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Thyroid Disorders Community
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Avatar universal

High RT3/Interpreting lab results?

Hello,

I'm a 23 year old female diagnosed with hypothyroidism (non-hashimotos) about 3 years ago. Trying to get on the right dosage/medication for about 2.5 years now. Have been on Nature-Throid for the past 1.5 years. Have been working with my doctor to titrate. Current dose:  227.5 mg M/W/Fri/Sun and 113.75 mg T/Th/Sat for the past 3 months. Previously was taking: 227.5 mg daily. I have felt better on naturethroid rather then when I was on Levothyroxine, but still so fatigued, inability to get back to my pre-hypothyroid weight despite my healthy lifestyle, and overall feeling "not right".

Urged my doctor to test a FULL panel for the first time, and here were the labs.

TSH: <0.006 (ref range 0.45-4.5)
FT3: 4.1 (2.0-4.4 pg/mL)
FT4: 1.31 (0.82-1.77 ng/dL)
RT3 Serum: 26.5 (9.2-24.1 ng/dL)
T3 Total: 188 (71-180 ng/dL)
T3 Uptake: 23 (24-39%)
Thyroglobin Antibodies: <1 (range < or = 1 IU/mL)
Thyroid Peroxidase Antibodies: 1 (<9 IU/mL)

Also tested:  Ferritin, Vit D, B12, Cortisol, and Iron.

Ferritin: 38 (15-150)
Iron Serum: 79 (27-159)
TIBC: 281 (250-450)
B12: 1105 (200-1100) have since backed down from taking b12 supp every day to 1-2x per week!
Vitamin D 1,25(OH)2 Total: 56 (18-72)
Vitamin D 25 OH Total: 67 (30-100)
ACTH plasma: 18 (6-50)
Cortisol: 9.0 (4-22) taken at 9 am.


Can a poor ft3/rt3 ratio cause hypothyroid symptoms even when ft3 is in a good spot? My ft3 has never been this high (normally ~2.9-3.0) and yet I haven't felt my thyroid symptoms lessening. How does one treat high RT3?

I have an appointment with an endocrinologist in 2 weeks, and am trying to be prepared with information before I go!

Thanks for your time and help.
17 Responses
Avatar universal
There is much to discuss, but first please answer a couple of questions.   Assuming from your data that the blood draw for all those tests was at 9 a.m., did you take your thyroid med in the morning before the blood draw?  If so, what was the amount of NatureThroid you took that morning?
2 Comments
At 9 am I did the cortisol, vit d, iron, b12, ferritin, tibc, and acth.

I realized I took my medication that morning at my normal time of 4 am, so they had me come back later in the afternoon for the thyroid panel. I came back and had it done at 3 pm.
I took 113.75 mg of nature throid at 4 am that morning, got my lab done at 3 pm.
Avatar universal
Although many doctors don't accept RT3 dominance, it does exist and can cause hypothyroidism.  Excessive RT3 is a conversion problem, not a direct thyroid deficiency.  Due to your high RT3 level your ratio of Free T3 to RT3 is 1.55.  Recommended level is more like 2.0 min.  There are a number of postulated causes of RT3 dominance, one of which you exhibit, which is low ferritin.  Ferritin should be at least 100. Low ferritin can also contribute to fatigue.    A good supplement is Vitron C which has iron plus Vitamin C to prevent stomach issues with the iron.  

From your NatureThroid dosage of 227.5 taken 4 days a week and then 113.75 taken 3 days a week, that averages out to about 2.75 grains daily.  Why in the world would the doctor dose you that way.  It makes no sense when T3 has a half life of less than a day, which means that you get the peak effect on serum levels in 3-4 hours and then it dissipates.  So taking 3 grains 4 times a week and 1.75 grains the other 3 days would lend itself to feeling worse on 3 days than the other 4 days.  Uneven doses will work for T4 med because it has a half life of about a week, but it makes no sense with T3.  I have to conclude that your doctor is not very knowledgeable about T3.  

