Armour and low t4

[JennaS]

Hi, I hope someone here can give some insight. In November My labs were:
0.4 TSH reference range 0.5-4.7
0.73 FT4 range 0.73-1.95
2.5 FT3 range 2.3-4.2

I have been on Armour for a long time and had a RAI about 15 years ago. Armour works better for me but, I have been doing some reading about optimal levels and I am finding that maybe I am never in the optimal range.
From what I am reading these numbers look hypo to me, even though my TSH is showing more hyper. My doctor lowers my armour every time my TSH goes a little hyper. I am reading that a TSH can be suppressed when on thyroid treatment for a long time and that he should be looking at my Free T3 & T4s...if this is correct then I have probably been hypo most of my treatment...about 15 years!

I am 45 and on 90mg of Armour...I have additional 15mgs. that he says I can add if I feel like I need to. My problem is that whenever he says that my TSH is going hyper, I pull back down to 90mgs.  With that said, I just went back to look at all my labs over the past years...and I am always low on Ft4..it is always near the bottom of the reference range and the FT3 is usually always low normal as well. I adjust my armour based on TSH when the doctor calls. About once or twice a year he looks at everything and usually says that my TSH is hyper or normal and that my FT3 and FT4 or low normal

Is this normal for Armour...or could it be that I have been living in a constant state of hypo and just didn't realize it.
I have always had more anxiety than what is normal...I am not overweight, but I do get brain fog sometimes and sleep problems and recently other issues that I believe are thyroid related.

He did retest my TSH only in December and it was 1.4.
I started feeling bad again..high anxiety and panic attach feelings. I have now added the additional 15mgs. in a few days a week with the 90mgs.

I am considering adding the additional 15mgs everyday...I wonder if that is a good idea based on my labs?
Also I read somewhere that low ft4 can be secondary thyroid issues such as a pitiutary tumor.  Am I worrying too much???

Thanks for any advice.

[flyingfool]

Don't rule out changes in Armour. There is a lot of activity in other places due to the sale of the Armour brand and many people returning to Hypo symptos.

My wife is definately one of them it seems.  Despite a recent increase in dosage a coiuple months ago she has several returning Hypo symptoms.

Her Dr's believe her thyroid is no longer producing any hormone due to the effects of Hashi's. So I do not believe that is the issue.  SOMETHING is definately not working like it did.  And the symptom return issue seems to be timed almost exactly or shortly after the sale of the Armour brand company.  It is just too coincidental to not at least consider as a possibility in my wife's case.

The real "rub" comes in that our HMO will ONLY cover Armour.  So if we switch brand names we will have to pay out of pocket.

OPh and throw a new Dr. into the mix as our old Dr. left for another practice!!!!!

[gimel]

Your mention of being tired in the afternoon made me wonder if you are splitting your Armour dose and taking half in the morning and half in the early afternoon.  T3 reaches peak effect in about 3-4 hours and then diminishes, so it is best to split the dose in order to even out the effect over the day.  For that reason it is also best to defer taking your morning dose of thyroid med until after the blood draw, in order to avoid false high results.  
I seriously doubt that you are adequately supplementing with the ones you mention.  All the more important for you to get tested for D, B12, and ferritin and then optimize as I listed above.  

How did the ND decide you had iron toxicity?

[JennaS]

You may be right...I may be grasphing at straws, researching too much and stressing myself out!  My doctors nurse advised me to go ahead and increase my does of Amour to 105 mgs. 90+15mg and test in 6 weeks to see how it's working. So I am adding the additional 15mgs daily. Basically I feel pretty good most of the day. Towards the end of the day, I start to get tired, that's when a glass of wine helps, I must admit. By nighttime, I am tired, but my heart beats hard some nights. I imagine that my bloodpressure and pulse are probably high. I've always had good normal bloodpressure until my thyroid gets out of whack. Back in 2010 it would go upto 165/110!  I don't want that to ever happen again. I also am having a tingling feeling in my head; I remember that feeling also from 2010. I suspect that I am just very hypo; but my problems are that I tend to have opposite symtoms. For example, I have never had constipation; even when I had a TSH of 39, i had loose bowels.  I think Armour thyroid makes me regular...sometimes too regular. One important thing that my doctor did tell me is that even if I think I am hyper; I'm probably hypo, because I don't have a thyroid due to RAI. Hypo and Hyper symptoms seem to be closely related and if I'm not careful I can confuse them...and obviously so can  my doctor by looking at my TSH only!  I am probably researching too much and stressing too much over it. My nurse said that my doctor had done those tests awhile back for D, B12, Ferritin. and that he doesn't like to do them because they are expensive...I will ask for them none-the-less when I got at 6 week followup. I am supplementing with WholeFood Garden of Life B Complex, Vitamin C and Womens MultiVitamin.  I am also seeing a Natural Doctor, who recently told me that I have too much iron toxicity in my system and shes treating me with Standard Process Supplements. If I do indeed have iron overload does anyone know if that is that the same as Ferritin?  Has anyone here used muscle testing and Standard Process? I actually think it has helped me greatly with breast tenderness and some sleep issues; but I probably wont feel my best until thyroid levels improve. Thanks again and I'll try to be more patient for my 6 weeks testing.

