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Armour dosage and Hashimotos

Hi, all.  I've been away for a bit, but back with the usual dilemma.  No adequate endocrinologist and worse, no primary that understands thyroid issues.  I am currently on 150 mg Armour.  Below are my last two labs.  I see they are high.  They want me to reduce back to 120.  Would this be wise?  To be honest, I did cut back, this past week, to 135, based upon how I felt, but that was after the recent lab test.  I don't know if its coincidence, but I find I am more tired, and more depressed, but edgy and off, somehow.  
Anyway, thanks in advance, and here are the labs.

Draw on: 11/5/2019                                    Draw on:  12/20/2019

TSH <0.005    L                                          TSH <0.005    L
T4 Free  1.04                                              T4 Free  1.05
T3 Free  4.31  H                                         T3 Free  4.36  H

Again, any thoughts or advice greatly appreciated.  Thanks.
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Avatar universal
what are the reference ranges?

By ranges we typically see, you are a little high on FT3, but you are low on FT4, which is not at all uncommon for many people on Armour.

If it was me, I would consider adding in T4 medication and cutting the armour dosage.  I don't have a guess as to the dosages.  I think Gimel would better be able to help do the equivilent numbers.
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1 Comments
Thanks for the response. I forgot to include the range references.
T4, Free  0.76 - 1.46
T3, Free 2.18 - 3.98
I’m starting to think returning to synthetic t4 & T3 might be a better way to get this in range.
Avatar universal
You are at 41.4% of the range for FT4.  Typically like to see about 50% or higher.

Your FT3 is above the range but not by that much.  So I would think a small reduction in Armour (T3 component) might make some sense.  

Cutting Armour will also further reduce your T4 level as Armour does have T4 in it as well.

While effects of T3 dose change are pretty quick. It may still take time for your body to get used to the lower dosage.  

The fact that you are tired may be an indication of this adjustment.  But remember, there is a delayed effect of the reduction in T4 as well.  So again, that would be another reason why you ought to consider adding in a T4 dose.  As your FT4 level won't get better over the next several weeks of reduced Armour dose.

Something you will need to discuss with your Dr to get him or her to write a Rx for T4 dose.

My total complete wild guess would be a T4 dose of something like 50 mcg to start and see how it goes.  Then in about 6 weeks check the levels again and make adjustments as necessary. Based on symptoms and blood lab results.

Which is why I suggest adding in some dosage of T4 (synthroid or Levvo etc).
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Avatar universal
Before trying to answer, please confirm the time of day for the  blood draw, and also the time of day when you took your Armour med before the blood draw.  Also, even more important than test results, what symptoms, if any, were you having before the blood draw on 11/5
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I’ve been sick and not online. As always, the labs are drawn before 9 am and before daily dosing. A full 24 hours. Symptoms are always tired, and always hungry. Also. I began to feel edgy, at times.  Day napping is back. Since that lab, I’m taking 135 mg of Armour-even more tired.  And I’m thinking to revert to the separate synthetics, due to such imbalance last in armour. Not sure where to begin.
Avatar universal
FT3 is the gasoline that runs your engine (your body).  FT4 also affects the thyroid status due to its being converted to FT3,  So in assessing test results, we need to consider both FT4 and FT3 (and sometimes Reverse T3).   Since you did not take any thyroid med before the blood draw for those tests,  results represent what is called trough levels.    Most people  taking  desiccated thyroid med seem to achieve symptom relief when  trough levels of FT4 are in the lower part of its range, and FT3 is above mid-range.   From that standpoint your levels could be considered as somewhat high: however, everyone is different in their needs for thyroid hormone.  Since symptom evaluation is even more important than test results, before making any assessment about med dose I think we need to fully evaluate your symptoms.  I know you listed a couple, but please review the following list to make sure you don't overlook any.   Don't make any assumptions about whether these could be age related. Just identify which ones you have.  

Fatigue
Increased sensitivity to cold/  body temp. below 98.6 (which is considered normal)
Constipation  ( have to use fiber or laxatives)
Dry skin ( use moisturizer)
Weight gain/ difficulty losing weight  
Puffy face    
Hoarseness
Muscle weakness
Elevated blood cholesterol level
Muscle aches, cramps, tenderness and stiffness
Pain, stiffness or swelling in your joints
Heavier than normal or irregular menstrual periods
Thinning hair
Slowed heart rate
Depression
Impaired memory
Enlarged thyroid gland (goiter)
insomnia/sleep apnea/never seem to get enough sleep
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1 Comments
Hi.  Well, not to sound full of complaint, but I have most of the symptoms on this list.   I am often easily winded and the weight just never, ever comes off, not matter what, or how little, I eat.  My face is bloated, my joints and muscles ache.  In fact, the battle to get my right rotator and bicep repaired never ends.  
I was getting acute upper thigh/quad muscle/hip spasms and pain for quite awhile. It was scary, I must admit.  Needless to say, with my insurance, we never diagnosed that one, and I gave up.  Thankfully,  its has stopped, and not impairing my walking anymore.  Recently, I read similar symptoms., related to thyroid, somewhere else on the MedHelp site.  
Recently. the pain has switched to vein pulse /pain, deep in my left calf.  UltraSound is pending, for vein issues.  
I have to admit, the depression is off the charts, and all I want to do is sleep.   Today, discussing the return to synthetics with the pharmacy, it was suggested a compounding medication.  I am willing to try anything, as I am simply sick of not being myself, at all.  And again, I am so sorry to complain. I am just really tired of it all.
Avatar universal
Before I comment further, have you been tested recently for Vitamin D, B12 and ferritin?  If so please post results.   If not recently, then please post  any other results for those.  also are you taking supplements for  D, B12 and iron?  

