fire the dermatologist

[RCinNY]

Quick background information: male, 29, developed alopecia areata in May, saw dermatologist in June, taking topical steroid cream ever since and the two bald patches I have are now stable in size for around a month (3cm, 5cm in diameter), though I have no regrowth of hair yet.

The dermatologist sent me for a blood test to check my thyroid, and these are the results:
TSH = 3.610; Free T4 = 1.43

He said that the free t4 was too high and wants me to see an endocrinologist.  After looking at my copy of the report and poking around the internet, I really don't want to doubt the doctor, but I think he only flagged the free t4 because the ranges on the lab report seem cut off on every copy.  The TSH range says 0.27-4 (I googled the range and it probably is  to 4.2).  The free t4 range is 0.93-1, and after googling it, it should say 1.7.  There's also a spot for abnormal results to be flagged and that's blank.

So could this doctor have just been lazy, realized that 1.43 > 1 and stopped there, without questioning the tightness of the range?  Or are these numbers plus having alopecia enough reason to be checked out by an endocrinologist?

I'm going to call the doctor later in the week, but I have less faith now, and would appreciate any feedback here.

Thank you very much in advance.

[kitcurious]

You could be on to something yes,  but your TSH may be a little high by AACE standards, if not by the lab standards. I'd keep the Endo appointment anyway and he/she can tell you if your dermatologist is being myopic or perspicacious.;-)

[EmpatheticJenny]

P.S. Regarding what you found when you asked Google to give you the normal range for a TSH level: It is much easier to find outdated information than it is to find accurate information, since the thinking about "normal" has changed both radically and rapidly in regard to TSH. If I had hair loss and a TSH of 3.61, then not only would I see an endocrinologist, I would see a second one if the first one did not do a careful assessment.

[EmpatheticJenny]

Your free T4 level of 1.43 does not seem too high according to what my endocrinologist has told me. I am a little surprised that your dermatologist homed in on it, but then your dermatologist is not an endocrinologist. It is exceedingly difficult for any physician to have current knowledge in a specialty area other than his or her own; there is just too much information to keep up with.

Ironically, it is not your free T4 that I think qualifies you for a visit to an endocrinologist, it is your TSH level, as pointed out by Kit. In the world of endocrinology, the definition of the upper end of "normal" has changed a LOT in a relatively short period of time, and I predict (as a researcher who has read some of the theoretical thinking about TSH levels) that it will keep changing as more research is carried out and findings are revealed. The AACE (American Academy of Clinical Endocrinology...I am guessing) officially says that 3.0 is the upper end of normal. The real upper end of normal probably is more like 2.0.

So with alopecia and a TSH level of 3.6, you have more than enough reason to see an endocrinologist. I agree with Kit's advice to keep the appointment. Just be sure that the endocrinologist has a special interest in thyroid problems. Many endocrinologists focus mostly on diabetes and are scarcely more help with a thyroid problem than any other physician would be. There is lots and lots and LOTS of specialized knowledge that a physician needs to have in order to do a competent job of assessing someone's thyroid functioning, so watch out for yourself by auditioning the physician carefully.

[EmpatheticJenny]

One more P.S.: My comment about its being easier to find outdated information about the normal TSH range than it is to find accurate information applies to what you see in a set of laboratory results. During the first few months in which I was treated for a mild case of hypothyroidism (mild according to my blood values, not according to how I felt, for I was impressively unwell), the laboratory that processes my blood tests never flagged my TSH level as abnormal. Morale to the story: The TSH reference range that a lab uses may be a glaringly outmoded reference range.

[RCinNY]

Thank you both.

I fully understand the short-comings of trying to diagnose yourself and trying to find accurate medical information online.  I was just trying to see what the lab range should have been, and sure enough, when I googled the hormone as it appears on the report and "0.93-", I found a page with the identical range except it was 1.7 instead of 1.

Some background information...
I've always had a bit of anxiety and depression.  I don't treat them with drugs.  I finally told my primary doctor about it in 2003, had the thyroid checked, and was told it was normal.  But normal has changed since then and now, and I'd be curious to know what it was then (I never got a printed copy). The symptoms associated with anxiety and depression (keyed up, racing heart sometimes; lethargic others) seem like they can't occur within the same thyroid problem, so they might not be related to this saga afterall.

In fall '06, my blood pressure was kind of high at my last visit, but I haven't checked it since, those I've lost 20 pounds thru diet and exercise and am close to the weight I want to be now.  Maybe it's time to visit the primary again first...

Back to the point...
So what should I expect with the endocrinologist?  What do I ask and what tests should be run?  It seems, based on what little I've read, that testing for antibodies would be the next step.

Thanks,

[rayneweather]

Antibodies would be good as well as the tsh, t3, t4, free t3 and free t4.  It is possible to have by hypo & hyper symptoms as there is an autoimmune condition that causes a person to swing from one to the other.  Also making it difficult is that many symptoms appear for both hypo & hyper.  I know for myself that I can get fatigued and have body/joint aches if I'm hypo or hyper so the only way to tell is by bloodwork.  The endo might want to get an ultrasound of your thyroid if it is enlarged or they think you might have any nodules (they can be felt through the skin if they're large enough).  And I echo Jenny on making sure you have an endo that's well versed in thyroid problems - many of us learned the hard way.  I wondered why my first endo never gave me much info on my throid condition and seemed to be more concerned about getting my weight down so I didn't go from pre-diabetic to diabetic.  Hindsight is 20/20 :-)  Another suggestion is to write down a list a questions for the doctor so that you're sure you've gotten all the info you want and don't realize you forgot something when you're on your way home.  And don't be afraid to get a second or third opinion if you still have questions - it's not uncommon to have to see several doctors before finding one that you feel comfortable with.  Please keep us posted and welcome to the board.

Rayne

[EmpatheticJenny]

Dear RC,

Rayne's comments are excellent. I am writing to underscore her comment that many symptoms can mean either hypothyroidism and hyperthyroidism. The standard lists of symptoms--in my experience--do not give a person that impression. In fact, not until I became a forum member did I realize that I am not a freak in having symptoms of hypothyroidism and hyperthyroidism at the same time. I am not a swinger, in other words. :o) For example (and this is only one of many examples I could provide), I can have a very rapid heart rate and spend fifteen out of twenty-four hours sleeping, all within the same twenty-four hours.

By the way, I have been impressively unwell with a TSH level that never rose higher than 4.11, and I do NOT have antibodies. Endocrine problems are simple and straightforward for some people. For others of us, our out-of-whack endocrine system is not a straightforward or simple problem at all. If you see an endocrinologist who seems to be thinking simplistically, then he or she is not the physician you need.  I wholeheartedly back Rayne's advice not to be afraid to see as many endocrinologists as you need to see in order to find one with whom you can work well.

Please do keep us posted, as Rayne said, and I join her in saying "Welcome!"

Sincerely,
Jenny