Should I be concerned?

[banker281]

Primary care sent me for an ultrasound of my thyroid recently after finding a lump at thyroid at a physical.  Turns out I have a multinodular goiter.

findings:  Left lobe measures 6.5 x 2.7 x 2.5 cm.  Large nodule is present on the inferior aspect of the left lobe measuring 4.8 x 2.5 x 3.3 cm.  Right lobe measures 6.9 x 1.7 x 2.1 cm, 2 nodules are noted in the right 2.2 x 1.6 x 2.2 cm inferiorly and 5 x 3 x 4 mm superiorly.  Isthmus measure 4 mm, no enlarged or calcified nodules, and lymph nodes are unremarkable.  

I have been having hypo symptoms for a long time however every time they are checked they tell me you are "normal".  
Latest labs:
THYROID PEROXIDASE ANTIBODIES   <1
T3 UPTAKE   32
T4 (THYROXINE), TOTAL     10.0
FREE T4 INDEX (T7)    3.2
TSH   2.17
Triiodothyronine,Free,Serum  2.9
T4,Free(Direct)  1.30

Should I be concerned about the goiter measurements?  What will probably be the next step with that?  Should I find another endo since they keep telling me everything is fine?


Thank you so much for any help/tips.

[gimel]

Try any way you can to get one of the doctors to run those tests for you.   Regarding another doctor, I am sending a PM with info.  To access, just click on your name and then from your personal page click on messages.

From your hormone tests, from my limited knowledge, I see nothing that stands out as a problem.  

[gimel]

If you do go to another doctor, it is going to take some time to get an appointment.  Do you think you could go ahead and convince your doctor to run those tests now, so you have a better idea of the problems?  Don't know if the hormone tests will help or not, but go ahead and post them, with ranges.  

Are you restricted to doctors that accept health insurance, or are you willing to pay cash?  

[banker281]

I really don't know how long it would take to get another appt at another dr.  I would like to say yes I could get my dr. now to do the bloodwork, however I can't even get her to call me back.  But I can certainly try or ask my primary care.  


Here is Hormone testing:    Endo said all the following labs were normal
Testosterone, Serum  39  8-48 (ng/dL)
Free Testosterone(Direct)  4.1  0.0-4.2 (pg/mL)  This is in the high range of so called "normal"
Estradiol  106.3  (pg/mL)
Adult Female:
- Follicular phase 12.5 - 166.0
- Ovulation phase 85.8 - 498.0
- Luteal phase 43.8 - 211.0
- Postmenopausal <6.0 - 54.7
Prolactin  15.2   4.8-23.3 (ng/mL)
Progesterone  8.4  (ng/mL)
Follicular phase 0.1 - 0.9
- Luteal phase 1.8 - 23.9
- Ovulation phase 0.1 - 12.0
LH  7.8  (mIU/mL)
Adult Female:
- Follicular phase 2.4 - 12.6
- Ovulation phase 14.0 - 95.6
- Luteal phase 1.0 - 11.4
- Postmenopausal 7.7 - 58.5
FSH  5.4  (mIU/mL)
Adult Female:
- Follicular phase 3.5 - 12.5
- Ovulation phase 4.7 - 21.5
- Luteal phase 1.7 - 7.7
- Postmenopausal 25.8 - 134.8

Thank you again for all your help, I really appreciate it.

[banker281]

I prefer to stay within insurance, but would be willing to pay cash up to a point, if needed.

[gimel]

First thing is that the T3 Uptake and Free T4 Index tests are very outdated and not very useful when far better tests for Free T4 and Free T3 exist.  I would not have much confidence in a doctor that still orders those tests.  In addition the doctor blew off the possibility of endocrine problems affecting hair loss, which further lowers his reputation with me.  What did the doctor have to say about all those other symptoms you have?  What was his response to the nodules?   Seems like you need to find a good thyroid doctor, for which we may be able to provide names of some candidates tht have been recommended by other thyroid patients.  

In assessing a person for possible hypothyroidism, the most important consideration should always be an evaluation for symptoms that occur more frequently with hypothyroidism than otherwise.  You have a number of those.  Next is to assess biochemical test results for the biologically active thyroid hormones, Free T4 and Free T3.  Your Free T4 of 1.30 is adequate, at about 51% of its range.  Your Free T3 of 2.9, however,  is only about 28% of its range, which is lower than needed by many people.  Note that the range is far too broad to be functional for everybody, due to the erroneous assumptions used to establish those ranges.   This results in the ranges being too broad and skewed to the low end.   Many of us have found that we needed Free T4 to be at least mid-range, and Free T3 in the upper third of these ranges to relieve hypo symptoms.  