So the first thing I recommend is to discuss with your doctor that you need to change your dose so you have the same dosage daily.  In addition you need to get your ferritin level up to at least 100, to minimize any effect on conversion of T4 to RT3.  While changing your med dosage the doctor could also consider reducing your NatureThroid dose and adding some T3.  That would decrease the amount of T4 available for conversion and the additional T3 would be to keep your Free T3 level near the high end of the range.  

If your doctor needs some encouragement to consider making these changes, I highly recommend reading at least the first two pages of the following link, and more if you want to get into the discussion and scientific evidence for all that is recommended.  Note on page 12 Rec. no. 9 related to RT3.  

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

I also noted that your cortisol is somewhat lower than optimal.  Is that why you are taking your med at 4 a.m. in the morning?   Even so, why not at least split the dose and take some later in the morning and early afternoon as well, in order to even out the effect of the T3 over the whole day?

You mentioned an appointment with an Endo in 2 weeks.  I hate to rain on your parade, but many Endos specialize in diabetes, not thyroid.  Also, many of them have the Immaculate TSH Belief, by which they really pay attention to only TSH, and would tell you that you are overdosed because of your suppressed TSH level, and will automatically want to reduce your med dosage.    This is of course wrong.  Endos also tend to use Reference Range Endocrinology, by which they will tell you that a thyroid test anywhere within range is adequate.   This is also wrong.  So unless you have specific information that the Endo is a good thyroid doctor that will test for FT4, FT3, and RT3 and accepts the possibility of RT3 dominance and will treat accordingly, then I have very little optimism for that Endo.  Since your current doctor is willing to prescribe desiccated thyroid med, which is better than most doctors will do, and has not reacted incorrectly to your suppressed TSH level, it may be that your best bet is to give him a copy of the entire paper and references linked above and ask him to read and consider the suggestions above, that are consistent with
recommendations in the paper.  
1 Comments
Hi Gimel,

That seems to be what I've experienced when going to Endo's as well. I'm hoping this one will listen to me, I will absolutely ask her about making my thyroid dose consistent daily and getting ft3/rt3 ratio in a good place. Originally I was on 226 mg/day but my first set of labs pointed to being overmedicated due to my total t3 and free t4 being way above range. Unfortunately my FT3 wasn't tested at that time. I also was very hot/borderline sweating all the time on that dose.

Thank you for the link, I'm going to study it/ print it out and bring it with me and reference it.

My doctor told me my ferritin was "normal" but I've also read it should be at least 80-100 for thyroid health. I've since started a chewable iron with vitamin c.

I for sure want to lower my NDT and add in Cytomel, if my endocrinologist refuses I will ask my PCP. If both refuse I will be on the hunt for a new doctor. I didn't get to choose the endo I go to, my pcp just made me an appt with one of her choosing. My pcp is really great and listens to me but doesn't seem to be well versed in thyroid treatment other than the standard.

For the dosing, I take my med at 4 am due to an early work schedule so it's just more convenient for me. Would splitting up the dose be helpful?

Regarding cortisol, my doctor says it's normal but I also thought it was low. I am totally at a loss as to how to regulate cortisol, as I know adrenals have to be addressed when trying to fix a thyroid issue.

Thanks for all your help, I guess all I can do is visit this next endo with a plan of what needs to happen and if it doesn't work out go back to my gp or find a different doctor...
Avatar universal
If you have a very early work schedule, the your Circadian rhythm for cortisol may have been affected by that schedule, along with taking the med at 4 a.m.  Cortisol level is highest around the time you get up in the morning and that could be the reason for a diminished result at 9 a.m.  With your schedule, the reference range for cortisol should probably be more like the lower one shown for mid-day for other people with more normal work schedules.  

So in order to determine if there is a cortisol issue,  I think it would be a good idea to do some further testing.  The best test is the diurnal saliva cortisol (free cortisol) panel of 4 tests taken at different times of the day (on awakening, about 4 hours later, around 5 hours later, and finally at bedtime).  You will likely have difficulty getting a doctor to order those.  If so, you can get those done yourself through an online lab.  Cost is less than $150.  Before doing any further cortisol testing however, I think you should get your dosage corrected and also start splitting the daily dose.  Then, after stabilizing the changes, would be the best time for further cortisol testing.  

