like to know how it has been ruled out rather than feel that it has just been dismissed because it's rare (not saying that this is what has happened but I don't have any information to reassure me that this is not the case).

Kelliek, re. our doctor. I am very happy with her so far. She has been willing to listen to symptoms and prescribe thyroxine where I'm sure many others wouldn't. She increased my dose even when my TSH was 0.64 because I still had symptoms and she is happy to check again in three months without reducing my dose despite a TSH of 0.02 because my symptoms have only just resolved and I don't have any hyper symptoms. I was on 37.5mg for a while but still have obvious symptoms that have gone since the dose was increased. Maybe placebo effect? But I don't think so.

Thanks again for your time.
Jos

[NURSELPN]

Have either you or your daughter had your B-12 checked? B-12
deficiency  is another disorder that is can occur with celiac disease &/or thyroid disease.
Good Luck  Jean

[Josleas]

Thanks for your reply. I have been tested for B12 and it was fine. I didn't realise it can be a problem with the thyroid as well. I'll see how my daughter does on thyroxine and iron and if she is still having problems when the next blood test is due I'll ask them to check B12. Despite 7 years of diabetes (or maybe because of 7 years of diabetes) my daughter doesn't like needles and wouldn't appreciate an extra blood test before then :-)

[NURSELPN]

Whenever my patients say they don't like needles. I tell them... I'd worry about you if you did! :-)
Be sure & get your own copies of your lab results to keep for your own record. Sometimes what's normal to one physican isn't to another. You have a right to have those copies just ask them to send them to you or pick them up at your doctor's office. It's usually not a problem..... Good Luck

[Dina95]

hi
I have been on thyroxine suppliment for about 4 months. My T4 and TSH levels are ok now however the antibodies are really high. i found out that had a miscarriage,didn't know i was pregnant. could the miscarriage be due to antibodies? how to treat antibodies? By the way, this is my second miscarriage since may 2005.

thanx

[NURSELPN]

Which antibodies were high?

...miscarriages are a symptom of thyroid disease. High thyroid antibodies means your thyroid is under attack either from graves disease or hashimotos thyroid disease. Both are autoimmune diseases which cause antibodies from your immune system to attack your thyroid. Graves causes high thyroid
Hashimotos causes low.

http://thyroid.about.com/od/hypothyroidismhashimotos/

This forum has many pts. discussing thyroid problems & pregnancy

http://forums.about.com/n/pfx/forum.aspx?webtag=ab-thyroid3&nav=start&lgnF=y  

Good Luck TJ

[debnels]

My 21 year old daughter was diagnosed with Graves Disease, I have Hashi's, medication would not put her in remission, so she had RAI 2 months ago. Yesterday, she noticed brusing all over her body.  Arms (11 spots size of nickels or dimes), under her breasts, groin and legs.  Has anyone heard of this, her endo is here in Denver and she is away at school in Nebr. (500 miles away), I'm waiting for Endo to call me back.  Could this be low ferritin? and how can this be treated?  worried mom