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Thyroid Disorders Community
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20852207 tn?1537766775

How can you be hyperthyroid with no hot it cold finding?

I just had a thyroid uptake and scan done.
Here are the findings:
Six hour uptake measured 21.7%
24 hour 40.6%

Impression: Elevated thyroid uptake favoring hyper thyroid state without evidence of cold nodule.

Images of thyroid demonstrate homogeneous activity without evidence of significant enlargement. No focal hot or cold nodules.

This test was ordered after an ultrasound that showed several nodules on both sides of thyroid glad as follows:
Largest nodule was isoechoic with increased periphral bloodflow. Second was heterogenerous with increased periphral and Central bloodflow.

Conclusion: bilateral heterogenerous with solid appearing nodules. With a recommended biochemical profile and uptake scan for further workup.
5 Responses
649848 tn?1534637300
COMMUNITY LEADER
The elevated 24 hr uptake is what favors hyperthyroidism - that means the thyroid is absorbing extra amounts of iodine, therefore, would be expected to be using that iodine to produce extra amounts of thyroid hormones.

The obvious way to confirm this is to test Free T4 and Free T3 levels.  If those are over-range, then you are hyperthyroid.  If they are not over-range, you are not hyperthyroid.  

You should be tested for thyroid antibodies, as well.  The #1 cause of hyperthyroidism is Graves Disease, however, many people have periods of hyperthyroidism in the early stages of Hashimoto's as well.  The antibody tests you need are Thyroid Peroxidase Antibodies (TPOab) and Thyroglobulin Antibodies (TgAb) to test for Hashimoto's.  Thyroid Stimulating Immunoglobulin (TSI) is the definitive test for Graves Disease.  These tests are all common and easy to get from most labs as long as your doctor is willing to order them.

If you've had any of these blood tests, please post the results and we can help you interpret them.  Be sure to include reference ranges, which vary from lab to lab and have to come from your own reports for the best comparisons.
4 Comments
All my blood work ups were within range, however I do not have the exact results. She just said the TSH was either on the lower or higher end and the T3 and T4 were within range. Those test were done before the uptake scan. I go see her Thursday I will all for a print out of my blood work ups.
Thanks for replying!
The impression just says that the result "favor" hyperthyroidism, they can't say for sure that you're hyper; only symptoms and blood tests can determine that.

There are a number of possible scenarios, depending on your blood work... Just having results "in range" does not mean there isn't something wrong and if you have a good, astute doctor, they will be able to figure it out relatively quickly.  

I do hope the T3/T4 tests that were done, were actually FREE T3 and FREE T4, though because if they were just T3/T4, that's Total T3 and Total T4 and indicates that your doctor may not be as good as we'd like to see.

Please do get a copy of your labs and post them here so we can see what was done, then we can help interpret what's happening.  Be sure to post reference ranges, along with the results since ranges vary from lab to lab and have to come from your own reports.  

I'll be looking forward to seeing the results...
Thank you so much. I will definitely post results when I get them. I am currently only seeing my primary care doctor, whom I haven't been seeing for very long. Think she is overwhelmed with me a bit because I have lots of health issues. She did mention referring me to a endocrinologist dependant on my update/scan.

From what I've read to date I'm thinking if my TSH and T3 and T4 were all within range there was really no reason for the uptake/scan?

If you could give any input on interpretation of my thyroid ultrasound that would be great!

I uploaded pictures of both reports on my profile. I couldn't copy and paste them so my initial post was piecing together what I thought may be most important. I also have no internet or computer... So do the best I can on my phone.  Lol

Thanks again!!
A primary doctor is okay as long as they know what they know thyroid.  A lot of endos specialize in diabetes and are not good thyroid doctors at all, so be careful there.

I'm not sure why the scan would have been ordered. Could have been because T4 and T3 were higher/lower in their ranges or something else they thought might be there.  

I'll try to take a look at your scan results and see what I can make of them.  From what you posted above, I didn't see anything out of the ordinary.  I'll look again, though...
649848 tn?1534637300
COMMUNITY LEADER
The uptake scan was performed following the ultrasound on the recommendation of the radiologist, due to the presence of the nodules, particularly, the dominant one on the right side.   The nodules are heterogeneous, which means the tiss-appue is not all the same.  They are also "solid-appearing", with some increased blood flow.  Has anyone suggested doing an FNA on the largest 2 of them just to be safe?

