On Thyroxine, but low t4. Increase dose?

[Moobot]

Hi, I'm 2 months post hemithyroidectomy. Was started on 50mcg thyroxine 4 weeks post surgery as feeling awful and blood result TSH 7.5, T4 4.5  I've been taking this dose for 6 weeks now, and feel a small improvement of symptoms but still very tired, lack of concentration etc etc! My TSH is now 3.6, and my T4 is 8.5, but my GP says that I should stay on the 50mcg, and wants to do other blood tests to see if something else is wrong. Am I right to disagree? I felt fine before surgery (except the nodule) and now I don't. Should I push for a higher dose (I'm thinking 9x 50mcg tabs per week, as I think upping it to 75mcg may be too steep). Don't like to argue with the doc, but I still feel rubbish.
UK resident

[gimel]

unfortunately doctors in the UK, due to the dictates of the NHS, will typically rely on TSH to diagnose and medicate hypo patients.  If TSH shows to be somewhat high, then they usually only  test T4 and if that falls within the so-called "normal" range, nothing is done for the patient.  This based on the false belief that TSH accurately reflects levels of the actual thyroid hormones.  In reality TSH cannot be shown to correlate well with either of the biologically active thyroid hormones, Free T3 or Free T4, much less correlate well with symptoms, which really should be the main concern.   Many members here say that symptom relief required Free T3 in the upper part of its range and Free T4 at the middle of its range, at minimum.

When already taking thyroid med, TSH is basically a wasted test because it so frequently is suppressed below range, even when the patient is not hyper, and does not have excessive levels of Free T3 and Free T4.  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 about clinical treatment from this link written by a good thyroid doctor.  

http://www.hormonerestoration.com/Thyroid.html

Yes, you should disagree with your doctor if he is unwilling to test for both Free T3 and Free T4, and treat clinically as described above.  I know this is sometimes difficult in the UK, but this is how one successful UK member described her approach.  "What I have learned from my experience is that you have to go to the Dr's office and TELL THEM WHAT YOU WANT and to go backed up with knowledge.  You have to tell them that you have done your reading and looked into your condition and care about the long-term treatment of your health and thyroid.  If you fight for what you want, you will eventually find someone that is happy to go along with your wishes.  But we all have to take charge of our own health, right?"

So, you need to discuss all this with your doctor and push for testing for Free T3 and Free T4, along with clinical treatment for symptoms.  I also suggest getting tested for Vitamin D, B12 and ferritin, since hypo patients are frequently too low in the ranges for those as well, which can cause symptoms as well as affect thyroid hormone metabolism.  If you cannot persuade your doctor to do all this, then you will need to find another doctor that will do so, of if possible, go private.  

[gimel]

Doctors in the UK, following the dictates of the NHS, tend to rely primarily on TSH level.  If the TSH is somewhat high they will then test for T4, and if within range, tell you that your thyroid levels are "normal" and any symptoms must be due to something else.  That is wrong for many reasons.  First TSH is a pituitary hormone that doctors like to portray as accurately reflecting thyroid status.  Since thyroid status is actually mostly dependent on the levels of the biologically active thyroid hormones, the obvious question is how well TSH correlates with Free T3 and Free T4.  The answer is that TSH cannot be shown to correlate well with either of those, much less correlate with symptoms, which should be the main concern.  

Even worse is that when taking thyroid medication adequate to relieve symptoms, TSH is frequently suppressed below the range.  Many doctors wrongly would interpret this as being hyper, even if no hyper symptoms are present, and Free T3 and Free T4 are within range.  Scientific studies for which I can give you links have shown that when already taking thyroid meds, TSH is basically a useless test.  

So how should a hypo patient be tested and treated?  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, not tet results, and especially not TSH results.  You can get some good insight from this link written by a good thyroid doctor.

http://www.hormonerestoration.com/Thyroid.html

In addition to always insisting on being tested for Free T4 and Free T3 instead of Total T4 and Total T3, you should also request to be tested for Vitamin D, B12 and ferritin.  Hypo patients are frequently too low in the ranges for those as well, which can cause symptoms as well as affect metabolism of thyroid hormone.

You should disagree with your doctor if he continues with the same approach.  I know that in the UK it can be very difficult to get the testing and clinical treatment needed; however one of our UK members who was finally successful told us the following.  "What I have learned from my experience is that you have to go to the Dr's office and TELL THEM WHAT YOU WANT and to go backed up with knowledge.  You have to tell them that you have done your reading and looked into your condition and care about the long-term treatment of your health and thyroid.  If you fight for what you want, you will eventually find someone that is happy to go along with your wishes.  But we all have to take charge of our own health, right?"

So, I'd say that you should press the doctor to test for both Free T3 and Free T4 each time you go in for tests.  Since Free T3 has been shown to correlate best with hypo symptoms,  if Free T3 or Free T4 are in the lower half of their range, that is frequently associated with having hypo symptoms, and you should push for a med increases until you feel well.