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Hypothyroidism? (had a recent hemithyroidectomy)

I am 34 years old, Male, and I had a recent hemithyroidectomy (right lobe) due to a large nodule (about the size of an avocado).

My Endocrinologist ran some blood work pre-surgery, and my levels were normal - she tested my TSH, T4, and T3 uptake. However, I'm still  having the same hypothyroid symptoms I had before the surgery. Lethargy, and mental slugishness are even more apparent now; everything is just so... for the lack of a better word... blah.  

To rule out the possibility of low testosterone, my Endo also tested my testosterone, LH, FSH, and Prolactin levels, and the results were also within normal range.

It's very discouraging because this isn't one of those mind-over-matter type of ordeal - I really can't brush it off when the symptoms hits me especially lethargy; I just sit or lie down and go blank.

Please help!
Best Answer
649848 tn?1534633700
COMMUNITY LEADER
Was the T4 test a Free T4 or Total T4? If it doesn't specify "Free" on the lab report it was total, which is considered to be obsolete and of little value.  T3 uptake is also obsolete.

Your doctor should be testing Free T3 and Free T4.  Those are the active thyroid hormones, with FT3 being the hormone that's actually used by the individual cells.  Free T4 is a storage hormone and must be converted to Free T3 for use by the cells.

Here's a quick Thyroid 101:  The thyroid produces mostly the T4 hormone.  About 90-95% of the hormone is bound by a protein and is unavailable for use.  The remaining (unbound) T4 is the Free T4 and that's what's converted to T3.  Most of the conversion is done in the liver, but some is done in other organs, as well.  

As with T4, about 90-95% of T3 is bound by protein and can't be used by the body.  The Free (unbound) T3 is that which is used by the individual cells.

You should also ask your doctor to do thyroid antibody tests to confirm/rule out Hashimoto's Thyroiditis, which is an autoimmune thyroid disease in which the body sees the thyroid as foreign and produces antibodies to destroy it.  Hashimoto's is progressive, in that as it destroys the healthy thyroid tissue, the thyroid makes less and less hormones, until eventually it makes nothing.  The antibody tests you need are Thyroid Peroxidase Antibodies (TPOab) and Thyroglobulin Antibodies (TGab).  You need them both, since some of us are positive for one or the other, while some are positive for both. Nodules are very common with autoimmune thyroid disease.  

Do you have other symptoms of hypothyroidism, such as weight gain, constipation, dry hair/skin, hair loss, fluid retention, puffiness in the face, especially under the eyes?  There are more, but these are the main ones.

If you can post the actual results of the tests you had done, we might get some idea of what's going on.  Be sure to include reference ranges, as ranges vary lab to lab and have to come from your own report.

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Avatar universal
Unfortunately, I don't think AACE or ATA are going to be of much help to you.  They issued a joint position paper a couple of years ago, and it was not pretty.  They basically reaffirmed that TSH is THE gold standard (even though they did acknowledge that it was highly variable even intraday), and said that FT3 was unimportant for hypo patients.  Remember, however, that AACE and ATA don't exist for the good of the patient.  They exist to set the "standard of care" whereby a physician can assure himself that his butt isn't going to end up in court for malpractice.  

So, if those are the only sources that she'll listen to, you might as well not waste your time and cut your losses.  If she'll read studies and listen to experts in the field, that's another story.

Underlying depression my left hind foot...

I pay just over $10 for FT3 (after my insurance company "discount").  They don't order it because they don't want to look at it, deal with it or deal with patients who want to treat according to it.

I think you'd often have a much easier time getting a script for a controlled substance.  I know you'd have a much easier time getting a script for an antibiotic when what you have is a viral infection.  Anti-depressant?  Pass those out like candy...  

You just have to find the right doctor.  

I keep meaning to ask...was that a Haas or a Florida?

It's a sad state of affairs, no question about it. Have you tried interviewing doctor over the phone or by fax or email before making an appointment?  I know it's hard working within the confines of Kaiser.  Can you go out of network?  

Helpful - 0
Avatar universal
*Update* My NOT-so Happy Friday.