From what you have said it sounds like that with some persuasion/direction from you, your current doctor is a better prospect to get what you need than the Endo or even looking elsewhere for a good thyroid doctor.  They are hard to find.  As a contingency plan, you might consider going ahead and giving your doctor a copy of the full link above and ask him to read it and work with you to get your dosage modified and consistent day to day.    Reducing the dosage of NatureThroid will reduce the T4 available for conversion to RT3, and improve your FT3 to RT3 ratio.   The reduction in T4 should be offset by an increase in T3 med.  Going to a consistent dose every day will also definitely help even out the effect of the T3 med over the day.

Please keep in touch and let us know how you are doing.
1 Comments
The cortisol was taken on one of my off days from work, I had woken up at about ~8:00 am that day and the test was at 9 am. However yes usually I'm up for the day by 5! I will look into purchasing the salivary cortisol test myself after my medication is more stable as I would rather test and know for sure.

If the endocrinologist appt goes poorly I'll just follow up with my Gp and give her the information. It seemed like she felt uncomfortable changing my medication without referring me to a specialist first.

I will definitely keep this updated with what happens!
Avatar universal
Now that you know that doctors are not infallible maybe you should consider going back and questioning your original diagnosis of hypothyroidism. Long-term it would be much, much better if you did not have to take these thyroid meds. Failing that, I think you are fairly close on your thyroid meds, so any changes you make should be one change at a time, "baby steps". A small change in your Naturethroid dose will make quite a noticeable difference in your labs.

Your average 178.75 mg per day of Naturethroid contains 104.5 mcg T4 and 24.75 mcg T3. For comparison a normal person's thyroid gland produces 90 - 100 mcg T4 and 6 mcg T3. You can see that what you are taking is about right for T4 but somewhat heavy on the T3.

Do your lab results make sense in light of what you are taking? I think the answer is yes. Your total T3 and free T3 are both at the very top end of their range, due to the high amount of T3 you are taking. Your FT4 is about mid-range due to the near normal amount of T4 you are taking. Why is RT3 high? It's a little more complicated. Normally your body converts T4 to T3 and RT3 in approx equal amounts. But your body is getting most, if not all the T3 it needs from the T3 in the Naturethroid; therefore your body does not need to convert nearly as much T4 to T3 as normal. Your body is protecting itself from excess T3 by converting more T4 to RT3. You do not have a "conversion problem", your body is doing a normal job of protecting itself.

What to do? For the first step I would only move to a constant amount of Naturethroid daily, then repeat the thyroid labs after about 4 weeks. You may find this moves all of the thyroid labs into range.

I'm afraid I do not see the rationale for decreasing the Naturethroid and adding T3. More to the point would be to decrease the Naturethroid and add T4 so that the ratio of T4 to T3 that you take is closer to natural.

On testing for cortisol, I suggest that you check out the DUTCH urine test, which is relatively new. It is easier to do and you get more information - you get an indication of total cortisol production as well as free cortisol. Thus you can determine if your free cortisol is low due to low cortisol production or due to some other reason.
1 Comments
telus2
I have a different opinion is several areas that we need to discuss, in order to keep from confusing mhanan4.  First she was originally diagnosed as hypothyroid based on having many symptoms that are typically related to being hypothyroid.  She also had a high TSH, likely indicative of Hashi's, although not tested at that time for antibodies.  So I see no potential benefit to going back and questioning that.

Second you really can't determine the need for thyroid med based on the average output of natural thyroid hormone, due to effect of absorption of the med.  For that and other reasons, thyroid med dosage is basically irrelevant.  Only the physiological effect on the individual patient matters.  

Third, her med dosage does seem to be about right based on having a FT4 near mid-range, and a FT3 in the high end of the range, which is typical for hypo patients taking NDT adequate to relieve symptoms.  Although I am not sure it is necessary, I have no problem with getting her dosage the same each day and splitting the dose to even out the effect,  before making any further changes.  

As for RT3,T4 med itself can cause excessive conversion to RT3.  "Other postulated 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,  hromium, 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”  I don't see her FT3 level as being excessive, nor have I seen scientific evidence that it would cause excess conversion of T4 to T3.  If you have such info please provide a link.  

