Aa
How to get my nature-throid dosage optimal?
Hello, I've been on Nature throid 1 1/2 grain for 2 months after switching to a doctor that would test my free t3/free t4, and feel much better than on the Levothyroxine, however feel still symptomatic. (Stalled weight, fatigue)
My OLD TSH from July 2016: 1.65 (felt terrible)
My new lab results as of October 3rd:
TSH: 0.70 (range: 0.4-4.5)
Free T3: 2.6 (range - 2.3-4.2)
Free T4: 0.9 (range- 0.8-1.8)
Thyroglobin antibodies: less than 1.
(Range-<1 or =1
Thyroid peroxidase antibodies: 1.
(Range- <9)
According to my results/symptoms, should my med be raised? My doctor advised me to stay on 1 1/2 grain. I was disappointed. Should I ask her to raise it?
Also, since my antibodies are so low, does this mean I probably don't have hashimotos?
I'm very interested in the root cause.
Thank you !
My OLD TSH from July 2016: 1.65 (felt terrible)
My new lab results as of October 3rd:
TSH: 0.70 (range: 0.4-4.5)
Free T3: 2.6 (range - 2.3-4.2)
Free T4: 0.9 (range- 0.8-1.8)
Thyroglobin antibodies: less than 1.
(Range-<1 or =1
Thyroid peroxidase antibodies: 1.
(Range- <9)
According to my results/symptoms, should my med be raised? My doctor advised me to stay on 1 1/2 grain. I was disappointed. Should I ask her to raise it?
Also, since my antibodies are so low, does this mean I probably don't have hashimotos?
I'm very interested in the root cause.
Thank you !
With that additional information I think we are on the right track now. Even though the TPO ab and TG ab tests were within range, it still shows autoimmune antibodies that are most likely early stages of Hashi's, or primary hypothyroidism. So starting you on medication was correct, but a starting dose of 25 mcg doesn't do much because the resulting reduced TSH will stimulate less thyroid hormone production. Since serum thyroid levels are the sum of both natural thyroid and thyroid med, the net result is very little change in Free T4 and Free T3 until the med dosage is increased enough that TSH levels are no longer having much effect on serum levels of thyroid hormone. After that additional med increases will raise the Free T4 and Free T3 levels. There really was no need to wait so long in between dose adjustments.
A good thyroid doctor will treat a hypo patient clinically by testing and adjusting Free T4 and Free T3 levels as needed to relieve symptoms, without being constrained by resultant TSH levels. Symptom relief should be all important, not just lab results, and especially not TSH results when already taking thyroid med.
So with lingering symptoms that are frequently related to being hypo still, you need to convince your doctor to increase your med. Your Free T4 and Free T3 levels are a long way from optimal for many people, as indicated in the quote i gave you above in my first post. In addition, you need to be tested for Reverse T3 and Free T3 from the same blood draw, cortisol, Vitamin D, B12 and ferritin. All are important. If the doctor resists, then push it and give her a copy of the paper linked above and point out suggestion no. 6 on page 2. In preparation for that I urge you to read at least the first two pages of the paper. If the doctor continues to disagree, give her a copy of the full paper and ask her to read through the suggestions and the analysis and scientific evidence. If that doesn't change her mind, then you have to look elsewhere for a good thyroid doctor that will test and treat clinically as described.
A good thyroid doctor will treat a hypo patient clinically by testing and adjusting Free T4 and Free T3 levels as needed to relieve symptoms, without being constrained by resultant TSH levels. Symptom relief should be all important, not just lab results, and especially not TSH results when already taking thyroid med.
So with lingering symptoms that are frequently related to being hypo still, you need to convince your doctor to increase your med. Your Free T4 and Free T3 levels are a long way from optimal for many people, as indicated in the quote i gave you above in my first post. In addition, you need to be tested for Reverse T3 and Free T3 from the same blood draw, cortisol, Vitamin D, B12 and ferritin. All are important. If the doctor resists, then push it and give her a copy of the paper linked above and point out suggestion no. 6 on page 2. In preparation for that I urge you to read at least the first two pages of the paper. If the doctor continues to disagree, give her a copy of the full paper and ask her to read through the suggestions and the analysis and scientific evidence. If that doesn't change her mind, then you have to look elsewhere for a good thyroid doctor that will test and treat clinically as described.
