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Hyperthyroidism and Symptoms

Hi Dr. Mark,

I was diagnosed with hyperthyroidism a little over 1 month ago.  My bloodwork showed that my TSH = .178, T3 Uptake = 25, and T4 Free Direct = 1.24.  I'm currently taking 20 mg of Methimazole and 75 mg of Toprol XL (just for the past week.  For the 2 prior weeks, I was taking 10 mg of Methimazole and 25 mg of Toprol XL).  My endocrinologist is telling me that my labs "aren't that bad", so she doesn't quite understand why I continue to have some of the symptoms that I'm experiencing (I feel quite anxious all of the time and have a hard time in certain settings (meetings, going to lunch with friends, etc.) I also feel shaky all of the time, dizzy, have significant neck pain which is causing tension headaches, pressure in my ears, etc.  Is this normal?  Should the Methimazole and Toprol help with these symptoms (given more time), or do I need to address these separately (such as taking anxiety medication, or muscle relaxants for the neck pain)?  I obviously would prefer not to be loaded up on medication, but I haven't really seen any relief with the current medication I'm on.
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Avatar universal
In response to the question of what is toxic Toxic nodular goiter, this is what I found on the internet:  involves an enlarged thyroid gland that contains a small rounded mass or masses called nodules, which produce too much thyroid hormone.


Alternative Names:
Toxic adenoma; Toxic multinodular goiter; Plummer's disease

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Avatar universal
hello all =)

if anyone has ever had ETS for hyperhidrosis, you can be sure thats where thyroid loss came from. And since Dr's do not inform anyone of this, i am informing all i can (took me 2 years to find this out)

take care
Alex
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Avatar universal
Just found out that I have Toxic Multi-nodular goiter.  Does anyone know what this means?  Can this be treated with ATD's, or does the thyroid need to be removed?  I'm 35, so I thought this typically occurred in the elderly??
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Avatar universal
Hi Dr. Mark,

I finally received my complete test results.

TSH (3rd Generation)
My Result = 0.312
Range = 0.35 - 5.50

TSH RECEPTOR Ab (TRAb)
My Result = < 5
Range = < 10
Description is as follows:  TRAB are measured in this assay by the thyrotropin binding inhibiting immunoglobin technique (TBII).  Results are reported as percent inhibition of TSH binding.
9% or less ..... Negative
10 - 15% ....... Indeterminate
16% or greater .... Positive
Positive results are consistent with autoimmune thyroid disease.

THYROID STIMUALTING IMMUNOGLOBIN
My Result = 94
Range = 0 - 129
Negative = 109% basal activity or less
Indeterminate = 110 - 129% basal activity
Positive = 130% basal activity or greater
Positive results are consistent with Graves disease.

ANTI-THYROGLOBULIN AB
My Result = < 20
Range = < 40

ANTITHYROID PEROXIDASE
My Result = < 10
Range = < 35

FREE T4
My Result = 1.0
Range = 0.8 - 1.8

FREE T3
My Result = 3.1
Range = 2.3 - 4.2

So, according to these results, I do not appear to have Graves or Hashimoto's.  Is that correct?

Are antibodies supposed to be present?  Does this signify some type of auto-immune disorder?

I have a thyroid uptake scan schedule for Wednesday.

Thanks again for the info.
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Avatar universal
Hi I have just been diagnosed with hashimoto's, and I'm wondering what to expect.
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Avatar universal
This question is for Dr Mark/Forum MD, and anyone else who may be able to provide some insight.

I just received my bloodwork back (independent study), and would appreciate assistance in interpreting the results:
Triiodothyronine Free = 3.1
Free Thyroxine (FT4) = 1.0
TSH (3rd Generation) = 0.312
Anti-Thyroglobulin AB = < 20
AntiThyroid Peroxidase = < 10
I'm still waiting on my TSI & TRAB results.