I have personally experienced RT3 dominance that I corrected by reducing my NDT dosage and adding T3 to compensate.  That is further reason why it was suggested to this member.  

Thanks for the info on cortisol testing.  It would be interesting to evaluate those results compared to the info gained from a diurnal saliva cortisol panel.  

.
Avatar universal
Gimel
1. I don't find any reference to a  high TSH, or symptoms, prior to the reported diagnosis of "hypothyroidism (non-hashimotos)". All I am saying is that if there was some other condition that could be causing the member to be hypothyroid, then that condition should be addressed, with the hope that the hypothyroidism would be resolved.

2. I believe that average output of natural hormone does give you a basic reference point (for any type of hormone replacement therapy) and, yes, one has to allow for less than 100% absorption.

3. Re constant dosing: I think that to overdose one day and under-dose the next and  expect the patient to feel "just right" is highly questionable.

4. RT3: In my opinion, high RT3 in hypothyroid patients is mainly due to the thyroid hormones that they swallow each day and subsequent conversion of those hormones in various organs.

Let me clarify my statement in my earlier post, where I said, " Your body is protecting itself from excess T3 by converting more T4 to RT3." I did not mean that the current level of FT3 was necessarily excessive. However FT3 is high normal and TT3 is above the reference range, meaning it is above the level of 95% of the normal population. These higher than normal levels are being recognized and the body is responding by converting proportionately more T4 to RT3 rather than T3, compared to normal, so that T3 does not become excessive.

Why do I believe that? The following are excerpts from the reference below. Type 3 deiodinase (D3), the main physiological inactivator of thyroid hormone (TH) , catalyzes the conversion of T3 and T4 to their inactive derivatives, T2 and reverse T3 (RT3). This enzyme is thought to control TH homeostasis by protecting tissues from excess of TH. Being positively regulated by TH, D3 represents a powerful mechanism by which increased TH inactivation participates in TH homeostasis in thyrotoxic states.

In other words the D3 enzyme is regulated higher in response to higher levels of thyroid hormone, resulting in increased conversion of T4 to RT3 in order to protect from production of an excess of T3.

Also I believe that there is anecdotal evidence to support this. I have seen cases on blogs where people are feeling hypo and take higher and higher T4 or combo T4/T3 doses but their FT3 refuses to go up. Finally they get a RT3 test and find it very high. The natural defences of their bodies are protecting them from becoming hyperthyroid by taking too much.

A final comment. I have seen a number of people suggest that the RT3 test provides little or no value in management of thyroid hormone replacement. My opinion is quite the opposite. A high RT3 can indicate that too much thyroid hormone or an unbalanced combination is being taken. This is especially useful when taking NDT, where the TSH is driven very low and cannot be used as an indicator.

reference: "Local impact of thyroid hormone inactivation Deiodinases: the balance of thyroid hormone", Monica Dentice and Domenico Salvatore, 2011.
Avatar universal
telus2
1.  When I looked back to the very beginning info on this member I saw a high TSH, but it was never confirmed with antibodies testing at that time.  

2.  The average output of natural thyroid hormone for a group of people is at best only a rough idea of the actual dosage required by an individual, for several reasons.  First is that individuals have different "set points" for thyroid levels, at which they feel best.  Second, is the absorption issue.  Third is that due to conversion, the ratio of circulating levels of FT4 and FT3 are different than the output ratio from the thyroid gland.  So comparing the ratio of natural thyroid hormone production to the ratio of NDTs is not a good evaluation of dosage.  The ratio of T4 to T3 in NDT is actually very close to the ratio of circulating Free thyroid levels levels after conversion.  Fourth is that scientific studies have confirmed that thyroid med adequate to just return TSH and FT4 to "normal" levels for a patient will result in Free T3 levels that are significantly lower than would be expected.  Even increasing T4 med to drive FT4 to the top of the range or beyond does not always assure adequate FT3 level for many patients.  In the words of an excellent thyroid doctor, " in tests done about 24 to 28 hrs after their last daily dose, most people on adequate NDT therapy have a suppressed TSH. They usually have FT4 levels that are 1 to 1.3ng/dL, and free T3 levels that are rather high in the range or even slightly above the range. The higher FT3 level compensates for the lower FT4 levels on NDT. These patients have no symptoms or signs of hyperthyroidism--if such occur the dose is reduced."

