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T4 vs. T3 supplementation
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T4 vs. T3 supplementation

My wife has always been low or borderline low on her thyroid levels, and she's always been prescribed Synthroid or some other T4 pill. I was just looking over her most recent blood work, and decided to search the Internet for the meanings of some of the tests. I came across the T3 vs. T4 and TSH discussions on several sites; never knew there were all of those components. In reading some of the symptoms of low T3 levels(difficulty losing weight despite daily exercise, always cold, headaches, sinus issues, etc.), almost every one is applicable to my wife, and has been for a long time. Understanding that I should only use responses I receive here as reference points, can anyone give me their thoughts on whether she should be getting some T3 supplementation based on her test numbers:

TSH - 11.74, ref range .34 - 5.6
T3-Free - 2.60, ref range 2.5 - 3.9
T4-Free - 1.02, ref range .61 - 1.12
T3-Total - 1.48, ref range .76 - 1.42
T Uptake (not sure if this is relevant) - 38.6, ref range 32 - 48

Any opinions would be greatly appreciated.

Thanks.
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17 Comments Post a Comment
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Avatar_m_tn
Several of the ranges you provided look strange to me.  I am used to seeing something more like .60-1.50 ng/dl for FT4 and  .87-1.90ng/ml for total T3.   Would you please double check those before I comment further?
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Avatar_f_tn
Yep, the ranges I listed are straight off of the printout she received. Do the range discrepancies that you've noted have any bearing on potential recommendations though? Really isn't it just the actual values that come into play?
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Avatar_m_tn
The reference ranges come into play in assessing whether the results are on the high side or the low side of the range.  For example the FT4 result you posted is toward the high end of the range listed, and sometimes this will influence a doctor's decision regarding medication dosage.  When I assess that same result against the range I am familiar with, the result is below the midpoint and frequently indicates the need for more med.  So I am still puzzled by the those ranges.  

Regardless, the TSH result is way over even the old ref. range limit of .5-5.0, and higher yet compared to the currently recommended range of .3-3.0.  Even though TSH is a pituitary hormone that is affected by many  variables, it is an indicator that should be considered along with the more important indicators, which are symptoms, as well as the levels of the actual, biologically active thyroid hormones that regulate metabolism and many other body functions ( FT3 and FT4).  The free T3 result is at the very low end of the very broad range.  FT3 is four times as potent as FT4, and FT3 correlates best with hypo symptoms.  We frequently hear from patients that have FT3 and FT4 within the lower range limits, yet they continue to suffer with hypo symptoms.  

Based on all those symptoms, along with the lab results, your wife definitely needs thyroid meds.  The questions  to be answered will be the type of med, the amount, and how the doctor will determine when she is getting enough meds.  By no means should dosage be determined by TSH.  In my opinion the very best way to treat a patient is to test and adjust FT3 and FT4 with meds as required to alleviate symptoms.  Symptom relief should be all important, not lab test results.  You may have to have some discussion with her doctor to assure that she is treated accordingly.

This is a good article that might provide you some useful info.  

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

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231441_tn?1333896366
Yes,

I have to agree that it looks like your wife may be undertreated.  Her TSH is too high.

Do you have any results prior to these so we can see if these are consistent results.

Given her symptoms, I would say she should definitely increase her thyroid meds.

If you get her levels ok using just t4 meds (thyroxine) and she feels ok, there is no need to add t3 meds.  If levels are ok, and still not feeling good then t3 meds may be added (if you can find a dr).

Have you asked your wife's dr about her results?  The dr should explain and also why the TSH levels are allowed to stay so high (and outside range).

Second opinion, definitely!
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231441_tn?1333896366
I agree with Gimmel that also need to look at Ft3 and FT4 levels, with FT3 being the active hormone.  Most people feel best when TSH is below 2 (some say target 1) and FT3 and FT4 are in mid to upper half of the reference range.

If the TSH is reduced and FT3 doesn't come up with increase in t4 meds, consider adding t3 med.

