Hyper and Hypo at the same time?

[criswatk]

I was diagnosed with Hashi and have blood tests to support with antibodies anywhere from 1500 to 300 (both globin and peroxidase) depending on the day of the test.  Also have TSH levels between 4.3-5. Symptoms cover both hypo and hyper.  Weight gain, fatigue, heavy periods, intolerance to cold, but also infrequent heart palpitations, tremors(mostly in left hand), dry skin, hair loss, insomnia just to name a few.  Doctor (GP) ordered a thyroid uptake test to rule out Graves and get a better picture of what was happening.  Test came back normal for the scan but Hyper for the uptake test.  So now I'm really confused.  The blood test taken the same day showed my TSH at 4.8.  Antibodies consistant with Hashimoto's. The doctor recommended that I get Radioactive Iodine Therapy to zap my thyroid because he says it will give us a level playing field to start medication and will get rid of swings from hyper to hypo due to Hashimotos.  I haven't been able to find anything that supports this treatment.  I can only find RAI for treatment of Graves.  Does this seem to be the right approach or should I consider something else?  I've had untreated Hashi for probably 10 years and had definite swings between hyper and hypo.  Just didn't know it at the time and have never been on thyroid meds.  These recent seemingly conflicting tests though have perplexed me.  I also have quite a bit of memory issues, forgetfulness, like I'm preoccupied and miss stuff I didn't used to miss.  I'm 36 and have always been very sharp so this part scares me a little. I'm ready to start feeling better. help

[Mark Lupo, M.D.]

You are borderline hypo due to hashimotos based on the labs presented.  Any increase in TSH will stimulate iodine uptake by the thyroid -- so the I-123 uptake is slightly elevated -- the elevated uptake is often confused for hyperthyroidism BUT only thyroid blood tests can diagnose hyper -- the I-123 uptake helps distinguish between graves vs thyroiditis as the cause of the hyper (it's a little more complicated, but that's the big picture).  If the only reason you have been told you are HYPER is the elevated I-123 uptake then I believe this is not the case -- as stated before and by others the symptoms you have can be seen in hyper so we cannot use symptoms to diagnose hyper in this case.  Hope that helps.

Regarding the antibodies -- TPO and Tg antibodies are seen in both Graves and Hashimotos. TSI is seen primarily in Graves.  There is some confusion about people going from "graves to hashi" - this is not the case -- the antibodies are positive in both and the reason for the hypo in most graves patients is a history of RAI - a different cause of hypo than hashi (chronic lymphocytic thyroiditis).

[criswatk]

well - I think I need to go back and talk to him again before I go through with this treatment that is irreversible.  I was so confused by the Thyroid uptake results and of course I just want to feel better.  Are the numbers other than the high antibodies a year ago cause for concern?  Am I hypo even?  And when they talk about antibodies what does high titers mean?
I want to armed with as much information as I can so that I'm not stumped but hold my own in the discussion - thanks!
Also Dr Mark...can you explain how the high uptake can result even if you are hypo?  How does that work?  This is very helpful to me thanks for bearing with all my questions

[Mark Lupo, M.D.]

In thinking more about the increased I-123 uptake - this is common in hashimoto's thyroiditis which is likely the primary cause in your case.  Classically the hypothyroidism will cause lower uptakes but in the case of hashimotos (the most common cause of hypo in the US) there can be increased uptake.  Elevated TSH can also cause increased uptake, but most likely in your case it is the hashimotos.  Hope that helps and does not confuse further --- Again, I am not convinced you need RAI at this point....in discussing with your doc, ask about the evidence that there is a hyper that needs RAI -- if it's the increased uptake, ask if hashimoto's thyroiditis could cause this as well (it can) - then state that you are reluctant to make a permanent change to the thyroid and given the labs consistent with borderline hypothyroidism either monitor the situation or try some thyroid hormone as previously mentioned.  Your doc may be right that eventually a pattern is discovered of hypo/hyper but from what you've presented this is not yet proven.....

[Mark Lupo, M.D.]

None of these numbers show hyper and the I-123 uptake is sometimes elevated in hypo due to the increased TSH.  While RAI is usually curative with one dose and most people do very well with close follow-up I am not convinced based on what you have presented that it is necessary at this point.

[criswatk]

Here are the labs I have access to if it helps the discussion
March 2004

Thyroglobulin AB. 1065 H (range <41)

TPO AB 1560 H(range <35)

TSH 4.76 (range .3-5.7) old standards

Free T3 3.14 (rage 2.3-4.2)

Free T4 4.76 (range .3-5.7)



June 2005

T3 uptake was Low 25.9% (range 27-37%)

T4 9.3 normal (range 4.5-12.5)

FTI calculation 7.5 normal (range 4.6-10.9)

free T4 1.13 normal (range .8-1.8)

tsh serum normal 3.4 (range .4-5.5) old standards

didn't do thyroid antibodies this time

November 2005

thyroid antibodies were both in the 300's

TSH 4.68

November 2005

Thyroid uptake test 34% after 24 hours (Hyperthyroid) - radiologist used my lab results as well as a scan to determin that diagnosis.

There they are...I also have high heart rate hovering around 100 beats per minute and also have high cholesterol.

[criswatk]

The common thing I keep hearing from people who have gotten RAI is that as a result they got Hypo, which was expected but the doctor's they have are not responsive anymore to their symptoms.  I've read 5 books on thyroid issues and it appears that RAI is safer than surgery because there is the risk in surgery of damaging the parathyroid gland that could damage your ability to process calcium? And also damage vocal chords.  There is the added risk of the surgery itself and the fact that you'll have a scar on your neck.  
The RAI is much less invasive.  They've been doing it for 50 year's in the US with no clinical evidence that the radiation has any negative results to the rest of the body.
Correct me if I'm wrong but it seems to me that people regret having the treatment because their doctors don't do good follow up.  My doc told me I could have a standing blood test order and could have one once a week if I wanted and he would work with me to keep my levels where they were comfortable to me.
My only fear is that for some reason I would lose a doctor that was so responsive.
Its a final step though and that is what scares me a bit.  no turning back...I don't want to get fat and even more tired.  When I told my doctor that he said that I wouldn't and that we would work to make sure I felt good....SO....my main question is how is it possible to have a hyper uptake (34% after 24 hours) and a TSH of 4.68 and test positive for Hashimoto antibodies.  Hmmm