3.  Totally agree about the need for consistent dosing and suggested that, along with splitting the dose.  The doctor who prescribed different doses on alternate days  clearly does not understand T3.

4. I respect the right of everyone to their opinion, but not their own facts.  So that is why we try hard to make sure members are given only factual information supported by scientific evidence.   I have gone through the reference you provided and find there are several things that make me question using that as the supporting evidence to conclude that the member's Reverse T3 level is due to excessive Free T3.  First the hypothalamus/pituitary system responds to FT4 and FT3, not Total T3, and the member's FT3 is not anywhere near excessively high.  Second, in the reference you gave, it states that, "Thus far, D3 activity has been identified in only a limited number of postnatal tissues, i.e. brain, skin, and pregnant uterus, whereas it is abundantly present in fetal tissues."  Also stated, "Being positively regulated by TH, D3 represents a powerful mechanism by which increased TH inactivation participates in TH homeostasis in thyrotoxic states."  Again, there is no thyrotoxic state here.  

As for anecdotal evidence, you can find enough of that to prove anything you want.  I have anecdotal evidence of just the opposite.  As mentioned I became hypo again due to RT3 dominance.  At that time my FT4 was slightly above mid-range, and my FT3 was slightly above range.    I corrected that, not by reducing T3, but by reducing my NDT dosage and adding T3 med to raise my FT3 level.  And it worked for me.  If my high RT3 level was due to excessive FT3, this approach certainly would not have worked.  

I appreciate our discussion and I am not trying to be argumentative, but instead, just make sure the member gets the best info we can all provide.  For all the reasons given, for this member  I just don't see the rationale for recommending the addition of T4 after reducing the NDT dosage.   Instead, adding a small amount of T3 med after reducing the NDT dose will both reduce the amount of T4 available that can be converted to RT3, and also help short term with the FT3:RT3 ratio.  

And by the way, several scientific studies have shown that TSH becomes suppressed for the majority of patients taking thyroid hormone adequate to relieve hypo symptoms.  So TSH should never be used to determine thyroid medication dosage.  You can find all that in the link I gave above.  
Avatar universal
Gimel:
I assure you that I have as much interest in separating fact from fiction as you do. I will try to explain the concept that I am trying to convey as succinctly as possible.

1. I think we can agree that elevated RT3 levels are associated with higher doses of T4. See for example the 1984 study cited below, where of 25 children who were considered to be over-treated with T4, 92% were found to have elevated RT3.

2. I think that we can agree that abnormally high T3 is not associated with over-treatment with T4. See for example the same 1984 study where 96% of the over-treated children did not have elevated T3 and all lacked overt hyperthyroidism. Even in your 2016 paper we find, "Under some conditions, including L-T4 medication in some patients, excessive RT3 will be produced, along with less T3 (page 12)."

3. I think we can agree that elevated RT3 is not a good thing for hypothyroid patients on T4 medication. Again from your paper, "There are however reports that link patients suffering from a range of hypothyroid symptoms to prolonged elevated RT3 levels (page 12)."

4. I now present my concept in the form of a hypothesis: Consider the case of an athyreotic (no thyroid) patient who is otherwise normal.  If that patient is subjected to stepwise increases of T4 medication, we will find that at the beginning lower levels of T4 medication the rate of conversion of T4 to T3 and to RT3 will be similar to 'normal people'. And as the T4 medication level is raised, we will eventually find a level at which the rate of conversion of T4 to T3 and RT3 will begin to shift more in favour of RT3 and less in favour of T3. And as the T4 medication is further increased, the rate of conversion of T4 to T3 and RT3 will gradually increase more and more in favour of RT3 and less in favour of T3.

