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Help me understand my numbers?
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This patient support community is for discussions relating to thyroid issues, goiter, Graves disease, Hashimoto's Thyroiditis, Human Growth Hormone (HGH), hyperthyroid, hypothyroid, metabolism, parathyroid, pituitary gland, thyroiditis, and thyroid Stimulating Hormone (TSH).

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Help me understand my numbers?

I am going in to the endo in a couple weeks.  I've suspected my thyroid for many years and have most of the common symptoms, especially fatigue.  My thyroid is enlarged, several OBGYNs have told me this, but labs always normal.

My most recent labs are:
TSH - 3.18
Free T4 - 1.28 with a range of .75 - 1.8
Free T3 - 3.0 with a range of 2.5-3.9

Any idea what's going on.  I'm told the endo treats symptoms, but I'm worried my numbers are too normal to get the help I need.

Thanks for any feedback!
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optimal TSH for people to feel good is in the range of 1 - 2.  If your doctor is forward thinking he may be happy to put you on a low dose of thyroid meds to bring your TSH down into that range (and bring up the Fts a little) and see if it helps how you feel.

Your FT3 and FT4, are about mid-range.  Many doctors would choose not to treat with levels such as you have.

Make sure you are also tested for anaemia and vitamin D levles as these can also contribute to feeling unwell.
A comment from Frank Shallenberger, MD, HMD:

"Many doctors will miss the diagnosis, however, because we were all mistakenly taught in medical school that the only way to diagnose hypothyroidism is when the thyroid blood tests are abnormal. This turns out to be completely untrue. There are many articles in the medical literature that explain how hypothyroidism can be present even when all of the thyroid blood tests are in the “normal range.”  This is particularly true for the most common test used to diagnose hypothyroidism, the TSH test."

Now to add to that, the American National Academy of Clinical Biochemistry changed the TSH to 0.2 - 2.5mU/L and the American Association of Clinical Endocrinologists (AACE) changed the TSH to 0.3 - 3.0mU/L.  TSH can be lower if you tested later in the day or if you are deficient in cortisol (stress hormone).

Testing for thyroid antibodies is recommended as well - thyroid peroxidase antibody (TPOAb) and thyroglobulin antibody (TgAb). An autoimmune cause accounts for approximately 90% of adult hypothyroidism, mostly due to Hashimoto's Thyroiditis.

One website that goes into normal vs optimal thyroid levels states:

Optimal levels:

TSH: 1.3 - 1.8
Free T4: 1.2 - 1.3
Free T3: 3.2 - 3.3

"Normal rather than Optimal. The frequently used term of ‘normal’ refers to a mathematical or statistical situation. Thus, a ‘normal’ state of health probably means you have some medical problems." :) Sounds about right. :P
You have already been given some good info from Sally and Red.  I only wanted to suggest that you should also request testing for Vitamin D and Vitamin B12.  Both of these can be low when hypothyroid, which your symptoms and Free T3 level suggest to me.

Regarding the website that Red mentioned, I think it is misleading of them to list optimal levels for all three tests.  This infers that you can adjust all three independently, which of course you cannot do.  If you medicate a patient to bring them up to optimal levels of Free T3 and Free T4, as necessary to relieve symptoms, then your pituitary will adjust TSH accordingly.  End of story.

In order to achieve symptom relief for myself, my Free T3 is 3.9 and Free T4 is .84.  My TSH is about .05, but it doesn't matter because I don't have hyper symptoms that doctors frequently will tell you go with a suppressed TSH.  

The so-called "normal" range was established based on a large data base of all patients tested for thyroid.  Then the range limits were set so that approx. 2.5% of results would fall outside the high limit (hyper) and also the low limit (hypo).  Over 8 years ago the AACE finally acknowledged that there are a lot more hypo patients than the 2.5% they assumed in setting the limit.  After purging their data base of suspect hypo patient data, the range limits were recalculated for TSH and went from .5 - 5.0 down to .3 - 3.0, which is a huge change.  Unfortunately, this has never been done to correct the ranges for Free T3 and Free T4.  Having some background in statistical analysis, I have previously estimated that the range for FT3 should be more like 3.2 - 4.3, and for FT4, more like 1.0 - 1.55.  So you can readily understand why there are various sites that talk about optimal  levels, rather than just going by the "normal' ranges.  From my estimates, the average of my suggested range would be about 3.7, so you can see how far below that your test result falls.

This is why I firmly believe that we hear form so many people with hypo symptoms, yet their FT3 and FT4 are within the low end of the "normal' ranges.  Many of our members, myself included,  report that symptom relief for them required that FT3 was adjusted into the upper part of its range and FT4 adjusted to around the midpoint of its range.  

When I return later today I will send a PM with a link that will give you some good data to give your doctor.
Thanks so much.  This will really help me going forward.

I should mention that I am trying to get pregnant.  I have been able to achieve only one pregnancy during more than 13 years of trying.  I've always felt this was a piece of the puzzle.  I've always tested normal on everything except I will not ovulate on my own which is of course not normal.  Medical science has much to learn!
Great advice so far.  I too would look to B-12 and Vit D.

A rule of thumb if there is one, since everyone is different is that it seems that most people feel will with their FT4 mid range AND their FT3 in the UPPER 1/3 of the range.

You test at exactly Mid range for FT4 @ 1.28.

Your FT3 is a bit BELOW mid range at 3.0.  3.4 being the start of the upper 1/3. This may suggest that you may have a slight conversion problem.  That is that your body does not convert T4 into T3 efficiently.