1 Comments
This is exactly the info I needed! I read over the source you provided and it's spot on with what I need to share with my doctor. I am emailing her today asking for the additional lab tests for b12, ferritin, RT3 and cortisol as well as the raise in medication.
Thank you!
Thank you!
With you still having symptoms that are often related to hypothyroidism, plus your Free T4 at 10% of the range, and your Free T3 at only 16% of its range, it seems clear that you need an increase in your meds. It appears your doctor is dosing your thyroid med based on TSH. That does not work. When already taking thyroid med, TSH is basically a useless test because it is frequently suppressed below range in order to raise the Free T4 and Free T3 levels adequate to relieve symptoms. In the words of a good 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."
You can also get some useful info from the following link. Note suggestion no. 6 on page 2. If you want to read further you will find extensive discussion and scientific evidence supporting all 6 suggestions. If you want to attempt to change your doctor's approach, you can also give a copy of the paper to your doctor and ask to be treated clinically as described above.
http://www.thyroiduk.org.uk/tuk/TUK_PDFs/diagnosis_and_treatment_of_hypothyroidism_issue_1.pdf
Based on the TPO ab and TG ab tests it is most likely that you have central hypothyroidism. Central is due to a dysfunction in the hypothalamus/pituitary system resulting in relatively low levels of TSH, thus inadequately stimulating the thyroid gland to produce hormone.
You can also get some useful info from the following link. Note suggestion no. 6 on page 2. If you want to read further you will find extensive discussion and scientific evidence supporting all 6 suggestions. If you want to attempt to change your doctor's approach, you can also give a copy of the paper to your doctor and ask to be treated clinically as described above.
http://www.thyroiduk.org.uk/tuk/TUK_PDFs/diagnosis_and_treatment_of_hypothyroidism_issue_1.pdf
Based on the TPO ab and TG ab tests it is most likely that you have central hypothyroidism. Central is due to a dysfunction in the hypothalamus/pituitary system resulting in relatively low levels of TSH, thus inadequately stimulating the thyroid gland to produce hormone.
From an article, "Your adrenal glands are responsible for manufacturing DHEA. Actually, the cascade of adrenal hormones starts with cholesterol, from which the brain hormone pregnenolone is made. Pregnenolone is then transformed into DHEA. And DHEA serves as the raw material from which all other important adrenal hormones--including the sex hormones estrogen, progesterone, and testosterone and the stress hormone cortisol--are synthesized." So, in view of your relatively low cortisol levels likely due to dysfunction in the hypothalamus/pituitary system, I just thought it would be a good idea to check that also, in view of its importance.
1 Comments
I understand! Great thanks. A lot to research.
It is good that your doctor responded to your request for a raise in your NatureThroid; however, that 1/4 grain increase is unlikely to be adequate, in view of your last Free T4 result of .9 and your Free T3 result of 2.6. Since the mor important indicator of thyroid status is symptoms, what symptoms are you having currently?
I am not well versed on cortisol but my interpretation from limited experience and some reading I did would indicate that you are low in cortisol, even though within range. Like many other tests just being within the lower limit is frequently inadequate. Also it is important to evaluate symptoms as well. The ACTH test result was double the cortisol test, so that indicates a dysfunction in the hypothalamus/pituitary system rather than an adrenal gland issue. After we discuss any symptoms you have, I think you will need to also discuss those with your doctor and ask about the low cortisol.
You mentioned testing in 2 months. You should make sure to be tested for Free T4, Free T3, Reverse T3, (TSH would be a waste since you are taking thyroid med.), Vitamin D, B12 and ferritin. I would also request testing for DHEA-S. And yes it is more accurate to wait and take morning thyroid med dosage after the blood draw. Note the following in Item 7 on page 12 of the link above.
'In addition,the guidelines 1, 2 recommend that “blood for assessment of serum FT4 should be collected before dosing because the level will be transiently increased by up to 20% after Levothyroxine (L-T4) administration”. For the same reason, L-T3 medications should be deferred until after the blood draw for FT3 testing in order to avoid false high results. 72
.