3 Comments
They have not at this point, I was kindof surprised they didn't do that before the uptake/scan. I go in Thursday to discuss the uptake test with me Dr.
Should find out what her next plan is then. I hate hurry up and wait...  
Yes, do try to find out what the game plan is.  I'm not saying that FNA is necessary; just that it's always a lot easier when the doctor outlines the steps they plan to take rather than keeping you guessing from one step to the next.  
I just left Dr office. She seems to think there are no more concerns. She seemed like she would have only been concerned if the uptake had shown cold nodules.

I did get a print out of my labs

TSH. .091. Range 0.30-6.0
T4 Free. .9. Range 0.6-1.7
I don't see a T3 so she must not have ordered that.

I'm feeling more uneasy than I was this whole time. I guess I feel like she's dismissing the ultra sound results solely on thier being no cold appearing nodules. Maybe I'm overthinking and there shouldn't be any more concerns.

She also stated that I'm not hyperthyroid at this time so no need for treatment as of now for that.
649848 tn?1534637300
COMMUNITY LEADER
Cold nodules are more likely to be cancer than hot nodules, so that's probably what she's basing her decision on.  I looked at the ultrasound again...American Thyroid Association (ATA) recommends FNA on nodules over 2 cm unless they have certain characteristics; being solid is one of those characteristics, but as I noted previously, your ultrasound says "solid-appearing", not that they nodules are actually solid.  I've never actually seen a report that says that... They should be able to tell if they're solid - that's the only thing I would question about that report.  Cysts aren't anything to worry about.

I totally agree that you aren't hyperthyroid and I'm quite surprised that your uptake was so high and your Free T4 is so low.  Yes, I know it's in range, but I can't help asking if you have any symptoms that could suggest hypothyroidism...Hypo symptoms include fatigue, weight gain/inability to lose, constipation, muscle/joint aches/pain, facial swelling, loss of body hair, especially the outer eyebrows, puffiness around/under the eyes, swelling/edema in the legs/feet and hands... there are many more, but those are some of the more common ones.

Most of us feel best with Free T4 about the mid-range point and your Free T4 is only at 27% of the range.  That's pretty low and indicates that your thyroid isn't producing enough hormones.  Of course, with Free T4 that low, we'd expect TSH to be higher.  Since it isn't, this could be an indication of Secondary, otherwise known as Central hypothyroidism.  Secondary/Central hypothyroidism is when the thyroid works fine, but there's something wrong with the pituitary or the hypothalamus so there isn't enough TSH being produced to adequately stimulate the thyroid.  Many doctors miss Secondary hypothyroidism because they place too much emphasis on TSH and as long as labs are "in range" they think all is well.

You can try to talk to your doctor about this or try to get a second opinion.
3 Comments
Thanks for your reply.
As far as any symptom... The only ones you listed that I would say is fatigue( I want to sleep allot), aches and pains and puffiness under eyes.  
Oddly I've always been extremely thin. I'm 5'8 and my weight over the past years has ran around 115-120. There has been 3 times that I gained excessive weight (for me)and then lost it pretty rapidly. In March of this year I got up to 148, I was 127 today and have been around there the last 3-4 months.  I have had spirts of being extremely hot and cold. My pulse runs over 100 often even when I'm not active, the nurse had actually said something about it my last two visits.  The last two years I've had problems with random vision problems where I have trouble focusing... It has not gotten better with wearing my glasses daily (maybe has something to do with rapid pulse, I don't know).

My potassium has been low and my vitamin D was 12 in March when it was tested. I just started taking vitamin D,2000 IU. My Dr had waited a bit to tell me to take it because of a kidney stone surgery I had a couple months ago and she wanted me to get the ok from my nephrologist and/or urologist. Maybe that could be causing some of my symptoms.