Just to quickly remind you of my history:
(1) 9/11/05:  Went to ER with heart palpitations and dizziness.  Based on bloodwork, the doctor told me I may be hyperthyroid.
(2) 9/12/05:  Visited PCP and was prescribed Propranolol (40 mg, twice per day).
(3) 9/15/05:  Follow-up with PCP.  Bloodwork showed TSH = 0.178; T3 Uptake = 25; T4 Free Direct = 1.24.  All other blood test results were in normal range.
(4) 9/21/05:  First visit with endocrinologist.  After examination, she indicated my thyroid was enlarged.  She switched me to 25 mg of Toprol XL per day (I was feeling extremely dizzy, so she felt Toprol was a better solution due to the long-acting nature of the medication).  She also presribed 10 mg of Methimazole per day.
(5) Symptoms for next 2 weeks included: Extreme anxiety/nervousness, pain in lower/mid-back, tension headache, irregular menstrual cycle (started 12 days early), loss of appetite, sweaty palms, diarrhea, tingling extremities.
(6) 10/5/05:  2nd appointment with endocrinologist.  Thyroid still enlarged (more so on the left side).  Due to symptoms, dr increased me Methimazole to 20 mg per day & Toprol XL to 50-75 mg per day.  Doctor ordered additional bloodwork:  T3 RIA (Total), T3 Uptake, T4 Total and TSH.  I have not seen the results.
(7) As of today, I continue to have the following symptoms:  Extreme anxiety (especially social anxiety), mood swings (irritable, emotional, roller-coaster feeling), hand tremors, ear pressure/pain, jaw pain/stiffness, sore neck (starts at shoulder blades and goes up through the base of my skull), headaches, achiness (almost like I have the flu), loss of appetite.  My tongue has also turned white.

I would appreciate any insight you might have.  I'd like to be prepared when I visit my endocrinologist next week.
Thanks!
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97953 tn?1440865392
MEDICAL PROFESSIONAL
Your thyroid function seems to be improving - I am not sure if you have Graves - let's see what the other antibody tests show.

You may have subacute thyroiditis which is a transient over-activity of the thyroid due to inflammation.  Tapazole doesn't help and usually patients go through a hypo phase 5-7 weeks after symptoms begin.  The way to document this is the I-123 uptake scan -- which is still the best isotope study for hyperthyroidism (side-note to ancientmariner) -- would need to stop tapazole x5days to do scan.
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97953 tn?1440865392
MEDICAL PROFESSIONAL
Remission is usually defined as one year of "normal" labs without needing anti-thyroid meds.  If you still need tapazole, you aren't quite in remission - the absence of antibodies (? TSH-receptor Ab's?) is a good sign.  Usually I treat with tapazole (or less commonly PTU) for 12-18 months, minimizing the dose to keep the thyroid labs normal.  If I cannot get a patient off anti-thyriod meds after 18 months I would usually recommend RAI.
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Avatar universal
Hi Dr Mark, hope you can see this question. When would you say a person is in remission from Graves? I've been recently retested for ABs and they came back negative. However, I still need a very low dosis of Tapazole (5 mg/daily) to keep my values within range. I have an appt to see my endo in 3 weeks, but wanted to know your opinion if possible. Thanks!
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Avatar universal
I read somewhere, and can't find it now, that the I-123 uptake is an outdated test and there is another, better method to determine Graves' for sure. Do you know anything about this? I'll keep trying to find the article. I've also read theories that Graves' IS the hyper side of Hashi's - an interesting theory, but haven't seen any studies.
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Avatar universal
Thanks again for the info.

I think I might try a new endo (or at least get a second opinion).  In the meantime, I'm doing some "independent" bloodwork, and requested (1) Antithyroid Antibodies (Thyroglobulin Antibodies and Thyroid Peroxidase Antibodies), (2) Thyroid Panel (Free T3, Free t4 and TSH), and (3) TRAb and TSI Combination Panel.  Hopefully this will help me figure out what exactly is going on.  Once again, thanks for the insight.
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Avatar universal
ATD means anti-thyroid drug therapy...medication that cuts down on the amount of thyroid hormone produced by the thyroid gland.
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Avatar universal
In looking at the tests my dr requested last week, she only ordered T3 (RIA), T3 Uptake, T4 Total, and TSH.  In reading your comments, this makes me question my confidence in her.  Why would she be ordering old tests?  Also, I asked last time if she would test for antibodies to see if I have Hashimoto's, and she said that my symptoms point to Graves, and we would know if I was Hashimoto's if I started having hypo symptoms.  Maybe I should find a new doctor???  Today, I'm feeling extra shaky (major hand trembles), and I have some anxiety. I wonder if this is caused by my symptoms, or the medication.
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Avatar universal
Also, to test for Hashimoto's, should I request the Anti-thyroid Antibodies test, or the Thyroglobulin/Anti-Thyroglobulin test?
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Avatar universal
Because that is still the "standard" thyroid panel.  But it's outdated because there are newer tests that give better information.  Quite honestly, lots of folks just have to educate their docs on these newer tests.

But her comments about Graves vs. Hashimoto's are just ignorant imo.  A person with hyper labs MAY have Hashimoto's.  Maybe she doesn't know that either.  

But the very best thyroid tests you can get are the TSH, Free T4 and Free T3 and TPO antibodies.  If you want to confirm Graves, a TSI antibodies test is necessary.