Had an appointment today with a new Endo from Kaiser, and she refuses to order me a FT3 test, and also refused to prescribe me a low dose levothyroxine because my FT4 is within "normal" range. At least this one actually listened to me though. I told her that TSH test are obsolete when it comes to diagnosing hypothyroid, and that FT3, FT4, TGab, TPOab etc. are the test that should be looked at. I also mentioned that FT3 & FT4 should be in the mid-upper range for a better sense of well-being. She listened but I don't think she took any of it into consideration. However, she is willing to read (credible) articles that I come across on the internet, as I mentioned to her that I got all of my information from google'ing, forums etc.

If anyone can provide me some literature either from AACE, ATA etc. to back up my statement, I would be much obliged. So we can at least educate another ignorant endo...

Oh, and you'll love this one: she said that even if she orders a FT3 test, and the test comes back abnormal, she would still ignore it as the TSH test is the end-all-be-all test for diagnosing thyroid disorders... Really?! (-_-)

And to top it off, she said that I have a completely healthy half a thyroid, and gives me a referral, and sends me to the Behavioral Medicine department to make an appointment because she made an assessment that I have an underlying depression. LOL

p.s. Why are doctors so adamant on ordering FT3 test? Does this test cost the facility thousand of dollars or something? Also, why are they so adamant on prescribing levothyroxine? It's not like it's some Schedule I Controlled Substance that one can make millions of dollars off of by smuggling it across borders... What gives?
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Avatar universal
Good for you...happy to hear you'll get another opinion.

With thyroid meds, it's always best to start out low and increase slowly as tolerated and as needed.  I believe a full replacement dose is considered 1.7 mcg/KG (2.2 lbs).  However, weight is only a factor in determining the INITIAL dose.  We all react very differently to different amounts of meds.  What's much more important than your weight is what your FT4 is now and what you want to get it to be.  Some people with half a thyroid are very hypo, but you're just a little below midrange.  In your case, I'd think your doctor would want to start you out at 25 mcg max.

1-Subtract the bottom of the range from the top 1.7 - 0.8 = 0.9
2-Subtract the bottom of the range from your result 1.2 - 0.8 = 0.4
3-Divide result 2 by result 1 and multiply by 100  0.4 / 0.9 * 100 = 44%
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Avatar universal
Got a reply from my doc and he will be referring me to an endo, and hopefully, one that listens...

I know it will be difficult to persuade him/her on prescribing me Synthroid (just because my tests are within "normal") to get my FT4 range in the upper half, and FT3 on the upper half to upper third. When/if he/she does, and in your experience, what would be the dosage for a "low dose" treatment for someone like me - 25mcg, 50mcg/day? As far as I know, the dosage for patients that had a full thyroidectomy is 1-1.7 (needs sighting) mcg per pound of body weight... What about for people like me that only had half of their thyroid removed?

Sorry to sound ignorant, what is the formula on figuring out the range? You mentioned my FT4 is at 44% of range, and for the life of me, I can't figure out how you came up with that number... I'm so embarrassed! (>_<)  
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Avatar universal
Thanks for the advice. I'll talk to him again to order FT3, and possibly prescribed me T4 to get my ranges to 50%. If he still refuses, then, sayonara. While I'm at it, I'll ask him to order  test for vitamin D, iron/ferritin, and B-12 to see if I'm within levels.
Helpful - 0
Avatar universal
As you know, a lot of doctors think TSH is the be all and end all in thyroid testing.  It's not, but many of them haven't caught up to the fact yet that FT3 and FT4 are highly reliable tests in the 21st century.  Might be time for a new doctor, at least a new doctor for your thyroid...

Total T3 tells the total amount of T3 in your blood.  However, much of that TT3 is bound by protein and useless to your cells.  FT3 tell what's available.

T3 is seldom used alone to treat thyroid dysfunction.  Except in some very specific cases, it's almost always used in some combination with T4.  With both FT4 and FT3 a bit on the low side, all you might need is a low dose of T4.  Also, T3 is much trickier to use than T4 because it's very fast acting.  So, you can get yourself into trouble with it pretty fast.  I'd strongly urge you to find another doctor who will work with you.  FT4 and FT3 have to be in balance or you can get some pretty weird symptoms.

