Thyroid disease possible with normal TSH, T3 & T4?

[suega]

Is it possible to have a thyroid disease with normal TSH, T3 & T4?  I have a positive ANA, muscle twithches, extreme fatigue (comes and goes like flare-ups), aches and pains.  I have just recently started feeling a little pressure in the front of my throat- not problems swallowing or anything, just a sensation that something is pushing on my lower throat.  In the past I have also suffered from palpatations and chest discomfort which all checked out okay with the cardiologist.  The neurologist says the muscle twitches are benign and was thinking thyroid until he saw my TSH, T3 & T4 were all normal.  Now to the rheumatologist to see what he can come up with.  I don't really have lupus symptoms such as mouth sores, malar rash, etc.

Any ideas?  Thanks in advance!

[gimel]

From much experience, we have come to not accept the word "normal", when it comes to thyroid issues.  Too many times we  have found them not to be "normal" at all, after looking at the actual numbers.  So if you will post the actual test results and reference ranges, our many experienced members can help evaluate.

[suega]

Thanks for your quick reply!  

T3, total= 113                    range 97-219
T4, Free = 1.1                    range .8-1.8
TSH, 3rd generation= 2.69  range .40-4.50

January 2009 my TSH was 2.884 and October 2008 it was 3.187 so it has been tested several times (all with same reference range)

[gimel]

I can see from the results why most doctor would send you home as "normal; however,  there is more than ample reason to say that you are hypo and should be given at least a therapeutic trial dose of thyroid meds to evaluate the effect on your symptoms.  There are multiple reasons for saying this.  

First, the AACE recommended over 6 years ago that the ref. range for TSH should be lowered to .3-3.0.  Many thyroid authorities have stated that anything over 2.0 should be suspect.  In addition, TSH is a pituitary hormone that is only an indicator of thyroid hormone levels in the blood.  It is affected by many variables, including the time of day when the blood was drawn for the test.  Also, it does not correlate very well at all with hypo symptoms.  Why the medical community continues to use the old test range and rely predominantly on TSH as a diagnostic, when it is not, is a mystery to most of us on the Forum.

The most important tests are for FT3 and FT4, which are the actual, biologically active thyroid hormones.  Free T3 is actually four times as potent as free T4, and it correlates best with hypo symptoms.  Many patients with hypo symptoms have reported the best result by adjusting FT3 and FT4 into the upper part of their ranges.  Being in the reference ranges for FT3 and FT4  doesn't mean everything is okay.  The ranges should really be considered as guides within which to adjust levels as required to alleviate symptoms.

If I were you I would read and absorb the info in this link and make a copy and take it to the doctor and try and get him to treat your symptoms by testing and adjusting your "Frees" with meds as required to alleviate symptoms.

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

[goolarra]

I agree with all gimel has to say (today, anyway!).

I wrote the following to explain why so many are in reference range, but are still hypo.  Disclaimer:  not a doctor, just my opinion as a fellow patient.

Proper Use of Reference Ranges in Treating Hypothyroidism:  Some Ideas to Discuss with your Doctor

Many hypo patients or undiagnosed hypo patients have an array of hypo symptoms, yet their lab work (free T3, free T4 and TSH) indicate that they are within the reference ranges that doctors erroneously refer to as “normal”.  TSH is often high in the range (or maybe even above the range according to the latest standards of 0.3-3.0 which many labs and doctors still refuse use) and FT3 and/or FT4 are low in their ranges.  Many doctors think that if labs are anywhere within ranges, their job is done...patient is no longer hypo, any remaining symptoms are not thyroid related, patient is fat and lazy.  NOT TRUE.  

Please see illustration below.  Each of us has a personal reference range within the population reference range at which we are euthyroid (neither hypo nor hyper).  A shift in lab values of the individual outside of his or her individual reference range, but still within the population reference range, is not normal for that individual.  Many don't feel well until FT3 and FT4 are in the upper half of the ranges.  After all, the population ranges of FT3 and FT4 are statistically determined distributions of patient results; by definition, approximately half the population will be euthyroid in the top half of the range and approximately half in the bottom.  If you are one of the people whose personal range must be in the top of the ranges, and your doctor won’t treat you or won’t fine-tune your medication when your results are in the bottom of the range, you are left hypo.  Your doctor may tell you your labs are "normal", but they are NOT “normal” for you.

