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Do I need thyroid med increase?

Hi everyone!  Like your feedback/experiences with the following:

1) Is med increase warranted if TSH rose to the 4 to 6 level?  I've read that optimal range is actually around 0.2 to 1 which I never knew about before.  Symptoms of cold fingertips/feet, spurts of anxiety and muscle aches/pains, low bp (but ok).

2) Can elevated TSH/hypo also result in heart palpitations/PVC/anxiety? I've read that is more on the hyperthyroid side of the house, but if TSH shows hypo, how can that be?

Thank you!
7 Responses
Avatar universal
First off.  TSH is almost completely useless when trying to determine dosage.  however TSH as high as yours clearly suggests your dosage is too low.  ALL of your symptoms including PVCs and anxiety are or can be associated with Hypo.

I personally had PVC's that went away or substantially reduced after I started taking thyroid medication.

The tests you REALLY need are:

Free T 4
Free T3.

Like I said TSH is pretty useless, but a TSH above 3 would be suspicious of Hypo.

Commonly, in order to medicate to a level that eliminates symptoms, TSH is almost always suppressed.  This freaks out most Doctors and as a result MANY, MANY people are left under medicated and suffer symptoms needlessly because of their ignorance of how to properly treat thyroid patient.

The worst of the worst are Dr's who only test  TSH falsely believing that TSH alone is sufficient to base dosage decisions on.
1 Comments
Thank you!  Forgot to mention I am diag with Hashimoto for a few years now and basically been doing OK.  This is recent symptoms all combined.  I ordered my own full thyroid panel initially, where TSH was right near 6.  Rest showed:  free T4 at 1.4, TPO at 104, T4 at 7.5, T3 free at 2.7, and reverse T3 at 20.    When I had the PCP do labs a week later, they don't do full panel and now it shows TSH around 4.5, and free T4 down to 1.3, and free T3 at 3.

I agree...I got the email back that "TSH is in range", so going in to meet with them.
Avatar universal
The common assumption is that hypothyroidism is due to an "underactive thyroid gland", always correctly sensed by the pituitary gland and accurately reflected in the TSH levels secreted by the gland. This leads to the use of TSH as a surrogate for thyroid hormone levels and clinical criteria.   A comprehensive definition of hypothyroidism is "insufficient thyroid hormone effect in tissue throughout the body due to inadequate supply of, or response to, the hormones’.  

The reality is that except at extreme levels TSH has a negligible correlation with a person's tissue thyroid status. and related signs/symptoms that are the source of a patient's concern.   A patient should be diagnosed based on a full medical history, along with an evaluation for multiple signs/symptoms typical of hypothyroidism, supported with expanded testing.  Tests should include Free T4, Free T3 (not the same as Total T4 and Total T3), TSH, TPO ab if TSH is high, TG ab, if TSH is high and TPO ab is within range, cortisol, Vitamin D, B12 and ferritin.  

If hypothyroidism is diagnosed, then the patient should be started on replacement thyroid med adjusted adequately to relieve hypo signs/symptoms without creating signs/symptoms of hyperthyroidism.  That "sweet spot" is called euthyroidism.    So in answer to your first question, thyroid med dosage should never be adjusted based only on TSH.  If your doctor is unwilling to treat clinically, by adjusting Free T4 and Free T3 levels as needed to relieve symptoms, then you will need to find a good thyroid doctor that will do so..

In answer to your second question, those symptoms can be due to hypothyroidism as well as hyperthyroidism, so I think it is just an additional hypo symptom.  

What you need most is a good thyroid doctor that will adjust your Free T4 and Free T3 levels as needed to relieve symptoms, without being influenced by resultant TSH levels.  If you will click on my name and then scroll down to my Journal you will find an Overview of a paper on Diagnosis and Treatment of Hypothyroidism: A Patient's Perspective.  You can give your doctor a copy and try to get treated clinically, as described. If the doctor is unwilling to consider clinical treatment, then you will need to find a good thyroid doctor that will do so.
1 Comments
I will check it out, thank you!
Avatar universal
Your symptoms, "heart palpitations/PVC/anxiety", may in fact be atrial fibrillation. If you search online for "hypothyroidism and atrial fibrillation" you will find many references that show atrial fibrillation is associated with both hypothyroidism and hyperthyroidism. If you search hard enough, you will find case histories of hypo patients being relieved of these symptoms by raising their thyroid hormone dose (but not always).
P.S. if your TSH used to be in range, but now it is above range, make sure you are leaving a long enough time interval between when you take your morning med and when you eat or drink, to make sure you get full absorption of the med.
1 Comments
OK I will ask about that also (in addition to meds) if they want to do a holter monitor perhaps to be sure.  
It's always been above 2-3 while on meds (lowest was around 3, if I recall).  I do wait 3 to 4 hours before eating.
Avatar universal
TSH is irrelevant when already taking thyroid med.   Frequently it becomes suppressed when taking adequate thyroid med.   The suppression is due to taking the med in a short period as compared to a continual slow flow of thyroid hormone in the untreated state.   A significant dose of thyroid med will suppress TSH for the whole day.   So a suppressed TSH during treatment does not mean hyperthyroidism, unless it is accompanied by hyper symptoms due to excessive levels of Free T4 and Free T3,.