[gimel]

What action did you take regarding increased dosage to increase your Free T4 and Free T3 levels?  The only test results you provided showed FT4 and FT3 at rock bottom of their ranges.  From a very long list of symptoms that may be related to hypothyroidism, this is the section on energy level and sleep.  
    Chronic fatigue
    Less stamina than others
    Long recovery period after any activity
    Inability to concentrate
    Sleep apnea
    Snoring
    Insomnia
    Need naps in the afternoon
    Weakness
    Wake feeling tired
    Frequently oversleep

I fear that you may be grasping at straws about changes in Armour Thyroid med.  Just my opinion.  Also, have you taken any action to get  tested for Vitamin D, B12 and ferritin?  Those are also very important.  

It seems that you have pushed all those issues aside and decided that it must be an adrenal problem.  Personally, I would work on getting FT4 and FT3 levels up to optimal, along with optimizing D, B12 and ferritin, and monitor the result of that, rather than assuming at this point that it is only adrenal related.  If you want to be sure of that you can get  diurnal saliva cortisol tests done.  Doctors don't want to run anything other than a serum cortisol test which is hard to interpret, due to the swing from morning to night that usually occurs.  You can get the saliva test done through online labs for about $140.

[JennaS]

Thank you all for the posts. I believe that after doing even more reading up and studying, that maybe I have weak adrenals as well. I think I probably have a double whammy of both hypo thyroid and adrenal fatique. One of my biggest concerns is that I often have a hard time going to sleep and then I sometimes wake up and can't go back to sleep, but what scares me the most is feeling my heart pounding when I lay down at night. I have had good energy during the days. I get alot done so at night, I should be able to lay down and fall asleep. My husband is fast asleep in no time and I toss and turn, sometimes for hours. I think this is a sign of high cortisol at night. I started taking 100 mg of Phosphatidyl Serine at night and that seems to help, but I think I will increase it to 200mgs at night. I wonder if I am stressing myself out by researching....or if something did change with Armour when it was bought and maybe it is just now affecting me. I know back in 2010 I was a horrible mess with the Armour shortage. Being undermedicated is likely contributing, but I wonder if it is possible to heal adrenals without adding hydrocortisone?  I did the blood pressure test and just doing that stressed me out. My blood pressure was 127/82 pulse 75 laying down and 124/87 pulse 89 standing.  I did the eye pupil test and to me it looks like my pupil flutters, but I'll get my husband to look at it when he gets home. Anyhow, I want to learn what I can do to feel better fast! Any suggestions or advice is so greatly appreciated. Blessings to you all!

[flyingfool]

Also understand that Armour or any Natrual Dessicated Thyroid (NDT) medication has a LOT more T3 in it than even your normal thyroid gland will produce.

I say this to keep in mind that it is not at all unusual that even with increased in NDT dosage, the FT4 level does not change a lot.  And it is therefore not unusual for the patient to need to ALSO add in a straight synthetic T4 medication in order to increase the FT4 level into the middle of the range.

At your current situation it is too early to tell if you will need to add the T4 as well or not.

I think directionally increasing your armour dosage made sense.  I also agree the next increase to 120 mg would make sense.

You also stated that you are taking it in THREE separate dosages.  While some people do that or find out they need to do it in order to feel well.  The majority of people seem to do it in two equal split dosages. Once in the morning and once in the early afternoon.  There is no problem with doing it in three dosages, other than the pain it is to have to remember three times instead of two.  Also it is harder to cut a pill in 1/3s rather than 1/2.