Reference ranges of test results do not imply that everyone is going to be well as long as they are anywhere in the ranges.  The ranges are broad (e.g. 0.6-2.0 for FT4).  If your personal FT4 reference range was 1.6-1.8 when your thyroid was functioning properly, does it really make any logical sense at all that now that you are on replacement hormones, you should feel comfortable with an FT4 of 1.0?  No, it doesn't.  We all have a set point that is optimal for us...doctors should be finding it and adjusting medication to it.

If labs are within ranges, it's time for fine-tuning (or initiating a low dose trial)...increasing meds slightly if hypo symptoms are still present.  This will move FT3 and FT4 up in the range and alleviate symptoms…that’s the goal.  The ranges define the universe in which we can freely adjust medication; its entire breadth from lower limit to upper should be used for this purpose.  The patient will still be in the reference ranges, but he or she will no longer be symptomatic.  

Illustration:
                                                 Personal
                Current                      Reference
                  Level                          Range
0.6               1.0                       [1.6……1.8]          2.0
|-----------------Population Reference Range-------------------|

With an FT4 of 1.0, patient is still hypo according to his/her personal reference range.

[Lynn1988]

I found this website recently and wanted to comment on your question concerning normal TSH,T3,& T4 labs with symptoms.  I had the same symptoms with inability to concentrate, (or feeling like I was in a box), cold hands and feet, palpitations and flutters in my chest with some anxiety.  My TSH was 6.3 with normal thyroid panel results, otherwise.  I am very healthy and athletic and it hit me 3 weeks ago.  I was put on a low dose synthroid of 50 mcg and have taken it for 2 weeks.  The strange thing is that my labs were repeated a week ago and I had a normal TSH level.  I still get the palpitations, cold hands and aching joints, but not as severe.  My doctor told me that as long as I felt better on the synthroid, to keep taking it with a repeat of labs in 6 weeks.  I know it is possible to become hyperthyroid with the medication and wonder if I will have to be on this forever, or that my thyroid might "correct" itself and I might be able to get off of it alltogether.  Nontheless, I know how you feel and it's very strange to have thes symptoms with normal thyroid lab results.

[gimel]

What were the actual results and reference ranges for the thyroid tests that you said were "normal"?

[Lynn1988]

I was told by the doctor that everything repeated was "normal".  I plan to get the test results from him next week and will post those.  He told me to keep taking the 50mcg of Levothyroxine as long as I wasn't getting symptoms of hyper and will repeat thyroid labs 6 weeks after starting meds.  I did start having irratability and new abdominal cramping the 17th day of dosing, along with muscle aches and palpitations, but alot of the other symptoms have subsided.  I will f/u with an endo after the test results come back knowing that my only abnormal lab was my TSH of 6.3. It's all a balancing act and I'm just starting the process and learning much more from this panel than I ever learned in nursing school or being an ICU nurse.  The endocrine system is very complex and I realize that now more than ever.  Thanks!      

[gimel]

With your training and experience I thought you might like to read one of my previous posts about FT3 and FT4 and why test results in the low end of the ranges are not really "normal".  Since TSH is a pituitary hormone and affected by so many variables, I have little regard for its use as a diagnostic.   At best it is an indicator, to be considered along with symptoms and the "Frees".  In my opinion, the best way to treat a thyroid patient is to test and adjust FT3 and FT4 levels with meds, as required to alleviate symptoms.  It should be all about symptom relief and not just getting test results somewhere within very broad reference ranges.



The reason the reference ranges for the "Frees" are called "normal", is that they are based on a large population of patients' test results.  From that data base the decision was made that about 2.5 % of people would fall out of this "normal" range because they were possibly hypo or hyper.  From this decision limits wereplaced  at plus and minus two standard deviations (which correlates with plus or minus 2.5%) from the overall average and that was called the "normal" range, supposedly representing people who had no thyroid problems.  

After many years of bad experience with this "normal" range for TSH, they finally acknowledged 6 years ago that there were a lot more patients out there with hypo  and hyper problems, than previously accepted when they originally established the range.  
After excluding from the data base those patients who were suspect for hypo and hyper, they again analyzed the remaining data base and established limits that included 95% of the total data base and called these new limits "normal".  This changed the reference range from .5-5.0  down to .3-3.0, which is a huge change.  Unfortunately this change hasn't yet been accepted or acknowledged by most labs and doctors.

Also, realize that the reference ranges for the "Frees" were established the same basic way.  These ranges have never been reexamined and modified like the range for TSH.  I am absolutely convinced that this is the reason why so many hypo people fall into the lower end of the ranges for FT3 and FT4 and are still told they are "normal".

