Can someone help me?

Question

My T4 level is at 1.15. My TSH level is at .85 and my T# level is at 124. Please someone help me understand what this means. I feel terrible all the time, im so completely tired all day and im always cold. Any comments would help immensely. Thank you

gimel · Accepted Answer

Both your Total T3 and Total T4 were below the middle of the range.  If your Free T3 and Free T4 are consistent with that, then that may be the cause for your hypo symptoms.  Please try to get done all those tests I mentioned above.  If the doctor resists, just insist on them and don't take no for an answer.

Sweetgirl3192 · Answer

Absolutely Perfect! Thank you so very much. Its comforting to know that someone is willing to help me. I will send this letter to my doctor and keep you posted. Again thank you :)

gimel · Answer

Letter continued


______________________Next is that TSH is even less useful as a diagnostic by which to medicate a hypo patient when already taking thyroid meds.  This link from the British Medical Journal and quote confirm that position.

http://www.bmj.com/content/293/6550/808
"To establish their role in monitoring patients receiving thyroxine replacement biochemical tests of thyroid function were performed in 148 hypothyroid patients studied prospectively. Measurements of serum concentrations of total thyroxine, analogue free thyroxine, total triiodothyronine, analogue free triiodothyronine, and thyroid stimulating hormone, made with a sensitive immunoradiometric assay, did not, except in patients with gross abnormalities, distinguish euthyroid patients from those who were receiving inadequate or excessive replacement. These measurements are therefore of little, if any, value in monitoring patients receiving thyroxine replacement."

Further, from the full pdf of this study, evidence that suppressed TSH is frequently experienced when taking adequate dosage of thyroid meds.   "When FT4 levels were normal, however, TSH levels were normal in only 51.5% and abnormal in 48.5%. We also examined the possibility that FT4 levels may remain within normal range when TSH is suppressed during L-thyroxine treatment for goitre or cancer. FT4 and TSH were measured in 45 patients on L-thyroxine as TSH suppression treatment. TSH was suppressed in 23 patients (51.1%), normal in 20 (44.4%) and elevated in 2 (4.5%). When TSH was suppressed, FT4 was elevated in 30.4% but normal in 69.6% of patients."


The next big issue is reference ranges.  Even though my test results fell within the bottom end of their ranges, from my personal experience, and what I have learned, that clearly does not mean those levels are adequate to relieve symptoms.  The ranges are far too broad  because the ranges were erroneously established.   The ranges were established based on all patient data for which test results were available.  Then assumptions were made that about 2.5% of patients were hypothyroid and about 2.5 % were hyper, and reference range limits were established at those points.  About 10 years ago, the AACE finally acknowledged there are many, many more than 2.5 % hypo and hyper.  After purging the data base and recalculating the range limits, they made a huge change to the TSH range from .5 - 5.0, down to 3 - 3.0.  Unfortunately TSH is a poor diagnostic, as discussed above, so this change didn't help hypo patients very much.  Plus most labs and doctors continue to use the old range, even after 10 years.  The biggest impact from the acknowledgement that the TSH range was wrong, is that the ranges for Free T3 and Free T4 were established the same way as TSH.  Thus, it is extremely unfortunate that the ranges for Free T3 and Free T4 have never been corrected like done for TSH.  

If the data bases for Free T3 and Free T4 were purged of suspect patient test data, as done for TSH, the new ranges would be more like the upper half of the current ranges.    This clarifies why so many hypo patients with Free T3 and Free T4 in the low end of their ranges are still symptomatic.  There is some good info in this link.  Note the statement, "The Free T3 optimal range being above the midpoint is corroborated by three different sources.", and the references to scientific studies.  

http://tiredthyroid.com/optimal-labs.html

Also, the following conclusions regarding individual ranges versus group ranges were taken from the scientific study also linked below.

"High individuality causes laboratory reference ranges to be insensitive to changes in test results that are significant for the individual.

The width of the individual 95% confidence intervals were approximately half that of the group for all variables.

Our data indicate that each individual had a unique thyroid function. The individual reference ranges for test results were narrow, compared with group reference ranges used to develop laboratory reference ranges. Accordingly, a test result within laboratory reference limits is not necessarily normal for an individual."

Andersen S, Pedersen KM, Bruun NH, Laurberg P. Narrow individual variations in serum T(4) and T(3) in normal subjects: a clue to the understanding of subclinical thyroid disease. J Clin Endocrinol Metab. 2002 Mar;87(3):1068-72. 