I am not well versed on cortisol but my interpretation from limited experience and some reading I did would indicate that you are low in cortisol, even though within range. Like many other tests just being within the lower limit is frequently inadequate. Also it is important to evaluate symptoms as well. The ACTH test result was double the cortisol test, so that indicates a dysfunction in the hypothalamus/pituitary system rather than an adrenal gland issue. After we discuss any symptoms you have, I think you will need to also discuss those with your doctor and ask about the low cortisol.
You mentioned testing in 2 months. You should make sure to be tested for Free T4, Free T3, Reverse T3, (TSH would be a waste since you are taking thyroid med.), Vitamin D, B12 and ferritin. I would also request testing for DHEA-S. And yes it is more accurate to wait and take morning thyroid med dosage after the blood draw. Note the following in Item 7 on page 12 of the link above.
'In addition,the guidelines 1, 2 recommend that “blood for assessment of serum FT4 should be collected before dosing because the level will be transiently increased by up to 20% after Levothyroxine (L-T4) administration”. For the same reason, L-T3 medications should be deferred until after the blood draw for FT3 testing in order to avoid false high results. 72
.
1 Comments
Hi Gimel, I appreciate your response and all your insight.
My symptoms include stalled weight while exercising and eating a well balanced diet, mild fatigue especially in the morning, trouble concentrating and ice-cold extremities/temperature disregulation.
I gained about 30 lbs within 6 months going from 115 to about 145-150 lbs when my hypothyroidism was undiagnosed while eating a 12-1500 calorie whole foods/Mediterranean diet, exercising and taking care of myself. This was when my TSH was a 6.4. After going on the levo/naturethroid, am at a stable weight however can not lose an ounce.
I also have have extreme temperature intolerance, usually being very hot when I first wake up and for about 2-3 hours after that, suddenly getting ice cold for the rest of the day until I exercise. I take my medication at 6 am. All in all I can feel things are dramatically off balance.
I thought Cortisol looked low as I know it's supposed to be at it's highest in the morning. I am waiting to hear back from my doctor about the follow up and what she will recommend. I really hope she doesn't say "they were in range so you're fine".
I am aiming for her to raise my thyroid med again after my next set of labs in 2 months, I agree I don't think this 1/4th of grain increase will do the trick.
I asked my doctor already to do the RT3, Ferritin/b12/vit d and she only agreed to do the cortisol/ACTH, raise my med and retest in 2 months and go from there. I will make it clear I want the extra tests done.
So that's where I am right now. What does the DHEA-S correlate to?
My symptoms include stalled weight while exercising and eating a well balanced diet, mild fatigue especially in the morning, trouble concentrating and ice-cold extremities/temperature disregulation.
I gained about 30 lbs within 6 months going from 115 to about 145-150 lbs when my hypothyroidism was undiagnosed while eating a 12-1500 calorie whole foods/Mediterranean diet, exercising and taking care of myself. This was when my TSH was a 6.4. After going on the levo/naturethroid, am at a stable weight however can not lose an ounce.
I also have have extreme temperature intolerance, usually being very hot when I first wake up and for about 2-3 hours after that, suddenly getting ice cold for the rest of the day until I exercise. I take my medication at 6 am. All in all I can feel things are dramatically off balance.
I thought Cortisol looked low as I know it's supposed to be at it's highest in the morning. I am waiting to hear back from my doctor about the follow up and what she will recommend. I really hope she doesn't say "they were in range so you're fine".
I am aiming for her to raise my thyroid med again after my next set of labs in 2 months, I agree I don't think this 1/4th of grain increase will do the trick.
I asked my doctor already to do the RT3, Ferritin/b12/vit d and she only agreed to do the cortisol/ACTH, raise my med and retest in 2 months and go from there. I will make it clear I want the extra tests done.
So that's where I am right now. What does the DHEA-S correlate to?
Hello! Just as an update- my doctor agreed to raise my thyroid med to 113.5 mg of nature throid. Also, she tested my cortisol and ACTH and here were my labs
ACTH: 18. Ref range (6-50 pg/mL)
Cortisol: 9.0. Red range (4-22)
My labs were taken at 8:45 am and these ranges are applicable between 7-10 am. I am getting my FT3 and TSH retested in 2 months. Since my values were within range does this mean my adrenals are functioning normally? Also, is it more accurate to wait to take my thyroid med getting my labs done? For the last set of labs (in the original post) I did not take my medication until after getting my blood drawn.
