Thyroid Disorders Community
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Avatar universal

Hypothyroid symptoms, low t4 free, normal TSH and T3 free

Hi everyone,
I am new to the forum so please bare with me if this question has been asked before. Since I had my son, about 2.5 years ago (2nd child), I have the following symptoms (which have been in overdrive for the last 6-8 months):

- weight gain- Ive gained 10 lbs over the last couple of months (after running 25 miles per week and dieting) I have always been thin and usually could lose weight just thinking about it

- extreme fatigue - so hard to get out of bed in the am but I thought it was because I had a hard time falling asleep and staying asleep

- dry skin

- swelling- face and hands, water retention and bloating in belly

- foggy and memory loss. I couldn't remember parts of conversation that I had just the night before and just felt like I was on a cloud throughout the day

- anxiety because of all of the symptoms

- very low libido

I'm sure there is more that I just can't remember right now :/

I've been to a GI Dr. for my chronic constipation, weight gain despite exercise and diet, and water retention and bloating - NOTHING

I was diagnosed with PCOS about 3.5 years ago while having difficulty trying to conceive my son. It took 2 IUI's before we became pregnant.

I went to ENT for dizziness and foggy feeling thinking it was related to sinus issues. NOTHING

My primary sent me for an ultrasound of my gall bladder (because of the GI issues) and said to have them look at my thyroid too because he felt it looked larger than usual. Gall bladder was fine but the found 2 complex cysts. Followed w/ u/s 3 months later and the one shrunk and the other grew so I had a biopsy 2 days ago. Waiting for those results.

I am just seeking treatment now because I am a nursing student and thought that my symptoms were due to stress but they have worsened and the weight gain is very rapid and unexplainable.

Anyway, after they found the cysts I scheduled with the first endo I could find. He took the blood work results from my primary and said my tsh and t3 levels were normal. I demanded (nicely) that he run them again (3 months later) and include the t4free, t3 free and tsh. these were the results (including glucose and isulin to ck for insulin resistance with the weight gain and PCOS:

TSH - 1.25
T4 free  1.0
T3 free  3.1

fasting glucose 94
insulin < 2
c - peptide  0.94

Now I am waiting for my biopsy results to go in and discuss all of my symptoms and lab results with him. In the meantime I called and asked for a lab slip to check my cortisol levels and for the thyroid antibodies. I read that a normal tsh and low t4 could indicate a pituitary issue.

So my questions are, am I requesting the correct tests and is there any thing else I should request?

If he is willing to do so, do you think I could benefit from hypo meds?

I absolutely hate taking any medication at all. I fractured my femur a few years ago and couldn't stand to take the pain meds because of how they made me feel.

But my current symptoms are almost debilitating some days and I have developed such anxiety in trying to learn what it is. There is definitely something wrong and I am desperate to find answers.

I apologize for the length of this. Your suggestions and opinions are much appreciated. I just want to feel better... especially before I am 100 lbs over weight!

Thank you,
26 Responses
Avatar universal
Could you please post the reference ranges along with those thyroid levels, ranges vary from lab to lab,  Thank You FTB4
Avatar universal
Oh ok...

TSH - 1.25    range 0.40-4.50 mIU/L

T4 Free 1.0   range 0.8-1.8 ng/dL

T3 Free 3.1   range 2.3-4.2 pg/mL

Glucose 94   range 65-99 mg/dL

Insulin <2      range <23 uIU/mL

C-Peptide 0.94  range 0.80-3.10ng/mL

Thank you!
Avatar universal
Also, under the T4 free it says "The current lot of free T4 reagent available from the manufacturer produces results that are approximately 9% higher than previous reagent lots. Please interpret these results accordingly"

Not sure if this effects anything?
Avatar universal
Your thyroid hormone levels may be in range but they are low, TSH is low also, and it should be higher with low thyroid although it is a Pituitary Hormone, but Your Free T4 is only 20% in its range, Your Free T3 is higher (As it should be) at 42% of its range, but should be higher. I would think you would feel much better with Free T3 higher at or around 65-70% and Free T4 at least 50%, That is where someone with Hypothyroid on medication would feel best at, so I would assume that would even apply to a person not on thyroid meds. Its easy for an MD to look at your results and say "Your in range, so your thyroid is OK" We hear that all the time with MD's that don't treat symptoms, and treat by lab ranges. Free T3 is the active hormone that controls your body's metabolism, which in turn has a direct affect on weight gain or loss and energy levels. I would advise you to request tests for Thyroid Antibody tests for Hashimoto's Thyroiditis  which are Tgab and TPOab  you could be in the beginning stages of this common cause of Hypothyroid Disease. These tests will prove or disprove,
Low Ferritin and low Iron Levels can cause low thyroid levels and symptoms also, so these tests would be needed along with two other tests for deficiency's in Vitamin B12 and Vitamin D, I assume the notice about the reagent used in testing throws off the result by 9% so for Free T4 you would add the 9% to the 20% = 29% in range. If you have any more results or questions do not hesitate to ask.  Best Wishes FTB4
649848 tn?1534633700
I agree that you need the antibody tests to see if you have Hashimoto's.