I do feel a bit better about my test after reading your reply, so thank you for that. I will mention to her my concerns and maybe monitor things instead of just calling it good and forgetting about it.
It's beginning to sound like you could have beginning stages of Hashimoto's, as well.  Although Hashimoto's is related to hypothyroidism, beginning stages are often characterized by periods of hypothyroidism (which could be what caused your weight increase up to 148), alternating with periods of hyperthyroidism and/or normal.  Each of these periods can last for weeks, months or years.  I've figured out that I had Hashimoto's for approximately 15-20 yrs before my thyroid completely stopped working and I settled into permanent hypothyroidism.  A couple of times, once in my mid 30's and once in my mid 40's my weight jumped up to about 120 (I'm 5' tall and never weighed more than 105-106, except when pregnant), then suddenly, I lost the weight as quickly as I gained it.

The main symptoms I had for all those years were fatigue and constipation, but then I noticed that I began having the same periods of hot/cold (mostly cold) you describe; I got huge bags under my eyes, I had swelling/edema in my feet/legs, horrible muscle/joint pain, and I lost the outer part of my eyebrows.   I had most of these symptoms for quite a few years and my doctor kept telling me they were "menopause" because I'd had a hysterectomy at age 46... by the time I was 56, I knew that menopause could no longer be affecting me this great and my doctor agreed, but he wasn't willing to try to find out what was wrong.  He simply said it was "age"...  

In 2007, I was finally diagnosed with Pernicious Anemia (autoimmune Vitamin B-12 deficiency) and my doctor insisted that all would be great once I started B-12 shots.  When that didn't resolve all my symptoms, he actually pegged me a hypochondriac...  In early 2008, I suddenly went from about 105 lbs to 130 lbs in a matter of about 3 weeks... I knew something was wrong, so the nurse who did my B-12 shots suggested I make an appointment with the Nurse Practitioner at my doctor's office to see about getting my thyroid tested.  At first, the NP didn't want to test my thyroid; she said there would be nothing wrong and that it was MY fault I'd gained that weight so quickly.  She did, however, go ahead and test TSH and Free T4.  My TSH came back at 55.5, with Free T4 at 0.6 (0.8-1.8).  Bingo - we had a reason for all my symptoms, but the doctor refused to test for Hashimoto's; he said it wasn't necessary because it wouldn't change the treatment and that insurance companies get upset when doctors order too many tests.  That was so much BS...

In a round-about way, I ended up getting the antibody tests and was confirmed that I have Hashimoto's; I also got an ultrasound that confirmed multiple nodules that I'm still dealing with today.  I'm no longer with that original doctor and I've been through 2 endos, since then, as well.  I'm telling you all this because what you're going through is reminiscent of what I've gone through over the past 10+ yrs.  

Potassium is an electrolyte and electrolyte imbalances do affect heart rates.  I've had low potassium levels also.  I also have magnesium and vitamin D deficiencies, stomach issues (another story entirely) - all thyroid-related.  I should have mentioned that acid reflux is also a very common symptom of hypothyroidism, as is high cholesterol/triglycerides.  

Vitamin D deficiency is very common with thyroid disorders.  12 is very low for a vitamin D, as I'm sure you know.  I'm surprised your doctor didn't put you on a mega-dose (typically, 50K IU/week) in order to build up your stores).  Vitamin D is necessary for the proper metabolism of thyroid hormones, but doctors don't often think of this.  So, yes, low vitamin D can contribute to some of your symptoms.

In addition to Vitamin D, Vitamin B-12 and ferritin (iron storage hormone) should also be tested.  Vitamin B-12 and iron are also necessary for the proper metabolism of thyroid hormones.  If you haven't had B-12 or Ferritin tested, I'd suggest you ask to have them tested.  The autoimmune form of B-12 deficiency (Pernicious Anemia) is relatively rare, but there are other reasons for B-12 deficiency.  B-12 is not only necessary for proper metabolism of thyroid hormones, it's necessary for nerve health, energy/red blood cell production and other processes.  Iron is also necessary for energy/red blood cell production.

