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Test Results Guidance
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Test Results Guidance

My thyroid was nuked over 20 years ago.  Long story short, I've reached menopause and can't seem to get my medication at a dose that consistently works.  I started on Tirosint earlier this year and was feeling great but Dr. reduced my dose in increments to get my lab tests in line.  My last med decrease was in July---150 mcg daily and I can feel myself starting to feel poorly again.  Symptoms include being emotional, sluggish energy, hair starting to fall out and a bit of depression.  I am occasionally heat intolerant, but I'm wondering if these aren't hot flashes instead of thyroid issues.

Here are my lab tests from this week:

TSH:  0.006 (Range .82-1.77)
Free T4:  1.98 (Range .450-4.500)
Free T3:  3.2 (Range 2.0-4.4)

Dr. had a goal of T4 at 1.8 so I'm anticipating she'll want to reduce my current dose further.  Also, Dr. is leaving the area, so I'll need to find another doctor which has me a bit stressed out.

I've been reading the forum here quite a bit so I know that each individual is different and good doctors will respond to how I feel rather than results.  My current doctor has worked with me as best possible over the last 3 years with different medication combinations, but I'm starting to feel as if I'm on a never-ending roller coaster.  At this point, I'm not sure what avenue to pursue to get back on track to feeling myself once and for all.  Any advice would be appreciated.

Thank you!
11 Comments Post a Comment
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Avatar_m_tn
AARRRRRGGGG.  So frustrating when a doctor wants to reduce your meds when you were feeling great, just to "get your lab tests in line"?  

What med and dosage were you taking at the time?  What were your Free T3, Free T4 and TSH at that point?
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649848_tn?1357751184
Could you please check the reference ranges for the TSH and FT4?  It appears that you might have reversed them?  

Your symptoms definitely, indicate hypo.

Rule of thumb is that FT4 should be approximately mid range and FT3 in the upper half to upper third of its range.  Your FT3 is only at 50%, so you have lots of room to increase that.  When on thyroid replacement hormones, TSH, often becomes useless, which yours has.

FT3 is the hormone that's used by the individual cells, and is the one that correlates best with symptoms.  FT4 is a storage hormone and must be converted to FT3.  The fact that your FT4 is so high and FT3 is lower in the range, indicates that you aren't converting adequately.

I suggest that you talk to your doctor about decreasing the T4 med and adding some T3 med, such as cytomel or generic liothyronine.  You could also switch to desiccated, which contains both T4 and T3.  Desiccated thyroid hormones are derived from pig thyroid; pigs produce considerably more T3 than humans do.  Many of us don't need that high level of T3 and  it's easier for most of us to control levels if we can adjust them separately.

Typically, T4 med is decreased by about 25 mcg for every 5 mcg T3 added.  In your case, since your FT4 is already over range, I might suggest decreasing it by and additional 12.5 to 25 mcg to bring it down near that mid range.  You can always increase later, if need be.

Since your doctor has been willing to work with you, she should have no trouble trying this.  

You might talk to your current doctor, and ask for recommendations for a new one.  Be sure that you stress that the new doctor must always test FT3 and FT4, along with TSH and also that s/he be willing to prescribe whatever medication it takes to make you feel well.  The new doctor will also need to be willing to treat you according to symptoms.
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Avatar_n_tn
Thanks for your response.  In all fairness to my current doctor, she has been great about working with me on finding the right medication/dose.  She’s a thyroid patient herself, so understands.  It just seems like we keep trying something new every 6-8 weeks and the roller coaster effect is getting to me.

I started Tirosint in 9/12 at a dose of 200 mcg. daily.  Before that, I tried compounded meds at 212/T4 and 10/T3 and experienced major roller coaster symptoms of hypo/hyper.  I learned that compounded meds are not 100% accurate.  I’ve never done well on generics either.  Also, fillers used in some meds don’t play well in my body as I seem to be very sensitive.  Tirosint has been a life saver in that regard.

Here are lab reports from this year.  I’ve used LabCorp for all tests so ranges are as noted in my original post (except I reversed FT4 and TSH ranges!).  I take meds daily between 7:00 and 8:00 a.m. and take all blood tests in the same time frame (11:00-12:00 noon) :

January (200mcg dose):   TSH .006   FT4 2.59   FT3 4.1
April (188mcg dose):   TSH .006         FT4 2.32         FT3 3.4
June (176mcg dose):         TSH .006         FT4 2.27         No FT3 test
September (150 mcg dose): TSH .006         FT4 1.98         FT3 3.2

Further info in my response to Barb below.
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Avatar_n_tn
Thanks for your response as well.  See my post to Gimel above.  Sorry---I did transpose ranges for TSH and T4.  

I was considering asking about T3 but one concern is whether or not this roller coaster I seem to be on is effected by my current menopause state.  There has to be a reason I can’t seem to find the correct dose these last four years.  Also, is there a natural T3 available beyond Armour?

It might be helpful to know I have no other physical issues and take no other medications.  I do take a 300 mg calcium supplement every other day with dinner and 1 Primrose Oil supplement capsule every other day (to help prevent hair loss).  I’ve always been super high energy (prior to thyroid issues) and a “get it done” type person with an upbeat attitude.  My current state of mind is so not like me that I’ve put myself on a mission to get this resolved.  I’m wasting life.