ACTH: 18. Ref range (6-50 pg/mL)
Cortisol: 9.0. Red range (4-22)
My labs were taken at 8:45 am and these ranges are applicable between 7-10 am. I am getting my FT3 and TSH retested in 2 months. Since my values were within range does this mean my adrenals are functioning normally? Also, is it more accurate to wait to take my thyroid med getting my labs done? For the last set of labs (in the original post) I did not take my medication until after getting my blood drawn.
IF you are able to get the Reverse T3 test done, you should also get a Free T3 also so that it is from the same blood draw. That will give the best estimate of the ratio of Free T3 to Reverse T3.
1 Comments
That makes sense! I will mention that and see what she lets me have tested.
Having a TSH of 6.4 was inconsistent with central hypothyroidism. So before getting overly you concerned about a brain tumor, we need to get some additional info. Do you have any T4 and T3 results from that time? Also, was your T4 and T3 tested back in July? If so, please post those as well. When did you start on thyroid med, what was the starting dose, and what was the diagnosed cause at that time, that prompted the medication?
2 Comments
Last September, I went in to my PCP knowing I felt off - very rapid weight gain, fatigue, trouble sleeping and a faster response to stress. I was 21 at the time. Immediately she tested my TSH and Total T4. My TSH came back at a 6.4. I do not have the total t4 number! I believe it was around a 1.4. My PCP told me it was "most likely" caused by primary hypothyroidism and told me that 99% of hypothyroid patients have it caused by an autoimmune disease. She didn't test my antibodies.
I was put on Levothyroxine that month at 25 mcg. 3 months went by with zero improvement symptom wise. My TSH was then a 1.75 after the 25 mcg, tested in December.
In march, frustrated with my pcp who refused to test my free t3 t4 or consider changing my medication to NDT, I saw an endocrinologist. He raised my Levothyroxine to 50 mcg and said see you in 3 months.
This brings me to July. This endo also wouldn't test my free t3, just my free t4 and TSH. My TSH was a 1.70, and my free t4 a 1.2.
Still feeling very hypo on levo, and frustrated that no doctor has told me whether I have hashimotos or not, I finally got in with a recommended thyroid doc, dr Nelson in August who immediately put me on NDT, 1 1/2 grains. 2 months later here I am with my most current lab results in the original post, and still symptomatic (but immensely better than the levo).
Ps gimel you are the best thanks for your time!
I was put on Levothyroxine that month at 25 mcg. 3 months went by with zero improvement symptom wise. My TSH was then a 1.75 after the 25 mcg, tested in December.
In march, frustrated with my pcp who refused to test my free t3 t4 or consider changing my medication to NDT, I saw an endocrinologist. He raised my Levothyroxine to 50 mcg and said see you in 3 months.
This brings me to July. This endo also wouldn't test my free t3, just my free t4 and TSH. My TSH was a 1.70, and my free t4 a 1.2.
Still feeling very hypo on levo, and frustrated that no doctor has told me whether I have hashimotos or not, I finally got in with a recommended thyroid doc, dr Nelson in August who immediately put me on NDT, 1 1/2 grains. 2 months later here I am with my most current lab results in the original post, and still symptomatic (but immensely better than the levo).
Ps gimel you are the best thanks for your time!
Correction to my previous post, in November last year my PCP actually did test my antibodies and f t4.
FT4: 1.10 (range .80-1.80)
Anti- thyroglobulin: 25.9 (range 0-39.9)
Anti thyroid peroxidase: 36.4 (range 0-39.9)
FT4: 1.10 (range .80-1.80)
Anti- thyroglobulin: 25.9 (range 0-39.9)
Anti thyroid peroxidase: 36.4 (range 0-39.9)
Note the following info.
"Hypothalamic-pituitary tumors can cause central hypothyroidism by compression of the hypothalamus or pituitary, which results in a decrease in TRH or TSH secretion, or by disrupting signalling between the hypothalamus and pituitary. Other causes of central hypothyroidism include lymphocytic hypophysitis, Sheehan syndrome, traumatic brain injury, subarachnoid hemorrhage, and infiltrative disorders. Patients with central hypothyroidism frequently have other pituitary hormone deficiencies."
