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Good News?

I was diagnosed with Hyperthyroidism a few weeks ago and the doc put me on Methimazole. I went back today for blood work and an ultrasound.

The results were that my TSH was even lower than last time it was checked a few weeks back. Then it was .037 and today .014. The statement he made was "Overall, the thyroid appears symmetrical and heterogeneous in appearance. No distinct nodules or cysts are noted right or left thyroid lobe at this time. No suspicious lymphadenopathy is noted right or left neck level II-V at this time. the gland is heterogeneous and slightly enlarged consistent with suspected Graves disease"

...Whatever all that means. He's put me on Methimazole four pills a day-two twelve hours apart. I'm hoping this will cure it and not have to take RAI, which I'm dead set against.
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Avatar_f_tn
TSH can vary a lot intraday, just depending on the time of day the blood was drawn.  That change is fairly insignificant.

The U/S report says that your thyroid looks pretty good.  Your thyroid is slightly enlarged, which is consistent with Graves' Disease, which apparently they think you have.  Has TSI been tested?

Methimazole inhibits thyroid hormone production, but it doesn't cure Graves' Disease.  However, Graves' often goes into remission, but also frequently comes back at a later date.  You may be one of the lucky ones who go into remission.  Most people are given methimazole or another ATM for as long as it works.
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He gave me a copy of the paper work to include the ultrasound and at least part of the blood test.

The Ultrasound indicated a "Thyroid Vascularity" in the right side as Hypervascular-Mild. The left side was Moderate. There is drawn a left and right lobe with a 4 inside of it which according to the chart means Heterogenous.

The left lobe was 4.50x1.52x1.39 cm. The right was 4.34x1.70x2.16 cm.

The blood test didn't tell me much other than the Free T$ was 2.12 and TSH .014. I don't see TSI listed.
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Avatar_f_tn
What's the range on your FT4?  Ranges vary lab to lab, so you have to post both together.  A good way to do that is:

FT4  2.12  (#.## - #.##)

Is that FT4 and TSH from before you started meds?  Are you feeling any better on meds?
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T4 Free is 0.58-1.70

Back last month my T4 was 1.87. Yesterday it was 2.12. I haven't been on the meds long enough for much to show I would suspect.

TSH yesterday was very low at .014...twice as low as it was last month at .037. They symptoms I mentioned to him about the meds according to him was indicative of the symptoms of hyperthyroidism...not the meds. I can't tell I feel any different at this point.
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Avatar_f_tn
When did you go on meds?  What strength methimazole tablets are you taking?

Your FT4 has gone up, rather than down, so I'm not surprised you don't feel any better.  

Your doctor isn't testing FT3?  While a lot of doctors don't think FT3 is significant for hypo patients, most of them do think so for hyper patients.  He should definitely be testing that.

Please list your symptoms.

Your doctor should also test TSI (thyroid stimulating immunoglobulin), which is the definitive test for Graves'.  It's very important to track this because it can indicate when/if you are going into remission.

Do you feel your doctor knows what he's doing when it comes to thyroid?

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He put me on 10mg of Methimazole first of the year. I took them for about ten days and felt they were causing my BP and pulse rate to increase so I called them and was told to stop for several days to see if it made any difference...if didn't really. I went back on t hem this past Monday but this time instead of three a day he told me to take two twice a day.

I had both FT3 and FT4 checked just last month but this endo didn't check FT3 that I know of, at least it didn't show on the paper work he gave me-just TSH and FT4.

As for symptoms, I didn't know I had any. I had went to my family doctor last June for my usual blood work and they send me a copy of the results. I noticed my TSH, FT3 and FT4 were out of specs but didn't pay a lot of attention to it. Around the first of December I looked at it again and got concerned FT3 was so far out of the reference range at 5.49 and the TSH was .037. Back in June it was .049.

All those results were normal prior to this past June and have progressively gotten worse with my TSH the other day being .014 so, it's getting lower by the week it seems. I didn't know of symptoms of hyperthyroidism at that point. I felt a little winded at times, hands shook a little now and then and muscle weakness in the thighs. I have a Corgi that lives with me and if I'd bend over to pet him or hug him my thighs would start shaking and the muscles would ache like I had just done 50 deep knee bends.

The paper work the endo gave me the other day at the top list a Clinical Dx as Graves Disease. How is came to that I don't know. If he did a TSI is wasn't shown in the papers he gave me.

This doctor was recommended by my family doctor. I know nothing of endo doctors so can't pass judgement on him. His credentials on the card I picked up says he's an MD, PHd, FACE- what ever that means.