If your doctor isn't open to testing for these things, I'd certainly suggest finding someone who is.  I'd also suggest insisting that Free T3 be tested EVERY time you get a TSH and Free T4.  Free T3 is the hormone used by nearly every cell in your body; you can have perfect TSH and Free T4, but not enough Free T3...
Wow crazy, what you have gone through does sound like me. I have stomach issues as well, mostly related to my IBS, I also have GERD with times of extreme acid reflux where I feel like I've gargled with boiling water (that's how I've always described it because my mouth and throat feel raw). I had been on a perscription Prilosec for years and was just taken off it last year because I was disagnosed with kidney disease (medgulary sponge kidney/nephrocalcinosis) and those are known to be bad for your kidneys. I can now only take Ranitidine.  

My cholesterol and triglycerides are also high, I just started a cholesterol pill a couple months ago.

All this with the nodules came about when I had a heart screening and when they checked my carotid artery they found the nodules. That screening is also when I found out about my vitamin D deficiency and high cholesterol/triglycerides.

My last primary Dr I had I had for many years and basically left because I was feeling like he thought I was a hypercondriac even though he didn't say it. That's a horrible feeling when you know something is wrong and you're made to feel that way. It was a hard move for me because I do have many health issues and he knew about them all very well. I was diagnosed with COPD in my late 20's and along with that when the blebs from the emphysema would burst they would cause my lungs to collapse, I've had 3 lung surgeries to attach my lungs to my chest wall (3, because 1 gave way and collapsed again). So for him to know that I had enough valid health issues and make me feel like I wanted to add other issues was a smack in the face.  I'm still not sure it was a good move, but the Dr I'm seeing now is my mom's Dr and she has had her for many years and travels over an hour to see her.

I will mention to her the things you have told me and see how she reacts and go from there.

If i were in the "early" stages for Hashimoto's would a specific test tell me that now?

Sorry you went through all you did to get your diagnosis,I know that feeling of not being listened to, and it's not a good one.
649848 tn?1534637300
COMMUNITY LEADER
You need antibody tests to determine if you have Hashimoto's.  Those tests are Thyroid Peroxidase Antibodies (TPOab) and Thyroglobulin Antibodies (TgAb)... Both are markers for Hashimoto's; some of us have one or the other and some of have them both.  Some people are diagnosed with Hashimoto's based on the characteristics of their thyroid gland, even if they have negative antibodies.  Your ultrasound report doesn't mention that, but that doesn't necessarily mean anything...

You also need to get vitamin B-12 and Ferritin tested.  Most of us need to keep B-12 in the upper part of its range in order to feel best, even though doctors seem to think that anything that's in range is good enough - they tend to think that way about everything...

If your Ferritin is low, you need to get an iron panel.  Don't let them just tell you that you don't need that because your hemoglobin and hematocrit is good, because that's not always satisfactory.  

I know how frightening it can be to change doctors, but sometimes we have no choice.  I'd been with my previous doctor for 8 yrs and I really liked him, until my thyroid died; then he showed his true colors.  I like the doctor I have now and I've been with him for 9 yrs, but I've had difficulties with him as well and would leave him in a heartbeat if I have trouble getting decent treatment for my thyroid.  

I wouldn't let him treat my thyroid when I first started seeing him... first because I had an endo I was happy with and second because he would only look at TSH and wouldn't test Free T3.  My endo went out of practice and the next one I got was horrible... In the meantime, I'd convinced my pcp that he "had" to test Free T4 "and" Free T3 for me because TSH isn't reliable since mine is suppressed and I'm not hyper. Once I got that through to him, things began to turn around and I've since ditched the second endo and my pcp is doing well - so far... As long as he doesn't start trying to decrease my medication, we'll get along fine...
1 Comments
You mentioned hemoglobin and hematocrit, my hemoglobin is often high my last test results were:

Hemoglobin
18.1 Range 12.0-15.0

Hematocrit 46.8 range 36.0-48.0
I'm not sure how these play a role.

My monocytes were 10.2 range 3.0-10.0
(Just adding this because it was also out of range)

I should also say I've struggled with low platelets as well, I was seeing a hematologist a few years ago and he never disclosed a cause, he was happy when I gained weight and said I didn't have to see him anymore and said to have my PCP check them every six months. This last test they were fine, the test before they were low again... This is a ongoing thing for several years. They go up and down. I usually just get tested when I start to bruise more. My PCP was going to refer me back to him because of the low result and then they went back up.