One last thing.  My wife also was in hypo thyroid undermedicated hell for YEARS.  And we are still having difficulties with Dr's.  And the HMO we are in, the DR who was FINALLY getting my wife to near optimization has left!!!  Now we have to "train" a new Dr as to how real life medicine works rather than what they were taught in school or in a book!

[gimel]

If the RAI completely destroyed all thyroid tissue, then your FT4 and FT3 levels are totally a result of the med dosage.  Assuming that, your Free T4 level being at .73 is .49 below the middle of the range.  So that would required at least a 50% increase in your Armour  dosage.  That much of an increase would also work for your Free T3, since at 2.5 you would need at least 30% to get it above mid-range.  So that would suggest that from your 90 mg (1 1/2 grains) of Armour, after your next round of tests, you should be asking for the next increase up to two grains of Armour (120 mg).  That is not quite a 50% increase but it fits with the available  increments for Armour.  

Since you are increasing to 105 already, waiting for 6 weeks should provide enough time for the increase to be fully reflected in your test results, and also provide some time for your Free T3 level to reflect both the dose increase and conversion from the additional T4 med.  Then you would be ready for the additional increase to 2 grains and see how that works for you.  

Be sure to consider what I mentioned previously about the importance of Vitamin D, B12 and ferritin.  Those need to be optimal along with optimizing your Free T4 and Free T3.

[JennaS]

I called my doctors office this morning to ask for a TSH, FT3, FT4, D,b12 and ferritin lab work to see where I am right now. I told the nurse that I want to increase my thyroid medicine and treat my low t3 & t4 because I believe I am in a hypo state and I would like to get them into the mid to upper range. She told me that my labs done in Nov. was good baseline for where I am on this dosage and that I can safely increase the additional 15mgs, to 7 days per week. I was taking 90mgs and sometimes adding  additional 15mgs about 2-3 times per week. I asked her, If I take a total of 105 mgs..which I will divide into 3 doses daily,could I add another 15 mgs safely..and she said no, that I will need to check labs at 6 weeks and then maybe add, otherwise she said I could start having palpitations. I do not have a thyroid due to Graves after the birth of my son 15 years ago and RAI.  I wonder if 105 mgs is enough to get my ft3 & ft4 up? If I decide to add the additional 15 mgs more on my own; at what interveral can i safely raise it? Is it best to wait until 6 weeks as the nurse suggested and test before raising it another 15mgs?  Also, does dividing doses make some people feel even more tired? I started last week dividing my doses and I must admit that I am not getting that initial jolt of energy in the moring that I used to get. Sorry for the very long post, but I greatly appreciate any guideance and insight.  Thanks so much!!! :)

[handsinclay]

Hi Jenna,

Just so you know you have a lot of company- that is when it comes to being under-medicated for years.  And not knowing there was an alternative.  Countless of others have had their meds constantly reduced because the TSH is suppressed.  I too have lamented how my life could have been more productive and happier, etc.  

So I am grateful that my hashi crisis this summer prompted me into action.
And Today I feel so much better!! I take a combo of levo and armour.  Because of this forum I am now in the know and grateful for each day again.  Moving forward I have promised myself to be more assertive with docs to feel my best.  And if one doc isn't a good fit, I'll find another.

My husband too now knows first hand how much my mood, BP, and energy is connected to my thyroid medicine being right.  He said that he will come with me to the doc to make sure they never under medicate me again.

The other thing, is that it is recommended is to hold off taking meds the day of the lab draw, until after the lab draw.  This way the Free T4 and T3 are truly "free".  

Best of luck. and yes keep the faith.

[JennaS]

I understand what you are saying. Back in 2010 when there was an Armour stortage, I got terribly out of whack...it caused emorous stress...as i was put back on Synthroid when I couldn't acquire Armour and I didn't handle synthoid well at all. I was a terrible mess for awhile...so much that my husband and my mother told me to quit googling my  problems and just focus on getting better and what the doctor could do. I eventually went back to Armour and started feeling more normal again..Thank God! I still believe Armour is a lifesaver! I took my husbands advice and stopped doing research. When my doctor would call and say, cut back on your Amour because your TSH is hyper..I would. When he would call and say that my TSh was normal, He would also say that my Ft4 and Ft3 was low normal....all I would hear was NORMAL. He would say if your feeling great, let's keep on the same course, if not call me to see what we can do. I would think because he said I was NORMAL, then it must be something else that is bothering me...such as too much stress, from life, too much anxiety, too much perimenopausal symptoms etc. I took his word as normal with my TSH to mean I should be ok with my thyroid, and it must simply be something else....now I am finding out otherwise!  I wonder how much normal life mal I have missed because I have been kept in a hypothyroid state.
Yes, I would say that we must be our own best advocate for our own healthcare and not be afraid to research it!   I must admit that I was afraid to research it because quiet honestly it does stress me out!!!