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Avatar_f_tn
Methimazole inhibits the production of thyroid hormones, and as levels fall, both HR and BP should go down as well.  That's not to say that some people don't have esoteric reactions to the meds or the fillers in the tablets.  However, I think what's more likely is that you were not on a high enough dose of meds to control your levels, so you were becoming more hyper all the time.  This is evidenced by your falling TSH and rising FT4.  

You should strongly request (insist on) FT3.  If TSI hasn't been tested (maybe it was, and you just didn't get the paperwork?), it should be as it's a good indicator of remission.

Your doctor isn't testing FT3 and may not have tested TSI.  That's usually a red flag that the doctor isn't a very good thyroid doctor.  Although he's an endo (FACE = Fellow of the American College of Endocrinologists), many endos really specialize in diabetes and have little interest in thyroid.  If I were you, I'd probably press him to test FT3 and TSI (along with FT4 and TSH at your next labs), and if he balks at all, move onto another doctor.

When are you scheduled for more blood work?  
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This is a group of doctors that are all Endocrinologist-that's their specialty. My family doctor knew my problem but wasn't a specialist in that field so, she sent me to this doctor. He did, according to the paper work given, a "Hepatic Panel" to include Protein, Albumin ALT, AST, and a Total, Direct and Indirect Bilirubin. I have no idea what that is and why they checked it.

I'm to go back in about three more weeks for more blood work to see how the meds given have worked. I'll ask about the TSI and FT3 and to be sure that's taken into consideration when they draw blood next time.

I've noticed I get a bit shaky from time to time and my heart can be seen beating through my shirt. Thats a little daunting to say the least.
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Avatar_f_tn
Yes, the shakiness and heart palpitations and/or tachycardia are a little frightening.  I have a congenital heart defect that's made me prone to tachycardia all my life, so I kind of got used to it, although you never really do.  If the heart issue persists, you can ask your doctor for a beta blocker to help control that.  You'd probably only have to take it until your thyroid meds kick in.

In the meantime, it's a good idea to avoid foods with a high iodine content, like seafood and kelp.  You can google a list of the chief offenders.

I meant to ask if your Corgi was a Pembroke of Cardigan.  I've always wanted a Cardy.
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The heart palpitations seem to have slowed a bit or maybe it's my imagination. I'm on three blood thinners, aspirin, Plavix and Warfarin and it seems beta blockers cause a problem with that from what I recall some years back as I was doing research on my other problem, Peripheral Artery disease but can't recall the specifics.

Bubba is a tri-color Pembroke and the absolute joy of my life.
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Avatar_f_tn
There are alternatives to beta blockers.  You could ask your doctor if there's something you could try.

I just realized Bubba is in your picture...very sweet.  

Update me on how it goes, please.
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9088869_tn?1401643539
I made a photo album, per se, on Flickr of Bubba. He's most photogenic and it's hard to not take a good shot of him.

https://www.flickr.com/photos/126745434@N03/with/15118823706/

I'll let you know what happens next visit in a few weeks. I hope this med does what he thinks it will as I'm no big fan of RAI.
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It looks like he specializes in cute.

Meds work for most people, at least for a while.  I have a friend whose been on methimazole for probably close to five years now.  Her hyper is well-controlled.
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I use to say I wish I was as good looking as a man as he was a Corgi!!

I do hope the meds is all that will be required. I don't mind taking a few more pills as I'm already on aspirin, Plavix, Warfarin and Coreg. One more won't matter. I'll know more about it when I go back in a couple weeks. If he thinks I should take RIA I think I'll just walk out and go home.
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Avatar_f_tn
Well, don't burn any bridges.  Do some research.  If your hyper is controlled on meds, there's no reason to hurry into RAI.  You can take your time and make an informed decision.  
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Avatar_m_tn
I had been happily on methimazole for 12 years but last fall I had an episode where the methimazole effectiveness diminished and my endo prescribed iodine supplement (sski .3 mg 2 x day). I was worried that I'd need RAI. The Iodine slammed the brakes on my thyroid and I'm now happily back on methimazole only. So this idea of iodine increasing thyroid stimulation is ncorrect. It actually slows the thyroid and causes it to shrink as well.
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Avatar_f_tn
I don't know what your particular circumstances were, but avoidance of iodine is the typical recommendation for hyperthyroidism.  Iodine is one of the building blocks of the thyroid hormones, so adding iodine typically just fuels the fire.

While iodine may be prescribed under certain conditions for hyperthyroidism, that use is something that should only be done under careful medical supervision.  This therapy is difficult to control and seldom used today.  The general rule remains that iodine deficiency can cause hypothyroidism, and too much iodine can cause hyperthyroidism.  Avoidance of iodine rich foods often helps people to control their hyperthyroidism.      
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I don't eat foods that's laced with iodine. I was on a Doritos kick for about a year...loved those things and still do but won't have a bag a month anymore. Not because of this, I just lost my taste for it. Nor do I pour salt on anything. I still contend this was triggered by a huge amount of daily stress for six or seven months before it was even diagnosed.