So, if TSH and the existing reference ranges for Free T3 and Free T4 are inadequate to diagnose and treat hypo patients, what should be done.  From my position, clearly I think the best approach is clinical treatment.  During this search, I found a letter written by a thyroid doctor for patients that he sometimes consults with, after initial evaluation and testing.  The letter is then sent to the participating PCP of the patient to help guide treatment.  In the letter, please note this info.    "the ultimate criterion for dose adjustment must always be the clinical response of the patient.  I have prescribed natural dessicated thyroid for your patient (Armour, Nature-Throid) because it contains both T4 and T3 (40mcg and 9mcg respectively per 60mg). This assures sufficient T3 levels and thyroid effects in the body. Since NDT has more T3 than the human thyroid gland produces, the well-replaced patient’s FT4 will be below the middle of its range, and the FT3 will be high “normal” or slightly high before the next AM dose."   This is a link to the doctors website.

http://hormonerestoration.com/files/ThyroidPMD.pdf

I greatly appreciate your time and patience in taking up my concern.  I hope that I have given you enough evidence to reconsider my treatment.  I assure you that I have not cherry-picked this info, just to support my request.  I can provide references to more extensive scientific evidence than you would ever want to read, along the same lines.  I hope this will persuade you to at least let me have a therapeutic trial of thyroid meds, and and then adjust Free T3 and Free T4 as necessary to relieve my hypo symptoms.  I look forward to a full discussion when I return for my next appointment.  

Sincerely,  


______________


I'd give the doctor a copy of this letter, modified as you see fit, and also attach hard copies of each of the links listed in the letter, so he won't have to get on the internet to read them (assuming he will bother to do so). What do you think of this approach?

gimel · Answer

This is a form letter I wrote for use by several members with obstinate doctors.  

Dear Dr. ___________

I know you told me to ignore what I read on the internet; however, the kind of information I have been reading is based on scientific evidence.  So, I am sending you this letter in hopes you will take time to read and prepare to discuss with me at next opportunity.  I am writing because I still suffer with numerous hypothyroid symptoms, even though my TSH and total T3 and Free T4 are within their reference ranges, and you have declined to prescribe thyroid meds.  I have spent considerable time searching and reading related information and discussing all of it with an experienced and knowledgeable friends.  I have learned  a great deal, which leads me here.

First, the "Immaculate TSH Belief' is a big problem for hypo patients.  Until this test was invented about 40 years ago, hypo patients were routinely treated clinically.   One of the many places this is discussed is in this interview with Dr. Derry, which you will find revealing.

http://www.thyroid-info.com/articles/david-derry.htm

Next is the assumption that TSH accurately reflects levels of the actual thyroid hormones.  In actuality, TSH cannot be shown to correlate well with either Free T3 or Free T4, much less with symptoms, which should be most important.   The following link is graphical presentation that shows the best correlation tof TSH to Free T4 and Free T3 I have ever found, and it is very clear that the correlation of TSH to Free T4 is poor, and even worse with Free T3.  

http://www.clinchem.org/content/55/7/1380/F2.expansion.html


In fact, scientific studies such as the following, have shown that hypo symptoms correlated best with Free T3, while Free T4 and TSH did not correlate at all.  

http://www.ingentaconnect.com/content/routledg/cjne/2000/00000010/00000002/art00002

___________________

Letter exceeded 8000 character limit.  Continued in second post.

gimel · Answer

Then it looks like we need to swamp him with scientific evidence that he is off base.  I'll put that together and post as soon as I can.

Sweetgirl3192 · Answer

Thank you for all your help. I live in Gainesville, Florida. I cant see an endocrinologist without a referral from my primary. Since he is not willing to send me, id have to pay out of pocket. Thank you once again for your help!

gimel · Answer

Well, don't accept what he has told you.  Your only options are to present him with scientific evidence that what he says is incorrect and try to change his mind, or find a good thyroid doctor.  If you will tell us your location, perhaps a member can recommend a good thyroid doctor for you.  In the interim, I will dig out some links to scientific studies that I have used a number of times.  Sometimes they persuade the doctor, sometimes not.

Sweetgirl3192 · Answer

Hello again,

Yes i did specifically ask for those tests. I printed out your response and took it with me. Needless to say he was not to enthusiastic. He told me not to believe everything i read on the internet. He wont do the tests. So my only other option is to accept what he tells me, or find another doctor. As for the results of these tests, he says im going into menopause and this is my problem.

As for the link youve posted i have 15 of the listed symptoms. Ive also brought to my doctors attention, he says my numbers are in the normal range and will not medicate. I dont know what else to do.

gimel · Answer

Since your doctor was willing to run all those tests I wish he had thrown in about 5 more that would have give some good information on Free T3, Free T4, Vitamin D, B12 and ferritin.  Did you ask for those?

After all those additional tests, we really have nothing more to go on than the Free T4, Total T3 and TSH tests you previously posted.  The Free T4 and Total T3 tests are both in the lower half of their ranges, which can be indicators of hypothyroidism.  The best indicator is symptoms.  You mentioned feeling terrible, tired and cold.  If you look at this link there is a list of 26 typical hypo symptoms.  do you have any others of these?

http://endocrine-system.emedtv.com/hypothyroidism/hypothyroidism-symptoms-and-signs.html

Also, please clarify something.  You mention being cold, yet you said that in the doctor's office your temp was 99.5, which is higher than normal of 98.8.

Sweetgirl3192 · Answer

Hi! im sorry its taken so long. Ive finally convinced my doctor to run more tests. I dont understand the results at all. but he does not think i nedd meds for thyroids.