The notation regarding the reagent means that the result is 9% higher than previous batches of reagent had shown.  Therefore, if I calculated it correctly, previous reagents would have come up with a result of 0.91 vs 1.0.

There is some question as to whether those not on thyroid med need levels as high as those of us dependent on med, but since you have so many symptoms, I'd say your levels are not nearly high enough for you.

There's controversy over whether or not blood cortisol levels are helpful, since that is usually tested only once and cortisol raises and lowers according to a circadian rhythm.  It should be highest in the morning, as we prepare to go about the day, and gradually drop off as we prepare to sleep at night.  Supposedly, a 24 hr saliva test is the only way to check this, accurately and most doctors do not do the 24 hr saliva test.

I'm not sure I'd be looking at a pituitary issue just yet.

Vitamin B12 is the # 1 thing to check when fatigue is a prevalent symptom, as it can cause the most debilitating fatigue you can imagine.  It can also cause brain fog and memory loss, along with tingling/numbness in the feet/hands.

As FTB4 noted, an iron work up would also be good.

Do be aware that thyroid issues, along with B12 deficiency (Pernicious Anemia) often go hand in hand with PCOS.  Your glucose and insulin levels look good, but do be careful to eat things low on the glycemic index in order to prevent blood sugar spikes, which in turn produce insulin spikes, which in turn produces weight gain and eventually type II diabetes. That one becomes a vicious circle.
Avatar universal
Thank you both for your input. It is greatly appreciated!
So you feel with my free T3 and TSH being within "normal" range, I should still look into Hashimoto's first and not pituitary? I have the lab slip to check for the antibodies so I will def do that.

What other tests are done to check into the pituitary as the culprit?

Thanks very much. This forum has been extremely helpful!
649848 tn?1534633700
I do think you should look into Hashimoto's first.  

Thyroid Peroxidase Antibodies (TPOab) and Thyroglobulin Antibodies (TGab) to test for Hashimoto's

Other tests that might be helpful are:

Prolactin, Luteinizing Hormone (LH), Follicle Stimulating Hormone (FSH), Basic Metabolic Profile (BMP), ACTH, for pituitary testing.  

But since you have PCOS, you might already have been tested for some of these, so check previous lab reports to make sure you don't duplicate.
Avatar universal
Thank you. I will definitely check into these other labs. I was unaware of the connection to the pituitary..
649848 tn?1534633700
The pituitary is what drives the endocrine system, including thyroid, adrenals, reproductive system, etc.  TSH is actually a pituitary hormone, produced to stimulate the thyroid into producing hormones.  

I'm not saying there's nothing wrong with your pituitary; just that pituitary issues are relatively rare, whereas Hashimoto's is very common and it's not unusual for symptoms to show up, long before blood tests indicate a problem.
Avatar universal
I had the blood work done yesterday to check for the antibodies. If the results don't show the antibodies, is there still I chance I may have it then? Or are u just referring to the t3, t4, and tsh not showing Hashimoto's just yet?
649848 tn?1534633700
TSH and FT3/FT4 aren't indicators of Hashimoto's.  They only indicate how well the thyroid is functioning, as in hyper or hypothyroidism.

Antibodies and a thyroid ultra sound are what diagnoses the autoimmune aspect.

I've read that about 10% of people with Hashimoto's don't have positive antibodies.  An ultra sound could also diagnose it, if there is swelling and inflammation present, along with nodules.

There are also other types of hypothyroidism, as well, though Hashi's is much more common.  
Avatar universal
Oh ok, now I understand. My thyroid ultrasound said the size of my thyroid is normal but I had the two nodules. I'm awaiting the biopsy results now.
Avatar universal
I swear I was reading a letter that I wrote when I read your post!!
I have hypothyroidism,PCOS & had fertility issues too. Your symptom list made my jaw drop because they're my symptoms too. The foggy feeling is hard for everyone to understand unless you've experienced it. I swear if it weren't for having to get my kids to school,I wouldn't even get out of bed somedays because of the way my head feels & the fatigue.
Avatar universal
I have a similar problem. We have a history of hypothyroidism in female members of my family.

I did a blood test in my home country, while I was on vacation, and it flagged TSH as high.

When I got back in the US I did more thorough test for thyroid and he results were
In October 2014 these were my tests results:
TSH 0.50-4.50 mcIU/mL 3.96
Free T4 (Thyroxine, Free) 0.8-1.8 ng/dL 1.0
T3 free they didn't do.
Ferritin 13-150 ng/mL 11
Glucose  90
Insulin they didn't do.

My doctor said it is all normal and gave me some iron that has gone up to 22 in 4 months.

I have a lot of symptoms of hypothyroidism:
very low libido
dry skin (my psoriasis if getting wild)
weight gain
lack of physical activity due to general tiredness and fatigue

Do you think I should repeat my test now after 4 months?
Which test should I look for?

