Graves's and Hashi's?

[Dinahdo]

I had Grave's for five years and was told by an endo that I was in remission last August '16. That round of blood tests was the only normal round I have had in 7 years. I have been desperately searching for a doctor to help me with severe hypo symptoms and accordant low T3 (I can't get anyone to test FT3). I also have low FT4, although it is typically in the range, albeit the bottom 10%. The trouble is that my TSH is below normal. I asked one endo to test antibodies and he grudgingly tested TBI (high) and TSII (normal) but not TPOAb or TGAb - apparently I needed to specify that since I felt hypo I was concerned about those particular antibodies. Finally convinced my GP to run the tests and the results are:
TGAb - 260 (0-40)
TPOAb - 2575 (0-35)
FT4 - 1.23 (0.61 - 1.64)
T3 - 93 (87 - 178) note that T3 was as low as 66 in Jan and 83 in April
TSH - 0.02 (0.28 - 4.10)
I just saw a new endo who said I have Grave's because of the low TSH. Having had it for five years, I can assure you this does not feel like Grave's! She did an ultrasound and commented that it was heterogeneous and looked more Hashi than Grave's, but by the end of the appointment she was sticking with the Grave's diagnosis. She is suggesting I have my thyroid out, which I would do in a NY minute if I thought I would feel better after, but I'm not sure I will. She said she would prescribe T3 if needed as long as my TSH is in the range. As my TSH was always suppressed (<0.01) when on methimazole, regardless of FT4 or T3 levels, I am skeptical that even with TT, my TSH may never be normal and I'll be undertreated.
The fatigue, brain fog and memory loss are killing me. I am worried for my job. Oh, and I've gained 35lbs in less than two years and I've never struggled with my weight before!
Any thoughts on where to go next? The new endo has ordered a battery of labs including ANA (I'm guessing lupus?), B12, D, etc., but I had been taking a thyroid support supplement and she wants me off that for a month before I have the tests.
I did send a follow up email to clarify her comments in the ultrasound and she said I had Hashi's as well, but am not hypo.
Grrr!

[Red_Star]

I have Hashimoto's thyroiditis but for two months Graves antibodies showed up. This caused very hyperthyroid symptoms and also pretibal myxedema on my shin (this took a year to go away after Graves antibodies settled back down).  My labs however showed I was hypothyroid with a TSH of 6 (0.4 - 4.0) and free T4 at 13 (10 - 20) when I was VERY hyperthyroid. My thyroglobulin serum however was very high (due to being hyperthyroid).  The labs can get quite confused with Hashitoxicosis it seems.

Excerpt from Thyroid Disease Awareness - Hashitoxicosis...

"A probably diagnosis can also be made by thyroid antibody tests. In Hashitoxicosis, thyroid peroxidase, thyroglobulin, thyroid binding inhibiting immunoglobulins (TBII) and thyroid stimulating immunoglobulins (TSI or stimulating TSH receptor antibodies) will all be present.

Anyone who is genetically predisposed to autoimmune thyroid disease can develop Hashitoxicosis. It's not uncommon in one's lifetime to have HT, GD, primary myxedema and Hashitoxicosis at different times. According to some researchers, Hashitoxicosis is most likely to be encountered in the early stages of autoimmune hypothyroidism. Patients with GD who have achieved remission may actually be experiencing the early stages of spontaneous hypothyroidism when symptoms of Hashitoxicosis emerge."

[gimel]

In trying to diagnose a potential hypothyroid patient, the most important consideration is symptoms, followed by levels of the biologically active thyroid hormones, Free T4 and Free T3.  In addition there are a number of processes and variables that affect having adequate tissue thyroid levels and effects and being euthyroid.   It is not simply a matter of the TSH level, or even the FT4 and FT3 level.  Other factors are important also.  You can read about all this in the following link.  I highly recommend reading at least the first two pages, and more, if you want to get into the discussion and scientific evidence for all that is recommended.  Note especially Fig. 1, and its review, on pages 7 and 8.

http://www.thyroiduk.org.uk/tuk/TUK_PDFs/diagnosis_and_treatment_of_hypothyroidism_issue_1.pdf

So every diagnosis of potential hypothyroidism is a probability theory: it has a degree of uncertainty associated with it.  The ultimate test of the theory is a trial of thyroid med.  If symptoms improve with thyroid medication that adequately increases FT4 and FT3 levels, then the diagnosis is supported.

You have a number of symptoms that are frequently due to hypothyroidism.  Unusually, your TSH is suppressed, even though your FT4 is around mid-range, which is adequate and TT3 is low in the range.  If your Free T3 is similar in range to your Total T3, it is much too low, and the likely cause for your hypo symptoms.  The disparity between FT4 and FT3 levels indicate a conversion problem.  You are not adequately converting T4 to T3, or perhaps converting too much T4 to Reveres T3.  So you need to get the doctor to do additional tests in accord with Sugg. no. 4 on page 2 of the link.  Those would be Free T3, Reverse T3, cortisol, Vitamin D, B12 and ferritin.  Then you are going to need a doctor that will treat clinically, by adjusting your FT4 andFT3 levels as needed to relieve symptoms.  If the ratio of FT3 to RT3 is inadequate then that will also need to be addressed.  Since hypo patients are so frequently deficient in Vitamin D, B12 and ferritin, you need to test those and supplement as needed to optimize.  D should be at least 50 ng/mL, B12 in the upper end of its range, and ferritin should be at least 100.  I say all this assuming that the Graves' is truly in remission and no longer a factor.  

If you are unable to locate a good thyroid doctor that will test and treat as described, then perhaps we can suggest one that has been recommended by other thyroid patients in your area.