I was on B-12 and folic acid many years ago to per my PCP for low levels. Can't even say if they were ever tested again after that.

I will definitely be talking to my Dr, I really feel like this sounds spot on for many issues I've struggled with over the years.

I surely hope things keep going well with you and your PCP... Sounds like you're a tough cookie.


649848 tn?1534637300
COMMUNITY LEADER
Hemoglobin is a protein in red blood cells that carry oxygen all over the body.  Hematocrit is the number of red blood cells in your blood.  Because iron is necessary for the formation of red blood cells, doctors often use them as a signal that iron levels are adequate, when this isn't always the case.

Monocytes are a type of white blood cells.  There several types of white cells and these are, basically, used to fight infection/disease.

As for B-12 and Folate, both are also necessary for healthy red blood cells.  As I noted, B-12 is necessary for healthy nerve function, as well as other functions.  I have permanent nerve damage in my feet due to long-standing B-12 deficiency caused by Pernicious Anemia, which is an autoimmune condition in which one does not absorb vitamin B-12 via the gut.  Because of the inability to absorb B-12 via the gut, I take weekly B-12 injections in order to keep my level near the top of the range.  

Folate works in conjunction with vitamin B-12.  Folate is another of the B vitamins; I've also been deficient in Folate.  Folic Acid is a synthetic version of Folate and must be converted to something the body can actually use; therefore, it's not often recommended for those of us with Hashimoto's or other autoimmune conditions because we, often, can't absorb or convert synthetic substances.  It's best to get formulas that are "body ready" so we don't have to convert them.  This applies to B-12, as well.

If you look at your blood test reports, you'll see items called "RDW", "MCV", etc... Those are indications of vitamin B-12 status, but of course, they can't the place of actual B-12 or folate testing.

I also wanted to address the acid reflux/GERD issue... As I noted, this is very common with hypothyroidism.  I had it horribly bad for some years prior to being diagnosed - even when my thyroid hormone levels were supposedly "normal".  For several years, I had been on a prescription drug called Aciphex.  You don't hear about it very often anymore, but it was very expensive and it was a constant battle to get my insurance company to keep paying for it; they wanted me to switch to the generic "Omeprazole", which did absolutely nothing for my reflux.  I would wake up in the night, literally, choking on acid, unable to catch a breath...

I had not known that was a hypo symptom until I found this forum.  People here, also told me that instead of less acid, I actually needed "more" acid... I thought they were crazy.  One person, who no longer frequents the forum told me they used to drink dill pickle juice to calm acid reflux.   I just knew that if I had more acid in my stomach it really would kill me.  lol

One night I woke up choking and once I was able to catch my breath, I went to the fridge and took a couple big swallows of dill pickle juice... oh my, did that burn going down and I thought I'd made the mistake of my life!!  Ironically, it was only a few minutes before the acid settled down and although I sat up in bed because I was afraid to lie down, I actually did go back to sleep, which was something I'd hardly ever been able to do in the past.  I began to have jars of dill pickles with no juice in my refrigerator and eventually had to start throwing them away... lol  I also discovered that vinegar and water works, too, though it doesn't taste as good as dill pickle juice.  

I did read up on stomach acid and learned that many of us have too little which, strange as that sounds, does cause reflux/GERD.  For a while, I took Hydrochloric Acid (HCl) w/pepsin when at mealtime to help build my stomach acid, since we need a certain amount of acid in order to digest our food. Taking acid reducers prevents this from happening.  If you read the inserts of those medications, they were never meant to be taken on a long-term basis.  Of course, my doctors look at me like I'm nuts when I mention this...

I had the reflux for so long, my ENT did tests to make sure my stomach and esophagus had not been eroded by the acid.

Now, I only get reflux when my thyroid levels go out of whack or if anxiety levels are really high.  I did wake up last night with some reflux and a spoonful of dill pickle juice calmed it down quickly.  