As far as a physician referral, we live in the boonies with a shortage of doctors.  Most of the physicians here no longer take new patients so I’ll have to expand my search beyond the local area.  Due to our insurance deductible, I order and pay for all blood tests.  This works for us as we’re very proactive in our health and well-being.

Thanks for your detailed response.  I really appreciate the information.
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649848_tn?1357751184
Of course, your menopausal state would have a bearing, but I think not so much. It would have more to do with symptoms than with actual thyroid hormone levels, though all hormones have to work together...  

It's usually best to get blood work done prior to taking thyroid med, but I'll certainly give you credit for being consistent.

What med were you on, when you had the Sep labs?

It looks like the T4 med is driving your FT4 levels way too high, but you aren't adequately converting that to FT3...  This happens sometimes when one is on a T4 only med.  

As I noted in my post above:  "You could also switch to desiccated, which contains both T4 and T3.  Desiccated thyroid hormones are derived from pig thyroid; pigs produce considerably more T3 than humans do.  Many of us don't need that high level of T3 and  it's easier for most of us to control levels if we can adjust them separately."  

Please note that desiccated hormones are also called "natural", but I have a problem with that terminology, because I don't consider it "natural" to take a medication that contains much more of a hormone than my body would produce, if it could.  That said, there are people who really need that much T3, and for whom desiccated hormones are the only way to go... as always, all options should be considered.

There are other desiccated hormones that you could look into, including NatureThroid and ERFA, which is a Canadian med.  

Some of us find that combining a T4 med (in my case Tirosint) with a T3 med (in my case, liothyronine), make it easier to keep both FT3 and FT4 levels where we need them, because we can adjust them individually.

Did you know that hair loss is a hypo symptom? Calcium should be taken 4 hrs from thyroid med and it seems you do that, since you take your thyroid hormone in the morning, and calcium with dinner..  no problem there.

Simply looks like you need more T3... you  might try decreasing your Tirosint, as I suggested above and adding some T3; you can always switch to desiccated, if you find that you need that much T3.

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Avatar_n_tn
Thank you once again Barb for your thoughtful and thorough response.  You've eased my mind tremendously and I appreciate it.

The September lab report reflects my current dose of 150mcg of Tirosint.  As you suggested, I'll ask my doctor for a small dose of compounded T3 and reduce the Tirosint to 137mcg and see how that works.  I won't give up Tirosint since it's been working so well for me.

Thanks again!
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649848_tn?1357751184
I wouldn't expect you give up the Tirosint, but you do need a lower dose.  Remember that you should decrease T4 med by 25 mcg for every 5 mcg of T3 added, so if you add 5 mcg T3, you'd need to drop your Tirosint to 125; if you add 10 mcg of T3, you'd need to drop Tirosint to 100 mcg.

Why do you want compounded T3?  Why not try cytomel?  If you compound, you'll have a capsule and won't be able to split pills or anything to adjust dosage; you just get whatever is in the capsule.  I take generic T3... 5 mcg tablets and if I need to decrease a little I can split a pill in 1/2 and only take 1/2 of it. Additionally, most of us find that splitting our dose of T3 into multiple doses/day keeps levels more steady.  For instance, I'm on 10 mcg; I take 5 mcg in the morning, and the other 5 around noon/early afternoon. That way I have a steady supply of T3 all day, since T3 is faster acting, so is in/out of your system within a few hours.
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Avatar_n_tn
I should have said I wouldn't give up Tirosint for Armour or any other combination med.  As you mentioned, I think it's important to keep them in separate doses to maintain balance.

As far compounded T3, I looked at cytomel and a few others and the filler issue looms large for me since I haven't had good experience in the past with medication fillers.  With compounded meds, there's a bit more control over what type of fillers are used.

Thanks for the dosage guidelines.  I'd prefer to decrease the T4 slowly to avoid any "crash".  I think that may be part of the problem with the last dose reduction.....176 mcg to 150 mcg was too much of a decrease all at once for me.  So, my plan is to request 137 mcg Tirosint and 2.5 mcg T3 and try that for a bit to see how it works.

At the risk of sounding like a broken record, you've helped me tremendously and I really appreciate it!  Thank you!!
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649848_tn?1357751184
I'm sorry to tell you, but 2.5 mcg of T3 is probably not going to do anything for you.

You do understand, don't you, that even compounded meds have fillers?  Think about it -- "compounded" --- the med isn't the only thing in that capsule; it's compounded with fillers.

Of course, you will have to do whatever you and your doctor deem best....

Best of luck to you.
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Avatar_n_tn
Thanks Barb.  I realize I'll have to let the doctor guide the T3 dosage.  My plan is at least a starting point for discussion.

I've taken compounded thyroid medication in the past so I understand they have fillers.  The pharmacy we use is patient friendly with options on fillers, which works for me.

Thanks again for all of your help.
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649848_tn?1357751184
"I realize I'll have to let the doctor guide the T3 dosage.  My plan is at least a starting point for discussion."  I totally agree with you on that one... you have to start somewhere.

It's good that you've taken compounded med before; hopefully, you would have an idea of what fillers you can handle, then.  
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