In one my past lives I had a lot of training and experience in statistical analysis.  Based on that experience, if I had to estimate what a revised range for FT3 would be if the data base were purged of suspect hypo and hyper people, like was done for TSH,then I would say it the FT3 range should change from 2.3-4.2 pg/dl up to about 3.2-4.3.  And FT4 probably would change from .60-1.50ng/dl up to about 1.0-1.55. Quite a difference, huh?  Think maybe that is why we hear from so many people that have hypo symptoms, yet they are in the "normal" ranges for the "Frees"?  I'd bet my last dollar.






Also, if you haven't read this article, you may find it worthwhile.
http://www.hormonerestoration.com/Thyroid.html

[Lynn1988]

Thank you for the response and I find it amazing how even in the ICU we look at the basic "normal" ranges with the thyroid panel and assume the pt is therapuetic..... and the intensivists will treat according to those "norms"   I will be getting my hospital lab records and my f/u lab records from my GP next week.  It will be enteresting to see where I fall with the FT3/FT4 results.  My GP did say that I am probably on the low end of normal "for me", and did feel that a trial run of medication might help...and IT HAS!  I am still having some PVC's, weird pains/rushes through my body and fatigue, with some anxiety on the 18th day of taking my Levo.  It's very strange and so hard to explain how you feel to somebody.

The term, "subclinical hypothyroidism" must of come from the excepted reference ranges used for diagnosis.  I had really not heard that term until now...when my GP told me he felt I had it.   Your explanation of the lab values and the "normal" ranges explained it all very well to me.  I was thinking..."am I just a NUT?  LOL!!!!  " My thyroid panel is "normal"...what's REALLY wrong with me?"  (supposed to be plain and simple)  It's really not that simple and I have learned alot from this website.  Thank you for your time and knowledge....it is much appreciated.  I will post my results when I get them.  

[Lynn1988]

It took a while just to get the results from my GP on my thyroid labs.  I am still waiting for my hospital records (THS,T4,T3) results.  According to your analysis on the Free T3,T4 labs....IT"S making sense.  These are the results that I have right now.
8/14-  doctors visit   TSH  3.050
8/15-  hospital          TSH  6.8
8/19- f/u md             TSH 2.240
                               FT3- 3.2
                               FT4- 1.2
                               Anti-Thyroglobulin  <20
                               Anti-TPO-Ab     <10.0
All of these reults were prior to taking any thyroid meds.  I had alot of PVC' (Premature ventricular Contractions) with slow heart rate 48-52 BPM at rest, and went to the ER.  They kept me for 2 days with f/u echo and holter monitor ( All good results, just occasional PVC'S).  I'm very athletic...so, they assumed that is why I was so bradycardic.  I know different!  They couldn't give me a Bet Blocker because my heart rate was too low and sent me out the door with 50mcg of levothyroxine .  I must say...I'm NO drama Queen, but the night I went into the ER...I thought I was going to die.  I'm on day 24 of the meds.  Still get VERY fatigued with Brain fog..palpiations come around lunch and dinner time and last about 30-45 minutes. Resting heart rate is in the 60's with PVC'S now.  I get this weird feeling in my chest and stomach and then the low palpiations hit followed with extreme fatigue and flu/like sx's.  I HAVE to eat alot to feel good and I do.  Otherwise, alot of the hypo symptoms are disapaiting.  I know it takes time for the meds to regulate you (IF IT'S EVEN THE RIGHT ONE FOR YOU), and some litaratue states that it might take up to 8 weeks.  I f/u with my GP for more labs Oct 2.  I wake up every morning and pray I can feel good just to function and deal with my family.  I will keep a good attitude and press forward.  Any advise would be ppreciated.    

[gimel]

Since you started on the 50 mcg of Synthroid 24 days ago, then you should already be over 90% of the maximum level you will see as a result of the meds.  So by the time of the next testing on Oct. 2, that should give you a good idea of the total effect on blood levels.  
You should realize, however,  that symptom changes tend to lag changes in the blood levels of thyroid hormones. Although you should continue to notice improvement, alleviation of your symptoms may take a while, dependent on how long you have been hypo.  So all I'm saying is to be patient and not expect all symptoms to disappear overnight when your thyroid hormones get up to the right level.

Glad to hear that you are making progress.  Please keep us tuned in.

[MarBara]

What is your PROGESTERONE LEVEL? IS it on range?

I must know this before answer your question.

Also, have you checked for your  FSH?