I also went through an episode with H. Pylori at the beginning of 2017, which took a while to get diagnosed, as well.  H. Pylori is a bacteria that many/most of us have in our stomach but it lives there peacefully with all the other bacteria unless/until something happens and it gets a chance to get a foothold and we get an overgrowth.  That required treatment with 2 antibiotics simultaneously, along with acid reducers which allowed the antibiotics to work better and a better diet.

I do have IBS, also and have changed my diet to exclude dairy, sugar and am "almost" gluten-free.  I've never eaten soy, but if you do, it's not recommended for thyroid, as it's a goitrogen - you can research that... I try to eat lots of veggies, healthy fats, and protein.  I'm also pre-diabetic so I limit fruit to 1-2 servings/day and try to go with the lower sugar ones, except watermelon when it's in season as it's a favorite...  :-)

I also want to address the cholesterol/triglycerides, but I'll do that in another post...
2 Comments
Thanks again for all the info.

My RDW is 12.7 (10.5-15)
MCV is 93.0  (80.0-100.0)
So both are within range.

I suppose it wouldn't hurt to get my B-12 tested again. It's been many years.

I was on Omeprazole also until they took me off a few months ago, I had actually had less acid reflux for quite awhile after I stopped taking it,I was shocked by that. Now I just feel slight burning and my voice goes out often, guess that was one of my fears when then mentioned the nodules and after I read the ultra sound... But I guess it just goes back to the acid reflux. Funny you mention pickle juice, I had just heard about that from a friend and was kindof dumbfounded about it, I guess I'll have to give it a go. My mom had been trying to talk me into baking soda/water, I'd go for the pickle juice first. Lol


Ugh changing diet I am not good at, they want me on so many restrictions for my cholesterol and kidney stones both... It would limit me so much, with kidney stones some stuff that one would think of as healthy they don't want me to have because of oxalate. I did cut out deep fried foods and now only use an air fryer, which I absolutely love!!! I also cut way back on soda and was doing really good until recently. Blah. Lol

I'll be looking forward to your post on cholesterol and triglycerides. I'm soaking it all up. :-)
RDW is red blood cell width and is often high if B-12 is low, but not always.  And yes, if it's been a while since you've had Vitamin B-12 tested, you should go ahead and get it done just to be sure.

Baking soda/water neutralizes acid, which is the same time acid reducers do.  You want to add more acid not get rid of it... Pickle juice works because it has vinegar which is acidic so you're adding acid to you stomach not neutralizing it.

I know it's not easy changing diet, but sometimes that's what it takes.  I had trouble with my cholesterol and triglycerides for a long and for a while, they went up and down with my thyroid hormones since high cholesterol is a symptom of hypothyroidism.  However, it got to the point where thyroid levels were no longer affecting cholesterol and triglycerides unless they went to rock bottom which wasn't happening.  My first PCP kept insisting I needed to take Crestor (statin) and I kept refusing.  When I switched doctors my new one mentioned a statin once and I refused, so he tried working with me but nothing was helping... that's because I wasn't changing diet enough to make a difference.   I tried cutting out sugar, dairy, and most gluten.  I've never eaten soy, so I didn't have to eliminate that.  I've done really good not eating dairy - I eat a little cheese now and then, but that's it.  Gluten has been a little harder, but for the most part, I do well.  Sugar is really difficult because it's in almost everything, but I'm getting better.  

I also added healthier fats like coconut and olive oils and avocados, butter, more meat (mostly chicken) since I have trouble absorbing protein, more veggies, nuts, etc.  

I, too, have kidney stones so have to eliminate/limit certain foods for that reason, but I do still eat a little spinach now and then because I love it and it's too healthy to give up entirely...

Anyway, I didn't do it all at once so it wasn't so it wasn't so bad and it was worth it.  When I had blood work done, my cholesterol had come down from over 200 to 101 and my triglycerides had come down from over 300 to 189 - yep still high, but the next time both well within the normal limits and my pcp was pleased as punch and even my cardiologist was happy...

I even feel better not eating all bread, sweets and other stuff I was eating, even though I'm not 100% gluten and sugar free, plus I'm finally able to lose some weight and I'm not having nearly as much trouble with my stomach/IBS as I was...  so it's been worth the effort for me...  
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