5. I believe that the 2011 paper that I previously cited is supportive of the above hypothesis by providing a possible mechanism for it to happen. The mechanism being the gradual up-regulation of D3 enzyme in response to gradual increase in thyroid hormone (due to increasing T4 medication), resulting in gradual increase of conversion rate of T4 to RT3 (and less T3) and also a gradual increase in the rate of conversion of T3 to T2, all of which is happening as a natural defence mechanism to prevent the patient from becoming hyperthyroid.

I believe that the situation for member MHANAN4 is an intermediate case where TT3 has crept up to top of range and as a result RT3 has also crept up to top of range. However her body may be responding to the very high dose that she takes on alternating days and the RT3 might decline if she changes to a constant average dose.

To me the importance of all this discussion is that, if true, then the RT3 test rises in importance to all thyroid patients as an easy way to determine if a patient is taking too much T4, especially in cases where FT4 and FT3 may not be particularly high. In this respect I believe that the situation of recent member DOUGH5632, where she is taking a highish dose of 150 mcg T4 but suffering from hypothyroid symptoms is probably that she has crossed the point into taking too much T4, her RT3 is probably very high, and increasing the T4 dose will probably not help matters. And a simple RT3 test could prove it one way or the other.

I'm interested to hear your opinion. Thanks.

1984: The importance of reverse triiodothyronine in hypothyroid children on replacement treatment, Desai M, Irani AJ, Patil K, Pandya CS, Arch Dis Child. 1984 Jan; 59(1): 30–35.
Avatar universal
telus2
1.  I agree that excessive doses of T4 can cause elevated RT3.  

2.  I agree also.  In fact one of the co-authors of the paper has published several studies showing that L-T4 treated patients find that their FT3 lags significantly behind their FT4 levels.  

3.  Agree.

4.  and 5.  I agree about the mechanism of conversion of FT3 to RT3, and T2.   I also agree that it is likely that at some level of FT3, the conversion starts increasing even faster than the actual increase in FT3, as a protection against too much FT3.   However, we have no idea at what level that starts, nor whether it is a linear function or other.  The area where I disagree is the assumption that the member's RT3 level is caused by her FT3 level being at 87.5% of its range.  That does not fit with the experience of taking NDT med.  Due to the higher ratio of T3 to T4 than natural thyroid hormone, It is quite normal for a person taking NDT med to find that their FT3 is higher in its range than the FT4 level.   From my own experience over many years I saw the member's level to be quite normal for taking that much NDT med.  I saw no reason to suspect that the FT3 level was excessive and causing a high RT3 level.  I have personally experienced FT3 levels much higher, even well  over the range, while having a normal RT3 level.  

So, yes at some point the conversion of FT3 to RT3 and T2 will accelerate over the residual low rate.  But we have no evidence of where conversion starts to exceed normal, nor how fast it accelerates.  I expect that point  would be well over the reference range.  

Back to the member's case here, I suspect that her RT3 level is due to one or more of the many possible contributors listed, including low ferritin, since that is a known problem for her.   Her ferritin level is far too low, so rather than assume the RT3 is due to her FT3 level (which is really not excessive),  I would first go after the verified problem of low ferritin.  

So, my recommendation was to equalize the daily dosage and split it in half for morning and afternoon.  Also, she should supplement for Vitamin D and ferritin to optimize those.  I would also like to see her slightly reduce the NDT dosage to reduce the amount of T4 available to be converted to RT3, which we know will work accordingly.  Along with that I suggested adding a small dose of T3, to keep her FT3 at current level or slightly higher.  These actions should both reduce her RT3 level and increase slightly her FT3 level, both of which would improve the FT3/RT3 ratio and get her feeling better faster.

Regarding your last suggestion about an increased role for RT3 testing, I point you to the suggestions on page 2 of the paper, which lists RT3 as one of the tests that should be done initially.  That establishes a baseline for the patient's RT3.  For continuing testing, it is far more revealing to just test for FT4 and FT3 unless the patient is exhibiting symptoms that are not consistent with FT4/FT3 test results.  After all, due to the number of processes and confounding variables shown in Fig. 1 of the paper, tissue thyroid levels and effects may not be consistent with serum thyroid levels, in which case RT3 testing can provide important information about the underlying cause of continuing hypo symptoms.  