I am learning alot now and hopefully will be on the path to feeling even better than I ever thought I would.  I am going to work on getting my FT3 and FT4 in optimal range and getting them out of the cellar!  I believe I do have a doctor that will work for me...if only I had been more knowledgeable and known more,...perhaps I would be have been much better long ago. I am the one to blame for not knowing. However, I'll keep the faith and never give up!

[gimel]

Not sure what you mean by a secondary hypothyroid problem not diagnosed.  It is pretty clear to me that with your symptoms and your Free T4 and Free T3  being at rock bottom of their ranges, you need dose increases to adequately raise your levels.  

It is always best to understand enough about your medical problems to be able to be your best advocate for needed treatment; but no need to stress out over it.  We can provide you whatever scientific evidence you need to get your doctor on the right path, unless he is the type that is totally unwilling to consider being wrong.  If that turns out to be the case, then you need to find a good thyroid doctor.

[JennaS]

Thank you so much for that response!  I will get those test done as well...as it has been several years and my D and Ferritin was low then, but my b12 was high...so likely time to look into that again.

Does it appear that I am just under medicated; or could I have a secondary hypothyroid problem that he hasn't diagnoised?  I hope I am just under medicated..and not a secondary thyroid problem.

Just researching medical issues stresses me and makes my blood pressure go up!!

[gimel]

I can understand you being concerned because your doctor is not giving you the right advice on med dosage.  When a hypo patient is taking enough thyroid med, the TSH frequently becomes suppressed below the range.  That does not automatically mean you have become hyperthyroid, unless there are accompanying hyper symptoms, due to excessive levels of Free T4 and Free T3, which is certainly not the case for you.  Your Free T4 and Free T3 are at rock bottom of their ranges.  Members say that symptom relief required Free T4 at the middl e of the range, at minimum, and Free T3 in the upper third of the range, or as needed to relieve symptoms.  Whatever that does to your TSH is not a concern, and is basically a wasted test when on thyroid med.  

So I'd say you do definitely need to go ahead with the increase already approved and see  what that does for you.  I seriously doubt it will be enough based on your current lab results.  So you will need to have further discussion with the doctor and make sure he understands about TSH being suppressed so often when taking adequate thyroid med.  Here is info you can use.  


Fraser et al investigated the correlation between tissue thyroid activity and serum blood tests (TSH, free T4 and T3) and published their results in the British Medical Journal. The study authors concluded that “The serum concentration of thyroid stimulation hormone is unsatisfactory as the thyrotrophs in the anterior pituitary are more sensitive to changes in the concentration of thyroxin in the circulation than other tissues, which rely more on triiodothyronine (T3).” They found a suppressed or undetectable TSH was not an indication or a reliable marker of over replacement or hyperthyroidism. They state,

    “It is clear that serum thyroid hormone and thyroid stimulating hormone concentrations cannot be used with any degree of confidence to classify patients as receiving satisfactory, insufficient, or excessive amounts of thyroxine replacement…The poor diagnostic sensitivity and high false positive rates associated with such measurements render them virtually useless in clinical practice…Further adjustments to the dose should be made according to the patient’s clinical response.” (121)

The positive predictive value of the TSH, which is the likelihood that as suppressed TSH indicates over replacement or hyperthyroidism, was determined to be 16%. In other words, a suppressed TSH is not associated with hyperthyroidism or over-replacement 84% of the time, making it an inaccurate and inappropriate marker to determine appropriate replacement dosing.

Also, hypo patients are frequently too low n the ranges for Vitamin D, B12 and ferritin.  Low level can cause symptoms.  Low D and low ferritin can also adversely affect metabolism of thyroid hormone, so if not already tested I recommend it.  D should be about 55-60, B12 in the upper end of its range, and ferritin should be about 70 minimum.  So test and supplement as needed to optimize.