Your Free T3 level being much lower in range than you Free T4 is an indication of poor conversion of T4 to T3.  There is a conversion process that determines the balance among FT4, FT3, and Reverse T3.  FT4 is the main extracellular thyroid hormone, while FT3 is the main intracellular thyroid hormone.  T4 is converted to T3 and biologically activated on entry into cells.  The conversion process is affected by a number of variables, including levels of iodine, selenium, ferritin, zinc, and even TSH.   You should always make sure to test for FT4 and FT3.  At next opportunity it would also be a good idea to include Reverse T3 to determine if T4 is being converted to RT3 excessively.  Excess RT3 can block the effect of T3, causing hypo-metabolic effects.   In addition you need to test for B12 and ferritin and then supplement as needed to optimize.  B12 should be in the upper end of its range, and ferritin should be at least 100.  Hypothyroid women are especially prone to being low in ferritin, and it is very  important for good hair growth.  

Hypothyroidism is not just the result of inadequate thyroid hormone.  Properly defined, hypothyroidism is insufficient T3 effect in tissue  throughout the body due to inadequate supply of, or response to, thyroid hormone.   The response to thyroid hormone is significantly affected by Vitamin D and  cortisol.   Your Vitamin D is lower than recommended so you need to supplement to raise it to at least 50 ng/mL.  In addition it would be a good idea to test for cortisol.   Either too low or too high can be a problem.  So the takeaway from this should be that hypothyroidism is more than just low thyroid hormone levels.  Hypothyroidism is insufficient Tissue T3 Effect due to both thyroid hormone levels and the response at the cellular level.   Insufficient Tissue T3 Effect causes symptoms.  Their is no biochemical test that can determine Tissue T3 Effect.  That is why symptoms are the most important indicator of Tissue T3 Effect and thus thyroid status.  

As for the nodules, I think the best step would be to find a good thyroid doctor and find out what further testing should be done for those nodules.  The nodules are fairly large and may need to be biopsied.  If a biopsy is clear, then then question becomes, I think, whether they are obstructing your breathing/ swallowing or having an effect on thyroid hormone output.   Following is a good site on nodules.

https://www.mayoclinic.org/diseases-conditions/thyroid-nodules/symptoms-causes/syc-20355262

In summary, I think the first thing needed is to be tested for Free T4, Free T3, Reverse T3, cortisol, B12, and ferritin.   With those results available, needed treatment will be more apparent.   I know you are low in Free T3, but whether that requires thyroid medication or correction of other variables needs to be evaluated through these tests.
If you want to confirm what I have said, click on my name and then scroll down and read in my journal, the one page overview of a paper on Diagnosis and Treatment of Hypothyroidism: a Patient's Perspective.  

In addition you need a good thyroid doctor to do further evaluation for the nodules.   I see your location.  If you will tell us your insurance carrier perhaps we can locate and suggest a doctor for you to consider.  

[banker281]

Thank you so much for your response.

The dr. called and got the results of my ultrasound verbally over the phone, and said they biopsy anything over 2 cm., but she needed the hard copy.  So, I contacted my primary care and they say they have faxed it 4-5 times and even did it manually on Monday.  I went and pick up a copy myself yesterday morning and took it an dropped it off.  Telling the receptionist that this is what the dr. has been waiting for.  Still no response to the nodules.  Other symptoms, she didn't have any answer to; just not endocrine.  (They did test hormones as well; and everything was "normal".)  I do have those results as well.

My health insurance carrier is United HealthCare Choice Plus.

[gimel]

There is much to discuss, but first please post the reference ranges shown on the lab report for the Free T4 and Free T3.   The most important consideration in assessing a person for possible hypothyroidism is symptoms.  So please tell us about any symptoms you have.  

[banker281]

Here are my current symptoms:
Changes in the menstrual cycle -very heavy and long (but had ablation done before I knew it could be thyroid),  
Constipation (some)
Depression (on meds)
hair loss (endo said try biotin and if that continues to see a dermatologist that it wasn't endocrine related)
Dry and itchy skin
Fatigue (even with 8 hours sleep I wake up tired and low motivation to get things done)
Greater sensitivity to cold (will get cold in air conditioning and need to wear long sleeves and well as in the car with family with air conditioning on, however some nights I burn up and have night sweats
Swelling of the thyroid gland (goiter)
difficulty losing weight  (eat between 1200 and 1500 cal. and exercise 20-30 min at least 3 x week with some free weights)
Facial Hair Growth (lip and chin)

These are the my labs results along with ranges:

THYROID PEROXIDASE ANTIBODIES  <1  ( or = 20 Years 0.40-4.50)
Triiodothyronine, Free, Serum  2.9  (2.0-4.4 (pg/mL))
T4, Free(Direct)  1.30  (0.82-1.77 (ng/dL))
VITAMIN D,25-OH, TOTAL, IA   34    (30-100 (ng/mL))

Thank you, any input is greatly appreciated.