Since we haven't heard further from mhanan4 I hope we haven't scared her away with all our discussion.  LOL    Hopefully she will understand our intent to give her the best info possible supported with scientific evidence.  

1756321 tn?1547095325
My darling cat died recently and this was such a major shock/stress that I started to have extreme shortness of breath (my worst hypothyroid symptom). I was taking 400 mcg daily of thyroxine just to breath. I slowly went back down in dosage and was back to 50 mcg daily within 2 weeks.

But something else came up a week later that usually would not be stressful but in my state it clearly was as I was up to 200 mcg daily again. I'm back down to 50 mcg again currently but I'll take medication at any time I start to have shortness of breath.
1756321 tn?1547095325
I forgot to add that I have been watching plenty of ASMR videos to destress.
Avatar universal
Hello Gimel and Telus2,

Firstly thank you both for your advice and research! This has all been helpful and given me different points to consider.

Telus2- I have been dx with Hypothyroidism due to a high TSH when I was 21 (TSH of 6.4) and low-thyroid symptoms such as cold intolerance, rapid weight gain, and extreme fatigue.

I do believe my Ferritin and cortisol are major players contributing to my thyroid issues. I actually have my appt with my Endocrinologist tomorrow where I will bring this up with her.

The reference that Gimel gave does seem to make sense as to why low ferritin as well as high RT3 can keep making my low-thyroid symptoms linger.

Telus2 I am NO expert in any of this but it seems you're saying that my RT3 is elevated simply from me being overmedicated on NDT. This could certainly be possible, but I wonder why even when I was on a lower dose of NDT my thyroid symptoms weren't going away even when all my numbers where "in range" and didn't show that I was over-medicated.

It seems that throughout my journey of trying to get the correct dosage of Naturethroid I haven't been able to properly absorb and utilize my medication at the cellular level, which is why I asked specifically for my RT3 to be tested. My personal preference would be to at least TRY lowering my NDT, and adding in some Cytomel to see if that can help the ratio of RT3/T3.
1 Comments
The only thing that has been kind of confusing to me is how some doctors accept the RT3/FT3 ratio and how others think that RT3 doesn't really matter. Initially my GP told me my RT3 being high doesn't matter and that's when I asked to see a specialist..
Avatar universal
There's a lot of things that are unknown/ignored by a lot of doctors, including of course RT3, FT3, cortisol, Vitamin D, B12 and ferritin.   If they could see and absorb the process flow chart in Fig. 1 on page 7 of the link I gave you at the beginning of the thread, they could readily see that there is a lot more than just TSH and FT4 involved.  The desired end result is to have adequate tissue thyroid effects, which is affected by numerous processes and a large number of confounding variables.  That is why TSH doesn't even correlate well with FT4 or FT3, and even less with tissue thyroid effects (signs and symptoms).  When the entire process is reviewed, it is easy to see how ridiculous it is  to diagnose and treat a hypothyroid patient based on TSH.  
2 Comments
Exactly! Very true. Gimel, if you have any recommended physicians around Charlotte, NC area I would love to know. Thanks for all your information and time.
I just sent you a PM with info.  To access, just click on your name and then from your personal page, click on messages.
Avatar universal
Hello everyone,

I just had my endocrinologist appt. She took a great amount of time getting my previous health history and asking me questions/spent time with me which is promising. Unfortunately she does rely heavily on TSH and Free T4 over Free T3 however, and doesn't see a connection with my RT3 being elevated (extremely frustrating). She thinks i'm over medicated on my current dosage.

She is open to giving me Cytomel, but wants to change me to Synthroid + Cytomel to monitor my dosages that way. She was reluctant to add Cytomel plus Naturethroid, so I figure being able to play around with adding Cytomel is better than staying on NDT. I don't mind being on Synthroid due to not having any issues with Gluten, as long as I can get T3 too.

I told her I would be open to this as long as I am able to get enough Cytomel, and dose until I feel well /not go only by TSH. She told me that I can try taking Cytomel 2x per day and will work with me on a dosage she and I feel comfortable with.

My endo feels as though something else is going on besides my thyroid. She is testing my cortisol and creatinine by 24 hour urine test , a full metabolic panel, and testing my testosterone (as it was slightly high by 2 or 3 points in the past). Also getting tested are all of my sex hormones, thyroid antibodies, SHBG, and Insulin.