Again how she feels is also critical, not just the lab numbers.
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Avatar_f_tn
Thank you all for putting in the time to respond. My wife was just tested again the other day; I'll compare those results which come after two or three months on one of the T4 supplements to the results I posted above, then talk to her doctor.

Thanks again.
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649848_tn?1357751184
I agree with everything the above posters have said.  Why does it take 2-3 months to get results?  By then things may have changed again.  
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734073_tn?1278899925
The doctor should have labs ready in less then a week! Don't wait to your next appointment in a few months to see results. Go get a copy in a week and post all numbers and ranges here for verification. I'm thinking that a new doctor may be in order here!
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Avatar_f_tn
No no, I'll be calling today or tomorrow to get the results from her Monday tests. Now that I'm a bit more informed (thanks to this board) as to her results, I'll be all over the doctor's office.
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Avatar_f_tn
So after three months on one of the T4 supplements, my wife's results from this week, using the same reference ranges as above, are:

TSH - 1.75
T3 - Free - 2.76
T4 - Free - .82
T3 - Total - .89
T-Uptake - 34.5

So the TSH was lower, as one would expect, but why would the FT4 & total T3 be lower? I'd at least expect the FT4 to be the same or higher, unless I'm mistaken.

Most importantly, do these results indicate that she should receive some amount of direct T3 supplementation, given that she also exhibits many of the symptoms of hypothyroidism, as listed above?

Thanks for any help.
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Avatar_m_tn
In nine months on 100 levothyroxine my T3 and FT3 has steadily decreased even though I increased dose to 112.5 for six weeks in Aug and Sept. FT3 is now 2.21 (lab range 2.0-4.43). FT4 is 2 (0.71-1.85) and over the limit. T3 is 0.766 (0.846-2.02) first time below the range. T4 is 9.21 (4.5-12). TSH 1.41 (0.49-4.67) My cardio put me on 125 Levo two days ago and said to come back in two months. I have a' probable'  triple bIock CAD. have found five studies saying that low T3 can be quite deadly if there is a coronary event. But taking cytomel would be equally so? To me it  looks like I'm not converting T4 to T3. Is it time I saw an endo? How about an iodine 'capture, attract' test (that's what it's called in  Spanish where I live). I see the liver knocks an iodine molecule  off of T4 to make it T3?
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649848_tn?1357751184
Because it was so hard to scroll up to your original post to compare results, I've copied and pasted the results here.......

TSH - 11.74, ref range .34 - 5.6
T3-Free - 2.60, ref range 2.5 - 3.9
T4-Free - 1.02, ref range .61 - 1.12
T3-Total - 1.48, ref range .76 - 1.42
T Uptake (not sure if this is relevant) - 38.6, ref range 32 - 48

Most recent results: sorry, I getting old and like to have things close together for easier comparison…………lol
TSH - 1.75
T3 - Free - 2.76
T4 - Free - .82
T3 - Total - .89
T-Uptake - 34.5

Forget about the TOTAL T3 (I’m not even sure why this test is run any more) and concentrate on the FREE T3, which is the actual usable hormone, which actually came up.  The Free T4 went down, as did the TSH.  In my opinion, since her Free T3 came up with an increase in T4 dosage, she most likely doesn’t have a conversion problem and if you give her a T3 supplementation, the chances of going hyper are much greater.  Again, in my opinion, she may need an increase in T4 med, but make sure that the increases are done in baby steps, because you don’t want her to go hyper.  

I would also say -- don't worry so much about TSH -- yes, it is an indicator, but it's not the "be all/end all" for thyroid issues.  My latest TSH was only 0.03 (basically "in the basement"), but my "Frees" were only about mid range - the "frees" are what determine how we feel.

What is her current dosage of T4 med?  
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734073_tn?1278899925
I think a slight increase on the t4 med. will probably do it!
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Avatar_f_tn
I'll have to check on the dosage level when I get home from work. But it seems to me that although her FT3 did increase, it was only by a very small amount. If the goal is for FT3 to be in the high part of the range, doesn't that imply that she'd actually need a substantial increase in her T4 dosage? Or is there not really a 1:1 correlation? In other words, would a potentially small increase in T4 dosage be enough to bump the T3 up significantly?