Vitamin D and iron/ferritin are required for the proper synthesis and metabolism of thyroid hormones.  B-12 deficiency can cause debilitating fatigue.  Once again, with these vitamins and minerals, just being "in range" is seldom sufficient.  You want to be well up in all ranges.  

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Avatar universal
Thank you goolarra. We haven't talked about vitamins and minerals. Any suggestions? Btw, I emailed my doc on why he didn't order Free T3, and here is his response:

"T3 is the correct test. We sometimes will check Free T4. Best test to look at overall function is still TSH. Overall labs are fine."

So, at this rate, I don't think he will prescribe me cytomel (or whatever synthetic T3) so I can get on the 50% range. I wish they would just listen! I know my body, and this isn't my normal self! I can acquire cytomel by other means in hopes of rectifying this issue... any thoughts?
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Avatar universal
FT4 doesn't look too bad.  It's at 44% of range, and the guideline for FT4 is 50%.  So, it's a little on the low side.

TT3, for what it's worth, is at 40% of range.  If that correlates with your FT3, it could be an issue.  However, TT3 and FT3 often don't correlate, so we can't assume here.

Have we talked about vitamins and minerals?
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Avatar universal
Apologies for the delayed update, and for bringing this up again, but my employer was in the process of changing medical providers, so I couldn't get some lab work done until the dust settled.

I recently switch to Kaiser and I requested some test. Hear are the results:

Component             Standard Range             Your Value

Parathyroid hormone intact 10 - 65 pg/mL                 42

T3, Total                          50 - 170 ng/dL                 98

Thyroglobulin                   0.0 - 55.0 ng/mL       31.3
Thyroglobulin AB             <=20.0 IU/mL         <20.0

TPO AB                            <=35 IU/mL                 14

Free T4                            0.8 - 1.7 ng/dL        1.2

TSH                                   0.10 - 5.50 uIU/mL       1.25

Shoot, I just realized that he didn't order Free T3... I'll email him right now, and find out why he didn't order it.
Helpful - 0
Avatar universal
Your doctor did order an impressive array of obsolete tests.  Total T4 (thyroxine), T3U and FTI are all considered of little value.  He should be ordering FREE T3 and FREE T4.

I'd ask your doctor to run FT3 and FT4.  If he balks, you can order those online without a doctor involved.  If you decide to go that route, get back to us for details.  

Bear in mind that thyroid reference ranges are very flawed and many people have symptoms until FT3 and FT4 are midrange or above, in the case of FT3.
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Avatar universal
Hello goolarra and Barb135, thank you so much for replying, and many thanks for the crash course on Thyroid. First, here are the results that were taken 3 months ago prior to surgery:


TSH 0.987 uIU/mL
range 0.450 - 4.500

Thyroxine 8.0 ug/dL
range 4.5 - 12.0

T3 Uptake 41%
range 24 - 39

Free Thyroxine Index 3.3
range 1.2 - 4.9

Those are all the thyroid related test that I can see on this lab results. If it would help, I can post the other results as well e.g. HDL, glucose etc.

After my doc got these results, he said everything is normal but highly recommended the surgery anyway (as well as my Endo) due to two large goiters, and yes, it was the size of a whole avocado (not the pit!), and the other was a bit larger than a golf ball.

As far as symptoms goes:  very lethargic, sensitivity to cold weather, cold hands and feet, little to no libido, mental sluggishness, memory troubles, muscle weakness, joint pains (mainly knees), hair loss, dry skin and unexplained skin rashes.Funny that you mentioned puffiness under the eyes! I always thought that was just from when i used to work graveyard shift, and just never went away. As far as weight, I was 210 pounds prior to surgery, and I am now 190, and I am 5'11".

Again, thank you so much for your help.

Kind Regards,
Helpful - 0
Avatar universal
Please post the pre-surgery results and reference ranges.  Ranges vary lab to lab and have to come from your own lab report.  Also, is that FREE T4 or total T4.  If "free' or FT4 isn't specified, it's total.

Have you been tested again post-surgery?

Were you told that the PT would improve your hypo symptoms?

My goodness, an avocado or just the pit?
Helpful - 0
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