Have you ever been tested for Reverse T3?
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No to the recent testing for B12, D3 & Ferritin. And no, I am not on any of those. Also, it was years ago, the testing for RT3. There was an issue, and he was going to have me on T3 only. I can’t recall how that went, except he began to discuss how the TSH never really moved, and mentioned Cushings. I left that endo, straight away! Lol
Avatar universal
So it sounds like you are stuck with your current primary doctor.  In order to get what you need, you are going to have to make a strong case that you are still hypothyroid, in spite of your Free T3 being above range, and of course they always get excited by a suppressed TSH.    The most important indictor for thyroid status is an evaluation for multiple signs/symptoms of hypothyroidism.  Doctors like to say that symptoms are non-specific; however, there are a number that occur more frequently with hypothyroidism than otherwise.  Your having a multitude of symptoms is very strong evidence for being hypothyroid still.  So I would start with the list of symptoms from Mayo Clinic at this link.  Make a copy and mark all those you have and give it to the doctor.  If the doctor wants to argue that your Free T3 and Free T3 levels preclude you being hypothyroid, just say if that is true, then what is the cause for all those symptoms, so that can be treated.  

I would also give him a copy of the Overview of my paper on Diagnosis and Treatment of Hypothyroidism: a Patient's Perspective.   You can find that by clicking on my name and then scrolling down to my Journal.    You can ask to be treated clinically, by raising your med dosage as needed to relieve hypo symptoms without go too far and creating hyper symptoms.   That sweet spot between hypo and hyper is called euthyroidism.    And that is what you need: to be clinically euthyroid.

I would also point out to the doctor that with desiccated thyroid med the Free T3 is always higher in range than Free t4, but your levels may indicate that your body is converting extra T4 to T3 in an unsuccessful effort to maintain thyroid function as best possible.   There are two possibilities that also come to mind to explain your many hypo symptoms.   I think you need to get a Reverse T3 test done, along with a Free T3 from same blood draw.  The ratio of FT3 to RT3 is a good indicator of tissue thyroid effects.   The other possibility that comes to mind is thyroid hormone resistance.  Our bodies don't always react adequately to thyroid hormone, requiring higher than normal doses of med.   Another reason why treatment must be based on symptom relief, not just test results.  Another issue could be low levels of Vitamin D which affects response to thyroid hormone.   Also low ferritin can also cause some symptoms that mimic hypothyroidism

Since hypothyroid patients are so frequently deficient in Vitamin D, B12 and ferritin you also need to get those tested and then supplement as needed to optimize.  D should be at least 50 ng/mL, B12 in the upper part of its range, and ferritin should be at least 100.

I have some other information that will be useful with the doctor, but for that I need your email.   So please send by PM by clicking on my name and then clicking on the send message button.
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Avatar universal
Forgot to give you this link.

https://www.mayoclinic.org/diseases-conditions/hypothyroidism/symptoms-causes/syc-20350284
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1 Comments
Thank you, gimel, for all this information. I saw the New in network endo.  He refused to test for RT3, does not do compounding and was kind of flippant about my weight issues. However, he wrote for 50 mcg Levoxyl and 25 mcg Cytomel,. Back to where I believe I was , a year ago. I’ll wait a few weeks, then see the out of network woman. I’ll print out your article for the Dr. I just saw. I was surprised he was in network as he was not, several years ago. He isn’t great, but he’s not as clueless as the “primary”, which is essentially, a residents clinic. Thank you again, as always, you are a godsend.
Avatar universal
If you want something to really impress your doctor, use this link.

https://www.hindawi.com/journals/jtr/2018/3239197/

Go to Fig. 1 and click on it and then look at fig. 1b.    In that graph the authors for the first time quantified the effect of Free T3 on hypo symptoms.   The graph shows that, on average,  even with higher doses of T4, symptoms only improve slightly.   To relieve symptoms requires Free T3 to be in the upper half of its range.   The lower line  (blue) is for Free T3 at  5.9 pmol/L, which is 57% of the range.   These data proves that Free T3 is most important for symptom relief and it needs to be in the upper half of its range, and adjusted from there as needed to relieve symptoms for the individual.   Give the doctor a copy of the graph.
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