She doesn't THINK I have PCOS or Cushings, but wants to make sure I have nothing else going on. She is amazed i'm on this dosage of NDT and still cannot lose weight. I am annoyed that isn't that concerned that my RT3 is high, but she was considerate in listening to my concerns and working with me and not just forcing me to go on Synthroid without any added T3.

Avatar universal
With the NatureThroid, your previous average daily dose was about 107 mcg of T4 and 25 mcg of T3.  To reduce the amount of T4 available for conversion to RT3, and increase your FT3 to RT3 ratio, you could go down to 88.5 mcg  of T4, and increase your T3 to 30 mcg.  You could even consider reducing the T4 first and then about a month later, add the T3 and re-test in a couple of weeks.  It will be interesting to see what your doctor proposes.  
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I agree it will be interesting. I will post an update when lab results get back and she gives her recommendation of the updated dosage. I hope she gives me at least 25 mcg of t3.
Avatar universal
Just as an update: my endocrinologist has decided to switch me to 88 mcg of Synthroid and 20 mcg of Cytomil/day. I am to take 10 mcg Cytomil in the morning and 10 mcg in the afternoon.
Avatar universal
I wonder if the Endo realizes she reduced both your T4 and T3 meds?  I agree with the reduction of the T4, in order to reduce the amount of T4 being converted to Reverse T3, but with you still having hypo symptoms I don't understand reducing your T3 med from 25 down to 20.  Seems to me it should be at least 25.  I think you should at least make sure the Endo is aware that you still have hypo symptoms and that you are concerned that the reduction in T3 will make it worse.  From what she has done so far, I am somewhat encouraged with how she is trying to help, but probably her prior training about the importance of TSH and not recognizing the possibility of RT3 dominance is causing her to be very cautious.  So,if you are persistent, but patient with her, you may ultimately get what you need.  
5 Comments
Hi Gimel,

She believes I'm highly over-medicated right now due to my recent labs and didn't want me to take a higher amount of T3. I am supposed to get my labs redone in 6 weeks.

My most recent labs showed my total testosterone was slightly high and my AM cortisol was slightly low. She says she wants to make sure that my adrenal/sex hormones are figured out before upping my dosage of T3 too much which does make sense to me (although I preferably would like to be around 25-30 mcg of T3 per day but I understand where she's coming from).


I agree it does seem like she is working with me and I believe I'm on the right track. I tested negative again for Antibodies so hopefully she figures out the underlying cause of what's happening.
Hi sorry I should have posted my most recent labs taken at my endo appt.

TSH: <0.006
Free T3: 8.0 (2.0-4.4)
Free T4: 1.67 (0.82-1.77)
SHBG: 133.6 (24.6-122)
What time of day was blood drawn, and when did you take your thyroid meds that day?
I made the same mistake unfortunately of taking my medication at 4 am that day and getting blood drawn at 11 am. I let my doctor know that I took my medication that morning and she said she thinks my Free T3 is artificially elevated, but according to my SHBG and Free T4 signs are pointing to over-medication from those two numbers as well or "high end of normal" she said.

I know i'm getting the 5 mcg prescription of cytomil to dose 10 mcg 2x per day so hopefully I'll be able to adjust the T3 accordingly after the first 6 weeks.

I meant to say "SHBG and free t4 numbers* are pointing to over medication"
Avatar universal
I wonder if the Endo realizes she reduced both your T4 and T3 meds?  I agree with the reduction of the T4, in order to reduce the amount of T4 being converted to Reverse T3, but with you still having hypo symptoms I don't understand reducing your T3 med from 25 down to 20.  Seems to me it should be at least 25.  I think you should at least make sure the Endo is aware that you still have hypo symptoms and that you are concerned that the reduction in T3 will make it worse.  From what she has done so far, I am somewhat encouraged with how she is trying to help, but probably her prior training about the importance of TSH and not recognizing the possibility of RT3 dominance is causing her to be very cautious.  So,if you are persistent, but patient with her, you may ultimately get what you need.  
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