There are actually two thyroid antibody tests:  The TPO (thyroid peroxidase) and anti thyroglobulin.  Sometimes a Hashi's person has one or the other or both...but the TPO is a little bit more definitive according to some sources. If you can, go ahead and get both.  

As for your symptoms, without knowing what your Free T3 is..I'd find it hard to know whether it was your thyroid hormone levels or not.
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Avatar universal
What does atd stand for?

Pirate
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Avatar universal
many folks use the "independent" avenue to obtain the labs they need.  and it sounds like you have everything covered.
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Avatar universal
Just to add to ArmourGals last post, from what I have read, it seems as though the only way a person can feel better is if they go the "independent" way because most doctors treat by labs vs. symptoms.

Jenni
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Avatar universal
You are right. You need a new doctor for sure. The antibody test is really important right now and then an ultrasound, etc..  You also should not take any anti anxiety meds unless you want to open a whole new set of problems for yourself as they will never be your answer.  I know this first hand as they are very, very, addicting and not the answer to what you have going on.  You just need a good thorough docter right now.  Dawn
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97953 tn?1440865392
MEDICAL PROFESSIONAL
The best way to document Graves is a thyroid uptake of I-123 (nuclear medicine test) -- this is normal/elevated in Graves, and low in thyroiditis.

But -- the above only applies if the patient is HYPER -- the low tsh and normal t4 is usually subclinical hyperthyroidism and the uptake would be helpful.

Regarding antibodies - TPO and Tg can be positive in Graves AND Hashi.  TSI is more specific for Graves.  

Nomenclature in thyroid disease is complicated -- usually Hashi refers to destructive lymphocytic thyroiditis (chronic) from immune system attack and causes HYPO.

Hashitoxicosis is confusing as well -- I believe this to be a situation where there are both blocking and stimulating antibodies that attack the thyroid causing a flucuation between hyper and hypo (relatively rare).
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97953 tn?1440865392
MEDICAL PROFESSIONAL
I agree that your labs are less severe than your symptoms, but every individual is different.  It takes the methimazole 2-4 weeks to have a significant effect, so hopefully with the higher dose you will lower your thyroid levels soon to the point your symptoms abate.

The toprol is great for lowering heart rate, but some of the older beta-blockers (propanolol or atenolol) may be better for the shakiness -- would consider trying that before adding anti-anxiety meds (although I do sometimes use xanax, etc in graves patients initially as we are waiting for the anti-thyroid treatments to work).

Did your doc check the Free (or total) T3?  The T3Uptake is a different test (not used much anymore, but still part of the "thyroid panel").  Often Graves patients will make much more T3 than T4, so checking it may help draw a parallel between your labs and your symptoms.

If the levels "normalize" completely and you still have symptoms, ask your doctor to help you look into other causes.
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Avatar universal
TSI antibodies will confirm Graves Disease.  I can make a suggestion on this because I was treated for hyperT/Graves in late 2001-late 2003 with atd's.  Mine was methimazole.  Starting dose is 30 mgs or less, depending on severity.  TSH will stay suppressed, so you can't go by TSH.  What tests the dr should be doing are FreeT3 and FreeT4.  T3 and T4 which are the older, less usefull test just show what's circulating in the blood, and are considered bound hormones.  

FreeT3 and FreeT4, which are the unbound hormones are best to dose by.  About 4-6 weeks after the starting dose of atd's, if the FT3 and FT4 are going down, then it's time to reduce accordingly until you're on a maintenance dose.  In the mid to upper 1/3 range while on atd's is where most of us felt best while on atd's.  I could write a book on the mismanagement of anti thyroid meds due to a TSH test alone! This is a big mistake a lot of dr's make.  Elaine Moore has a book on Graves Disease called Graves Disease, A Practical Guide, and she's also on www.thyroid.about.com under the hyperT/Graves board.  Also, TSH lags behind 6-8 weeks but a lot of dr's have no knowlege of this.  

Doodaa
Formerly HyperT/Graves, now in remission and on thyroid replacement.  Oink!  :-)
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Avatar universal
Interesting!  I have another dr's appointment one week from tomorrow.  Should I ask that I have an antibodies test?  Are there any other tests I should ask for?  I had blood drawn last week, but I believe my doctor only ordered TSH, T3 and T4.
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Avatar universal
Hi tvfan. You know, you are the second person who's come on recently who's been put on anti-hyper meds, and the doc never did antibodies labs to CONFIRM that you have Graves! Granted, you could very well have Graves, but when you mention that you have neck pain, it makes me think you could also have thyroid  anti-bodies for Hashimotos disease, or thyroiditis! And your symptoms would be from being on the hyper swing.....IMHO.
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