You haven't mentioned your thyroid med and dose so please tell us about that.  Also, please give us the reference ranges for FT4, FT3, and RT3 shown on the lab report.  
1 Comments
free T4 at 1.4, TPO at 104, T4 at 7.5, T3 free at 2.7, and reverse T3 at 20.  I'm at .075mcg right now (years ago started at .050cg, so this is now about a year)
Avatar universal
Need to know the reference ranges, since test results and ranges can be different from one lab to another.
1 Comments
Two different lab companies.  Here they are:
TSH #1: 5.9.  Range:  0.450-4.500
TSH #2: 4.25.  Range 0.40-4.50
T4F #1:  1.41.  Range 0.82-1.77
T4F #2: 1.2.  Range 0.8-1.8
T3F #1:  2.8.  Range 2.0-4.4.
T3F #2: 2.8.  Range 2.3-4.2.

Just saw the primary care doctor, and said TSH was up there but said that (I think) T4 is in the middle so doesn't want to increase meds.  Disregarded TSH as being important because of the other values.  
1756321 tn?1547095325
Excerpt from Mary Shomon's book Living Well Hypothyroidism...

"Thyroid Tests "Normal" But You Don't Feel Well?

If you're undiagnosed, or a thyroid patient taking thyroid hormone replacement medications, being in the "normal" range does not mean you feel well, or that your treatment is optimized. What levels are considered "optimal*" by many integrative physicians?

~ TSH - Typically less than 2.0
~ Free T4 - Top half of the reference range
~ Free T3 - Top half - top 25th percentile of reference range
~ Reverse T3 - Lower end of normal range
~ Thyroid Peroxidase Antibodies (TPO) - Within reference range
~ Vitamin D - Above 50
~ Ferritin - Above 60 (Above 80 if experiencing hair loss)

* we are all different, one size doesn't fit all, so these are guidelines. Your optimal levels may vary."

Just to add to that, the vitamin D listed above is in ng/mL so above 50 ng/mL converts to above 125 nmol/L.
2 Comments
thank you!
No worries. :)
Avatar universal
From your lab results I would say that your Free T4 is adequate, but your Free T3 is too low.  Free T3 needs to be in the upper half of its range, and adjusted from there as needed to relieve hypo symptoms.    Another way to look at it is to calculate the ratio of FT3 to Reverse T3.  Your ratio is 2.8 (multiplied by 10) divided by 20  which equals 1.4.  Sources recommend at least a ratio of 1.8, and some say 2.0.  So your FT3 is too low and RT3 is too high.   Instead of just increasing your current T4 med,  the best approach would be to add some T3 to your med, in order to raise your FT3.   This would minimize the possibility of additional T4 being converted to more RT3.

To try and reduce RT3, consider that reported  causes of reverse T3 dominance include a broad spectrum of abnormalities such as: “Leptin resistance; Inflammation (NF kappa-B); Dieting; Nutrient deficiencies such as low iron, selenium, zinc, chromium, vitamin B6 and B12, vitamin D and iodine; low testosterone; low human growth hormone; Insulin dependent diabetes; pain; stress; environmental toxins; free radical load; haemorrhagic shock; liver disease; kidney disease; severe or systemic illness; severe   injury‟, surgery; toxic metal exposure”

That is part of the reason why Vitamin D, B12 and ferritin  levels are so important for hypothyroid patients.   In addition to adding some T3 med, you need to test and supplement as needed.   Vitamin D  should be at least 50 ng/mL, B12 in the upper end of its range and ferritin should be at least 100.
1 Comments
Thank you!  This is great :)
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