You may also want to consider Selenium as it is said to help with the conversion of T4 into T3.  Although I think the help is relatively small. Every little bit helps.

A small dose of T3 medication may be all you need to feel well.

Inform the Dr that the AACE has recommended the TSH range to be 0.3 to 3.0.  And since your TSH is above 3 you may have a chance that your Dr will actually prescribe a starter dose.

The battle may be whether this starter dose is a T4 med or a T3 med.  You might also get the Dr to go along with a low dose of natural dissected thyroid. This has both T4 and T3 in it.  Maybe 1/4 to a 1/2 grain might be enough.
I wanted to provide an update.  The endocrinologist was great!  He said he was surprised that no one had checked my antibodies levels, especially given my years of infertility.

They repeated the labs and this time my TSH was 4.55, and my antibody levels were up.  The value he showed me was 150 something where normal was under 20... I'm not sure which antibody test that was, but he said I have Hashi's.

After six wreks at a pretty low dose of synthroid (50mcg) my neck pain stopped, my energy levels increased (though they could still use improvement) and my TSH is down to .88!  I'm really excited to finally have this confirmed since I've known in my gut for years that it's a problem.

Thanks for all of your help!
Great news.  Thanks for updating us. I just wanted to give you this info to keep in mind, as your continue treatment.  

A good thyroid doctor will treat a hypo patient clinically by testing and adjusting free T3 and Free T4 as necessary to relieve symptoms, without being constrained by resultant TSH levels.  Symptom relief should be all important. I wanted to mention this specifically because as your meds increase and your TSH may need to be suppressed below the reference range to relieve symptoms.  Many doctors do not understand this and will try to keep your TSH in the middle of its range, resulting in hypo symptoms for you.

I think you can get some good insight about this from this letter written by a good thyroid doctor for patients that he sometimes consults with from a distance.  The letter is sent to the PCP of the patient to help guide treatment.

Take special note of this statement and always keep it in mind.

"The ultimate criterion for dose adjustment must always be the clinical response. I have prescribed natural dessicated thyroid for your patient (Armour or Nature-Throid). These contain T4 and T3 (40mcg and 9mcg respectively per 60mg). They are more effective than T4 therapy for most patients. Since they provide more T3 than the thyroid gland produces, the well-replaced patient’s free T4 will be around the middle of its range or lower, and the FT3 will be high-“normal” or slightly high before the AM dose."
I have recently been diagnosed with HYPO and my doctor prescribed SYNTHROID based on my TSH alone!  The range was .5-4.4 and mine was at 6.18.  I do have the retained weight (I exercise a lot) and Eyebrows and sleepiness a little bit.  My plan is to tackle this naturally!  I have changed my diet accordingly and herbal supplements.  I also read that stress can play a part into this!  My mother recently passed and I am dealing with a difficult brother on the estate!  I will go back for a blood test in 4 to 6 months.  If at that time it has not dropped I would try the Armour thyroid!  I have issues with taking synthetic medications.  I barely take aspirins!

In regards to my doctor I don’t think he was thorough enough.  He did not even check my thyroid for nodules.  He made this prescription on TSH alone!

The doctor should not make a diagnosis based on TSH alone.  The main value for TSH during initial diagnosis is to distinguish between primary hypothyroidism and secondary/tertiary hypothyroidism.  If the patient has hypo symptoms such as those you mention, and the TSH exceeds the AACE recommended range of .3 - 3.0, then the likelihood is that it is primary hypothyroidism, due to Hashimoto's Thyroiditis.  Hashi's can be confirmed with  Thyroid Peroxidase antibodies, and Thyroglobulin antibodies tests, usually designated as TPO ab and TG ab.  Both of those should be done for you.  

With Hashi's, the autoimmune system erroneously determines that the thyroid gland is "foreign" to the body and produces antibodies to attack and eventually destroy the gland.  Along the way to destruction, the output of natural thyroid hormone is diminished and has to be replaced with thyroid med.  Some thyroid meds are manufactured, some are desiccated porcine thyroid.  The main difference is whether they are T4, T3, or a combo of the two.  There is also differences in the fillers/binders used to make the pills.  I'm sure you can find the right type for you and use successfully.  Changing your diet and taking herbal supplements will not be a successful alternative.  If confirmed as hypothyroid, as I expect, you will need thyroid meds.  

As you go forward, please keep in mind that a good thyroid doctor will treat a hypo patient clinically by testing and adjusting Free T3 and Free T4 as necessary to relieve symptoms, without being constrained by resultant TSH levels.  You can get some good insight into clinical treatment from this letter written by a good thyroid doctor for patients that he sometimes consults with after initial tests and evaluation.  The letter is then sent to the participating doctor of the patient to help guide treatment.  In the letter, please note the statement, "the ultimate criterion for dose adjustment must always be the clinical response of the patient."

So when you go back for tests, I suggest that you should make sure they test for Free T3 and Free T4 (not the same as Total T3 and Total T4).  If the doctor resists, you should insist on it and don't take no for an answer.  Also, since hypo patients are frequently too low in the range for Vitamin D, B12 and ferritin, I also suggest those as well.  You should also ask if the doctor is going to be willing to treat clinically, as described.  If not, then you will need to find a good thyroid doctor that will do so.  

When additional test results are available, please post results and their reference ranges shown on the lab report and members will be glad to help interpret and advise further.  
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