It is also interesting that the general impression is that central hypothyroidism is very unusual. In reality it is quite common, but reported to be less frequent than primary hypothyroidism.
Also note that, "The hypothalamus produces corticotropin-releasing hormone (CRH) that stimulates the pituitary gland to produce adrenocorticotropin hormone (ACTH). The ACTH stimulates the adrenal glands to make and release corticosteroid hormones into the blood." If cortisol is too low or too high that can affect metabolism of thyroid hormone. So it is important for cortisol to be tested as part of early diagnosis.
"Hypothalamic-pituitary tumors can cause central hypothyroidism by compression of the hypothalamus or pituitary, which results in a decrease in TRH or TSH secretion, or by disrupting signalling between the hypothalamus and pituitary. Other causes of central hypothyroidism include lymphocytic hypophysitis, Sheehan syndrome, traumatic brain injury, subarachnoid hemorrhage, and infiltrative disorders. Patients with central hypothyroidism frequently have other pituitary hormone deficiencies."
It is also interesting that the general impression is that central hypothyroidism is very unusual. In reality it is quite common, but reported to be less frequent than primary hypothyroidism.
Also note that, "The hypothalamus produces corticotropin-releasing hormone (CRH) that stimulates the pituitary gland to produce adrenocorticotropin hormone (ACTH). The ACTH stimulates the adrenal glands to make and release corticosteroid hormones into the blood." If cortisol is too low or too high that can affect metabolism of thyroid hormone. So it is important for cortisol to be tested as part of early diagnosis.
1 Comments
Gimel,
At first my TSH was a 6.4. I researched that patients that have central hypothyroidism have a suppressed TSH with low T3 and T4 values. Is that incorrect? Now I'm just worried I have a brain tumor! I have to bring all this up with my doctor. I have been wanting to get my cortisol tested due to a severe response to stress while at college, then all of a sudden my thyroid went crazy and my TSH rose suddenly to the 6.4. I am unsure of who to go to to get my cortisol tested. I have been to my PCP, and two endo's who have never mentioned central hypothyroidism to me.
At first my TSH was a 6.4. I researched that patients that have central hypothyroidism have a suppressed TSH with low T3 and T4 values. Is that incorrect? Now I'm just worried I have a brain tumor! I have to bring all this up with my doctor. I have been wanting to get my cortisol tested due to a severe response to stress while at college, then all of a sudden my thyroid went crazy and my TSH rose suddenly to the 6.4. I am unsure of who to go to to get my cortisol tested. I have been to my PCP, and two endo's who have never mentioned central hypothyroidism to me.
Thank you so much for the information! I've researched quite a bit so when I looked at my labs I thought the free t3/t4 numbers were still quite low, and definetly correlating with my hypo symptoms, I just wanted to confirm I was in the right way of thinking before asking for an increase.
I am going to Jean Nelson in Grand Blanc, MI. She was absolutely wonderful at my visit with her in August, told me to let her know how I'm feeling, so today after seeing my labs I emailed her my lack of improvement in symptoms and asked for a raise in my medication- I'm just waiting for a response back..
I will look over the sources you provided and relay them to Dr. Nelson if she still won't raise my med. She seemed very open in my first visit to listening to me.
Is the dysfunction that causes central hypothyroidism treatable or is it life long like hashimotos?
I am going to Jean Nelson in Grand Blanc, MI. She was absolutely wonderful at my visit with her in August, told me to let her know how I'm feeling, so today after seeing my labs I emailed her my lack of improvement in symptoms and asked for a raise in my medication- I'm just waiting for a response back..
I will look over the sources you provided and relay them to Dr. Nelson if she still won't raise my med. She seemed very open in my first visit to listening to me.
Is the dysfunction that causes central hypothyroidism treatable or is it life long like hashimotos?
Have an Answer?
You are reading content posted in the Thyroid Disorders Community
We tapped the CDC for information on what you need to know about radiation exposure
Endocrinologist Mark Lupo, MD, answers 10 questions about thyroid disorders and how to treat them
A list of national and international resources and hotlines to help connect you to needed health and medical services.
Herpes sores blister, then burst, scab and heal.
Herpes spreads by oral, vaginal and anal sex.
STIs are the most common cause of genital sores.
