TSH is a pituitary hormone that is affected by so many variables, including the time of day when blood is drawn for the test, that it is totally inadequate as a diagnostic for thyroid. At best it is an indicator to be considered along with more important indicators such as symptoms and also levels of the biologically active thyroid hormones, Free T3 and Free T4 (not the same as Total T3 and T4).
If you haven't been tested for Free T3 and Free T4, then that should be a high priority for you. Also, please tell us what symptoms you have that might be related to hypothyroidism.
A good thyroid doctor will treat a 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 just test results. You can get some good insight into clinical treatment by reading this letter written by a good thyroid doctor for patients that he consults with from a distance. The letter is sent to the PCP of the patient to help guide treatment. I have to copy it in full because I cannot provide a link at this time.
For Physicians of Patients Taking Thyroid Hormones
Mild-moderate thyroid insufficiency is quite common and is an unrecognized cause of depression, obesity, high cholesterol, cold intolerance, atherosclerosis, chronic fatigue, and fibromyalgia. It is often secondary, so the TSH is normal, but the FT4 and FT3 levels are low in the reference ranged. Thyroid supplementation to produce higher FT3 and FT4 levels within the reference ranges can improve mood, energy, and alertness; help with weight control, and lower cholesterol levels. I have prescribed thyroid hormones for your patient because his/her symptoms, physical signs, and/or blood tests suggested that he/she had inadequate levels for optimal quality of life and long-term health. If they showed clear improvements, I kept them on the thyroid supplementation. The final dose we decided upon was based on symptoms and signs first, and on free T3 and free T4 levels second. As the TSH was usually normal initially, it is frequently suppressed when thyroid levels are optimized clinically. FT3 and FT4 are usually within the ranges, ruling out significant thyrotoxicosis.
We were all taught that the TSH perfectly portrays a person’s thyroid hormone status, supplemented or unsupplemented, and we need only obtain a “normal” TSH to know that our patient had no excess or deficiency of thyroid hormones. In fact, there is no reason to believe that the hypothalamic-pituitary axis is always perfect, and lots of evidence that it is not. TSH-based thyroidology is an unjustified faith in the infallibility of the hypothalamic-pituitary axis. One must instead base the diagnosis and dosing on symptoms first, and on the free T4 and free T3 levels second. Even here, “normal” is not good enough. The labs’ reference ranges for FT4 and FT3 are not optimal ranges; they are statistics: 95%-inclusive population ranges. They are excessively broad (2 to 3x from bottom to top) and define only the bottom 2.5% of the population studied as “low”. The prevalence of hypothyroidism is much greater than 2.5%.
T4-only therapy (Synthroid®, Levoxyl®), to merely “normalize” the TSH is frequently inadequate treatment as the H-P axis overreacts to once-daily oral thyroid hormone peaks, compared to the gland’s steady 24-hr glandular secretion. TSH-normalizing T4 therapy often leaves both FT4 and FT3 levels relatively low, and the patient symptomatic. Recognizing this, Nat. Acad. of Clinical Biochemistry guidelines call giving enough T4 to keep the TSH near the bottom of its RR (<1) and the FT4 at or just above its RR. But this is not sufficient; the ultimate criterion for dose adjustment must always be the clinical response of the patient. I have prescribed natural dessicated thyroid for your patient (Armour, Nature-Throid) because it contains both T4 and T3 (40mcg and 9mcg respectively per 60mg). This assures sufficient T3 levels and thyroid effects in the body. Since NDT has more T3 than the human thyroid gland produces, the well- replaced patient’s FT4 will be below the middle of its range, and the FT3 will be high “normal” or slightly high before the next AM dose.
Excessive thyroid dosing causes many negative symptoms, and such patients do not feel well. I suggest lowering the dose in any patient who has developed insomnia, shakiness, irritability, palpitations, overheating, etc.. Atrial fibrillation can unfortunately occur in susceptible patients with any increase in their thyroid levels. It should not recur if the dose is kept lower than their threshold. Thyroid hormone does not cause bone loss, it simply increases metabolism and therefore the rate of the current bone formation or loss. Most older women are losing bone due to their combined sex steroid, DHEA, Vitamin D, and growth hormone deficiencies. The solution is not life-long hypothyroidism, but the correction of their other deficiencies.
166 West Tioga Street (Bus. Rt. 6), Tunkhannock, PA 18657 Tel.: 570-955-3495 Fax: 570-836-3290 ***@****
My FT4 was 1.25 and FT3 was 3.6. The symptoms that I have been having are:
joint pain, dry skin, can not stand cold, can't lose weight,fatigue, muscle cramps, constipation, depression, irritability. Any info will help...
Assuming that your test results are current and representative of the dose you mentioned, I'd expect that you need to increase dosage, but that depends on symptoms. Free T3 is the most important because it correlates best with hypo symptoms, while Free T4 and TSH do not correlate at all. Your Free T3 is below the middle of the range, which is frequently associated with being hypo still. That is because the range is too broad. Your Free T4 is even below range, when it should be around the middle of its range.
Your doctor mentioned the possibility of a pituitary problem, but I don't think so. TSH is frequently suppressed when taking significant doses of thyroid meds. At least the doctor did not react as most of them do in similar situations and decide your TSH showed that you were hyper, (even if you didn't have hyper symptoms due to excessive levels of Free T3 and Free T4), and thereby reduce your meds.
If your doctor wants to see some scientific data on TSH suppression, here is a link.
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."
hi thanks again i have suggested to my new endo that i take extra t4 or t3 as i have some left over from previous prescriptions but she sent me a stern email saying she made herself clear that i was not to increase my meds and i could always get another endo!!! she is quite adamant i go for pituitary gland tests
weight gain 1 stone, hair loss & eyebrow edges (after just starting to grown back)
tired muscle ache, constipation, cant sleep at night, skin problems all the usual stuff although on armour no carpels or sudden leg weakness which was a big problem on synthetic T4 & T3
So what if you did have a pituitary problem (which I doubt)? Even if you had a pituitary issue, how would that account for your hypothyroid symptoms? It would have no impact on your need for higher levels of thyroid hormone, to relieve your hypo symptoms. Your FT4 is below range and your FT3 is too low in the range. And you need a good thyroid doctor, not necessarily an Endo.
I have the name of a doctor in Edwinstowe, Mansfield that was recommended by a fellow Forum member as being a good thyroid doctor. Would that be of interest to you?
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