WHITE BLOOD CELL COUNT 11.3 4.0 - 10.0 thou/cu mm
RBC 4.85 4.0 - 5.2 mill/cu mm
Hemoglobin 14.6 12.0 - 16.0 g/dL
Hematocrit 43.3 35.0 - 45.0 %
MCV 89.3 78.0 - 100.0 cu micron
MCH 30.2 26 - 34 pg
MCHC 33.8 31 - 37 g/dL
CHCM 33.1 32.0 - 38.0 g/dL
RDW 13.1 11.0 - 14.0 %
PLATELET COUNT 364 150 - 450 thou/cu mm
MPV 7.7 6.0 - 10.0 fL
Neutrophils Relative Percent 56.5 40.0 - 80.0 %
Lymphs 29.1 20.0 - 45.0 %
Monocytes 5.5 2.0 - 10.0 %
Eos 6.4 0 - 8 %
Basos 0.7 0 - 2 %
Large Unstained Cells 1.8 0.0 - 4.0 %
Differential Type Auto Diff
Neutrophils Absolute 6.39 1.70 - 7.00 thou/cu mm
Lymphocytes Absolute 3.28 1.00 - 3.20 thou/cu mm
Monocytes Absolute 0.62 0.20 - 0.70 thou/cu mm
Eosinophils Absolute 0.72 0.03 - 0.46 thou/cu mm
Basophils Absolute 0.08 0.02 - 0.09 thou/cu mm
Also he ran this tests

Sodium 141 136 - 145 mmol/L
Potassium 4.2 3.3 - 5.1 mmol/L
Chloride 104 98 - 107 mmol/L
CO2 23 22 - 30 mmol/L
Urea Nitrogen 12 6 - 20 mg/dL
Creatinine 0.63 0.40 - 0.90 mg/dL
Glucose 71 65 - 99 mg/dL
Calcium 9.4 8.0 - 10.6 mg/dL
Total Protein 7.4 6.4 - 8.3 g/dL
Albumin 4.4 3.5 - 5.0 g/dL
Total Bilirubin 0.2 0.0 - 1.0 mg/dL
Alkaline Phosphatase 82 35 - 129 U/L
AST 16 0 - 37 U/L
ALT 20 0 - 41 U/L
EGFR eGFR result is => 60 ml/min/1.73M2 ml/min/1.73M2
Reference range: =>90 ml/min/1.73M2
eGFR estimates are unable to accurately differentiate levels of GFR above 60 ml/min/1.73M2.

and last but not least he ran:

Rheumatoid Factor <10.0 <14.0 IU/mL

I dont understand what any of them mean. I appreciate you taking the time to look and see

Thank you!!!

Sweetgirl3192 · Answer

Thank you very much! i appreciate your time :)

Sweetgirl3192 · Answer

I forgot to metion that my body temp at the time of my visit (8/2/13) was 99.5 and my blood pressure was at 120/90

Thanks again :)

Sweetgirl3192 · Answer

T3 Total 124 80 - 200 ng/dL 

Free T4 1.15 0.93 - 1.70 ng/dL 

TSH 0.85 0.27 - 4.20 mIU/L 

Im sorry, im a little new at this. These were the results that were given to me. I feel so tired and cold all the time, i have difficulty swallowing and my vision blurrs often. Thank you very much for taking the time to answer my questions :)

gimel · Answer

That is not nearly enough information to conclude if you have thyroid issues or not.  Certainly being cold is a common symptom of being hypothyroid.  Tiredness can be associated with a number of things.  Please have a look at this listing of 26 typical hypothyroid symptoms and see if there are others you may not have realized.  Also, what is your normal body temperature?  

http://endocrine-system.emedtv.com/hypothyroidism/hypothyroidism-symptoms-and-signs.html

Although most doctors would look at your TSH and decide you were "normal", TSH is affected by so many things that it is totally inadequate as the sole diagnostic for thyroid issues.  Also, there is the possibility of secondary hypothyroidism, with which the pituitary gland does not produce enough TSH to stimulate the thyroid gland adequately.  

As mentioned by aahmad, we also need to know the reference ranges shown on the lab report for those tests.  I expect that those were for Total T4 and Total T3, which are somewhat outdated and not nearly as useful as tests for Free T4 and Free T3.  Most of T4 and T3 is bound to protein molecules.  Only the unbound (thus Free) portions are biologically active. 

So, I suggest that you should always request to be tested for Free T3 and Free T4 each time you go in for tests. Free T3 is the most important to know because it largely regulates metabolism and many other body functions.  Scientific studies have also shown that Free T3 correlated best with hypo symptoms, while Free T4 and TSH did not correlate at all. 

When you do go back for tests, I also suggest that you should request to be tested for Vitamin D, B12, ferritin, and a full iron test panel, which includes serum iron, % saturation, and TIBC.  

When all the above tests are done, please post results and their reference ranges shown on the lab report and members will be glad to help interpret and advise further.