And secondly, if you or anyone else knows, what is the significance of the T-Uptake value? I understand the definition, but not what the value means in the context of the rest of her results.

Thanks very much.
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734073_tn?1278899925
Try putting each test on a bell shaped curve, with the reference ranges at the ends of each bell. Then chart each lab result on it's bell. This gives a great visual of where you are at and if you are moving in the right direction with each test over time. Shoot for the middle of the range or higher (rt. side of bell) for the freet3 and freet4. They should line up in a perfect world! The TSH should be on the opposite side of it's bell (left side). Hope this helps! It's a little trick that I learned from my compounding pharmacist! I'm a very visual person so this is the way I keep track!
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649848_tn?1357751184
Increases in T4 med do not automatically raise T3 levels an equal amount since T4 has to be converted to T3 in order for the body to use it.  My point was that since the Free T3 DID come up with the increase in T4 med, there is probably not a great problem converting T4 to T3.  

Yes, it's possible that she may need a substantial increase in her T4 med -- what I meant about the "baby steps" is to do it in very small increments because some people can't tolerate large increases at one time, which could cause her to have to start back at "square one".   Yes, raising the levels slowly will take longer for her to get to the end result, but will be much less likely to cause a "reaction" or push her over the edge into hypER.  

I wouldn't rule out a T3 med, such as cytomel or an natural brand, such as Armour or NaturThroid - but you need to keep in mind that the T3 is approximately 4 times more potent than the T4, so even the slightest amount can send her into hyper.  

In my opinion, it's better to do it slowly with the T4 med, IF her Free T3 levels continue to climb up, if not -- try a low dose of T3 med or a combo/natural.  

I'd also like to point out that it's NOT cut and dried that we ALL need to have our levels in the upper 1/2 or 1/3 of the range.  We are all individuals and some may actually be optimal with lower levels versus higher..  There are so many different combinations of meds that it's impossible to even touch on them all.  For instance, *I* am on a rather "strange" regimen, but it's working for me...... I take 75 mcg levothyroxin (levothyroxine) + 5 mcg cytomel one day, then the next day, I take 88 mcg levothyroxin (levothyroxine) + 5 mcg cytomel.  The reason I did this is because I wanted to "bump" up my levels a bit, but there's where the "baby steps" comes in - it might take me longer to get where I'm going, but the ride should be less bumpy.........

Another thing I'd like to point out is that some people don't do well on certain brands/generics/manufacturers.........For instance -- my former pcp was stuck on synthroid and wouldn't consider anything else.  I did well for a couple of months, then things started turning back the other way.  My ENT finally referred me to an endo, who put me on generic levothyroxin (levothyroxine) and I've done good on it.  Each manufacturer might use different fillers in their med and maybe your wife won't do well with those.  You might want to note the manufacturers of her meds (pharmacies don't always get their supplies from the same maufacturers) and see which ones she does the best on.  

I know we all want to "hurry and get better" and our loved ones want that for us, but if your read some of the posts from people who's doctors put them on very large doses all at once, the reactions they had to it, etc, I think you will understand my point much better.  In fact, I wrote a journal not long ago about this very thing, feel free to read it.  

We all want it to "happen right now" and it just can't always be that way.  The illness most likely came on gradually, and you have to get it under control gradually or you could cause more problems than already exists.  I can tell that you love your wife and want her to get better, but I have to advise patience, patience, patience and when you think you've both run out of patience ---- you'll need to summon some more....

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Avatar_f_tn
I follow your point about the baby steps, and I wouldn't consider asking a doctor to bump up her levels by a large amount. She's currently on 50mcg of Levthyroxin. What's the next baby step incremental amount from that point, 75?

I might also add, for what it's worth, that her test for ferritin came back very low. I believe that comes into play somewhere in the conversion process for T4 -> T3 if I remember what I read correctly.

Thanks for taking the time to post the detailed response.
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