I'm not doctor but, I found it odd I had never had a problem until all that stress and it was everyday, 24/7. As for the RAI, I don't see how they can prescribe the proper dose for a given individual. I wouldn't think you'd give the same dose for a 200 pound man to a 105 pound woman and moreover, how do they know how much a certain dose will destroy the thyroid...half, one fourth or all of it? They can't know for sure.
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Avatar_f_tn
Stress is a huge factor in precipitating the onset or worsening of autoimmune diseases.  In fact, my endo thinks stress is the #1 factor.

Radiation dosage is based on the estimated size of the thyroid.  

The aim of RAI is to destroy the whole thyroid.  After RAI, you would be hypo and taking thyroid replacement hormones.    
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I have to wonder just what else RAI destroys. It goes though your entire system. I've read not to get around people for weeks or longer after you take it and that's impossible. I live alone with my dog and hand feed him a lot, especially treats and pet him off and on all day so that's not going to work.

I'll just hope when I go back to the doc the Methimozole will have worked toa degree he feels comfortable for me to continue it without the RAI.
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Avatar_f_tn
Well, RAI is pretty "targeted".  The radiation is attached to an iodine molecule, and the thyroid is the gland that takes up the vast majority of the iodine we ingest.  As with small children, you can't be around pets for a few days afterwards.  

I hate to do it to my dogs, too, but there comes a time when the slammer is the best place for them for a few days.

Surgery is another alternative.
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I can't board Bubba. I had to do that out of necessity this past summer due to being in the hospital. That was his first time due to his usual sitter having problems herself and couldn't do it. They told me he hadn't eat or drank since I dropped him off so, I can't do that.
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I have an appointment with the Endo this Wednesday. I'm hoping things are better and he wont have to recommend the RAI.
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There's a good chance of that.  Most hyper is controllable by drugs, at least temporarily (and that can be many years).  Good luck with your endo appointment.  Let me know how it goes.
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I will. Should I request a TSI? I don't think they did that last time. If they did, it wasn't on t he paper work I was given.
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Avatar_f_tn
Even if they have tested it before, you should request it.  When TSI starts going down, it's a sign of remission.  It's very nice to know when that's happening.
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I just got back from the doc's office. I had to request the TSI and they took blood work for it but told me the results wouldn't be in for several days. He said I had Grave's disease and the TSI would only be a confirmation of that.

My Free T4 today was .85 as opposed to 2.12 back around the middle of last month. The TSH was low at.006 as opposed to .014 last month. So, he's changed the amount of my meds from four pills a day(40mg total) to three in the morning to offset the low TSH, I suppose.

I have to go back in five weeks to be checked once again. I'm hoping the Free T4 will stay the same but that the TSH will go up.
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Avatar_f_tn
There's nothing wrong with confirmation.  If you continue to monitor TSI, you'll have a better idea of what's going on.

Your FT4 is now a little on the low side as well as TSH being low.  FT4 is at 24% of range, and they typically shoot for about 50%.  However, if you feel good where you are...

It's kind of doubtful that your TSH will come up.  TSI (thyroid stimulating immunoglobulin) is the antibody associated with Graves'.  TSI can stimulate your thyroid to produce hormone just like TSH can.  So, with a high TSI level, it's very hard for TSH to go up.  Basically, TSI has taken over its job.

No talk of RAI I take it?  Great!  
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9088869_tn?1401643539
According to the paper work he gave me yesterday the Free T4 is within range at .85. The reference range was .71-1.85 ng/dl.  The TSH is way low-about half of what it was last time.

RAI will be a last resort.
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Avatar_f_tn
Okay, I had used the range from up above in this thread that you gave last time to calculated percentage.  On this new range, you are even lower at 12% of range.  That is IN range, but we are not all comfortable anywhere in range.  Some of us feel better higher in the range, some lower.  Your doctor decreased your meds because your FT4 is getting close to being hypO.  Once on meds, we usually try to stay around the midpoint (50%) of range.  
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i wouldn't know if I'm about normal or not. I forgot what feeling normal was all about. At 69 just today I figured you're suppose to get sleepy around 6-7:00 PM. What I have a worse problem dealing with is the numbness and tingling, stinging in my toes and ball of my left foot, no doubt due to the extreme surgeries I've had due to Peripheral Artery Disease.