Thanks for the help
Avatar universal
In October, your FT4 was only 20% of range, which is low of the 50% target.  50% is where many of us have to be to relieve symptoms.  Your TSH is also on the high side.  Many years ago, AACE recommended that TSH range be changed to 0.3-3.0.  On this more reasonable range, you are high.  Both of those indicate hypothyroidism.  

Adequate ferritin levels are also necessary to metabolize thyroid hormones at the cellular level.  22 is still too low.

You should be retested for FREE T3, FREE T4 and TSH.  In addition, you should ask for the antibody tests to see if you have Hashimoto's thyroiditis, thyroid peroxidase antibodies and thyroglobulin antibodies..  
Avatar universal
I'm having the same problems you guys have been taking about. However a few extras. I'm also going through and almost all the way through menopause at 40. That doesn't help either. I did see an endocrinologist and had the t4 free done, tsh, and the antibodies along with others like the b12, vit d, and glucose. My main thing that came up was the antibodies. The labs said they should be 0-9 and mine were 149. T4 was at bottom limit normal. I did read this was signs of hasimotos. I've seen other people saying their levels were higher. I thought 149 was high. How high is too high? Just based on them and my symptoms is it likely to end up on meds? Thanks for any help. Enjoyed reading these posts.
Avatar universal
Please post your lab results with reference ranges.  Ranges vary lab to lab and have to come from your own lab report.  

We've seen higher antibody counts, but I'd still consider yours a strong positive. If your FT4 is on the floor of the range, you probably should be on meds now...I'll explain more when you post your labs.
Avatar universal
Hi. Thank you for getting back to me. My lab's are this:
T4 free .61 (.60-1.4)
Tpo antibody 149.70 (0-9)
bilirubin .22 (.30-1.00)
Tsh 1.82 (.44-4.21)
Sedimentation rate 22 (0-26)

Let me know if another lab would be helpful. I included bilirubin because use someone told some liver and thyroid things could go together.
Avatar universal
FT3 should be included in every thyroid panel.  The liver converts some of the FT4 to FT3, so liver dysfunction can impact conversion.  FT4 is the "storage" form of the thyroid hormones.  Before cells can use it, it has to be converted to FT3, the "active" form.

As I said, your TPOab is elevated, and that's a marker of Hashi's.

Your FT4 is right on the floor of the range.  This doesn't look too bad until you realize that thyroid reference ranges are very flawed.  The whole bottom half of the range should probably be considered hypo.  That's why the target for FT4 is midrange (based on where many of us had to be to be asymptomatic).  So, what seems "low normal" at first is really 50% below where it should be.

Unfortunately, your TSH looks good.  That's "unfortunate" because many doctors, even though they order FT3 and FT4, really never get beyond looking at TSH.  They were taught in med school that TSH was the gold standard in thyroid testing, and they aren't changing their minds.  So, what that means for you is that you will probably have to find an enlightened thyroid doctor.

They tested your sed rate to rule out deQuervain's thyroiditis, which is characterized by an elevated sed rate.

The first thing I'd do if at all possible is repeat TSH and FT4 and see what your FT3 is doing at the same time.  I think you'd feel a whole lot better on meds.  With elevated antibodies, it's a matter of when, not if, you have to start meds.  

Avatar universal
     Thank you again for the response. It was very helpful. I am onto an endocrinologist now rather than a family doctor and he is open to discussions so maybe he will be more willing when I do my follow up visit.  I'm starting to get worse and I'm getting more symptoms and problems I wasn't having before.
Avatar universal
Best of luck with your new doctor.  Keep us posted.
Avatar universal
I have had extreme fatigue for the last two years and started going to endo. I have my lab results of anyone can help me with them the dr says the only thing I need is b12. My ft4 is low .62 reference range starts at .66 ferritin 25 sodium 135 normal on range starts at 135 protein is also on the bottom number of normal b12 is 636 and he says that's low. Can anyone help with this he's not helped me at all and I am not on the search for a new endo.  Thanks!
Avatar universal
I have also had the same symptoms......fatigue, low libido, depression, and weight gain. My recent lab results are:
TSH  1.064  (0.358-3.74)
Free T4  9.7   (9.5-18.8)
Ferritin  16   (3-105)
B12  498  (156-672)
FSH  63.1    (50 yr old in menopause)
Prolactin  7.06   (1.8-20.3)
Cortisol   28   (155-570)
RBC's   all normal
Along with the low T4 my Cortisol is very low......
What could be the cause of these results?
Avatar universal
Welcome to our community.

It's usually best if, rather than tacking onto an old thread like this, you each start your own new threads.  You have two different issues going on here, and it can get confusing when responding to both.  If you each have your own thread, we can address your individual concerns.

Please include reference ranges with results as ranges are lab specific.

Tell us about your symptoms and any meds, especially thyroid meds you are on.
Sorry.....new to this procedure. Where do I add to my own thread?
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