I had my last and worse operation this past July where he took the Great Saphenous vein and used it to bypass around the blockage in the femoral artery. I was cut from the groin down to six inches above the ankle. It took months to get over that and walk again but ended up with numbness in the toes and foot. Lately, they've begun to have that old familiar stinging, tingly feeling I had before. The leg is fine, I can walk without pain again but I don't like the foot and toes problem. Maybe that's called neuropathy, I"m not sure or what to do about it. That is more of a problem than thehyperthyroidism by far.
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Have you talked to your doctor about your toes and foot?  There are drugs for neuropathy.  
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I'm going back for an ultra sound March 12th. He wants to keep tabs on things to be sure no scar tissue migrates to that bypass. I had trouble with the toes turning red, tingling, burning, stinging before the surgery and in fact, my last six weeks before that surgery in July I spent nights sitting up on the couch and had to sleep that way for six weeks. If I went to bed like normal within five minutes the foot would go numb. I found sitting up at the end of the couch with both feet on the floor would prevent that so; that's the way I slept.

. I finally had enough of that and knew what was coming but, I had to do something. That's when he did the vein stripping around an old bypass I had some years ago. The leg is much better in that I can walk without pain and the claudication that occurred before but the toes are beginning to act up recently. The first six months after the surgery they didn't do that. It's only been within the last week with yesterday the worse. Today, not so bad(knock on wood). It's most aggravating.
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Apparently the Methimazole has helped the weight situation. I couldn't get over 125 pounds no matter what. I weighed today and was up to 130.2 pounds. That's a milestone since I've weighed 125 since last July when all this started. I kept loosing weight for no known reason. At 5'-8 1/2" that's way too little for my height. I could see the bones in my chest and ribs and couldn't sit on anything hard like the steps of my deck without a cushion...nothing but bones.
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That's good.  Lowering your thyroid hormone levels will help you to put on a few pounds.  125 is pretty light for 5'8.5".  It's light for me, and I'm 5'6".  
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Right at the time of my surgery and at that weight, my eyes were slightly sunk in. I look like I'd just been rescued from Auschwitz! I never looked so bad. That look went away but I still don't know what may have caused it. Maybe all the stress before, during and after the surgery as it looked that way for about two weeks.

I'm hoping the new dose of Methimazole will not only make me gain a little but settle down what's gone on with the thyroid without anything further to do. I go back again for testing in five weeks.
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Doing a bit more research on this GD I found some interesting info that further stimulates my lack of desire for RAI.She makes a lot of sense.

http://www.thyroid-info.com/articles/gravesbook.htm
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It's always best to do your own research and explore all the possibilities.  From what I've seen on this forum, I think the days of doctors rushing patients into RAI are fast dwindling.  Most people start out on meds (this may not have been the case when EM had her RAI) and don't have RAI or surgery unless meds stop working or the patient requests it.  

The more you know, the better you'll be able to participate in your care.  
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I applaud doctors for their knowledge of which we would all be in dire circumstances were they no more knowledgeable than they were 100 years ago. At times I've found, we have to be our own doctors as they just cannot know everything there is to know about a given medical problem.

I have two cases in point so will make it brief. In 2004 when I had my first vascular bypass in my leg due to a blockage a stent was placed and I did superb for five years. I was put on aspirin and Plavix. Five years later I needed a hernia operation but was told I'd have to stop the meds for five days prior to the operation. I did as I was told. The very morning of the operation I had a pain hit my leg and ended up in the emergency room with blood clots. No hernia surgery that day but rather another surgery on the leg. At that point Warfarin was also added to my regiment.

Fast forward four years to 2013. I had been doing very good but had decided I was well pass the point of needing a colonoscopy so set that up. Unfortunately, the doc told me I'd have to stop my medication. I told him I couldn't as I'd get blood clots and he refused the procedure. I called my new vascular doctor, as my other one for seven years had retired, told him the story and he told me there should be no problem as the month before I had an ultrasound and according to him the artery was "wide open". Against my better judgement, and he knew my history, I stopped the meds and had the colonoscopy. The very day about 10:00am after the procedure I had that same pain hit my leg-back to the emergency room, an ultrasound, and they found a blood clot. Surgery again.

It lasted seven months and tingling, stinging, burning in the foot so, I had another surgery. That one lasted six weeks and my foot started going numb when I went to bed at night and could not elevate it. I had to sleep sitting up on the couch. That went on for months till my last surgery this past July when they used the Great Saphaneous vein to bypass the blockage. It's been a roller coaster. Had I not listened to that vascular doctor in 2013 who told me it was ok to stop my meds(especially Warfarin) I wouldn't be where I am today with my leg. I knew if I stopped Plavix I'd be in trouble like in 2009. I was right and won't stop taking it again.

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