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1383383 tn?1279360481

Hypothyroid with a normal TSH

This is an extensive post but gives many details that I believe are necessary. I have had increasing hypothyroid symptoms for about 3 years with current levels becoming intolerable. After becoming insistant with my doctor he finally started me on levothyroxine 25mcg (TSH has always been normal). After four weeks on this therapy the muscle and joint pain became so bad that I could barely walk. At six weeks my labs showed low FT3, low normal FT4, normal TSH. He took me off the levothyroxine and started me on 5mcg of liothyronine. After two doses I had noticeable relief from the pain (could cut back on the large amounts of ibuprofen) but no other improvements noted. After six weeks of this therapy my labs showed low normal FT3, a drop in FT4 to the bottom of the range and an increase in TSH (still normal though). I visited my doctor and told him that my energy levels were at an all time low. At this point I don't think he new where to go so he put me back on the 25mcg levothyroxine as well as the 5mcg liothyronine and gave me a referral to an endocrinologist.

An interview with the endocrinologist resulted in him stating that I was "clearly hypothyroid" although he was a bit confused about my ultrasound that showed no thyroid abnormalities. A complete set of labs were ordered which came back with FT4 in the normal range, FT3 in the low normal range, TSH normal, TPO antibodies were ok. An ACTH stimulation test showed good adrenal response and no other endocrine problems were found. Please note that I was taking the low doses of thyroid hormone. His assistant called and stated that I was to be released back to the care of my primary doctor.

At this point I was extremely dissapointed and still suffering. My MD is at a loss to explain anything much less offer a solution. I requested a reverse T3 lab be done but this never happened??? Previously when I asked about this his reply was "we don't do that". My continued requests have resulted in a referral to another docter who does do RT3 testing (the only one in my area).

I have many questions about this but the one that comes to the front is why all the mystery about what seems to be a thyroid hormone problem. I seem to have resistance at every step of the way. I called the endocrinologists office inquiring about non-thyroidal illness syndrome and was told that my symptoms were not consistant with NTIS and I was not hypothyroid??? Getting FT3 and FT4 labs ordered by my primary docter was only accomplished because of my insistance???

As for the hypo symptoms. Does anyone have any idea of what is going on? The symptoms at this point have been very difficult to tolerate but I have no choice but to grit my teeth and hope that the next docter has some answers. Patience (and my wallet) have become very thin. Please advise.
26 Responses
Avatar universal
You don't give exact lab numbers, so let me give you kind of a "general" answer and if you want to post exact numbers (with reference ranges because they vary lab to lab), we can be more specific.

FT4 often has to be in the middle of the reference range before symptoms are relieved.  FT3 should be higher in its range and in the upper half to upper third of the range.  (These are rules of thumb, and don't work for everyone.  They're a "starting point" until you know where you feel best.)  Both FT3 and FT4 have to be in balance for us to feel our best.

Do you split your T3 meds into two half doses?
1383383 tn?1279360481
Thank you for your interest. The following labs were taken without the thyroid supplements being taken for several weeks. I stopped taking them after the endocrinologists office called and said that I was not hypothyroid??

FT3      2.30   (2.57-4.43) pg/mL

FT4      0.64   (0.50-3.00) ng/dL

After my labs revealed that I did not have a problem with TPO antibodies I decided to try supplemental iodine (500 mcg/day). These labs were unchanged by that but it is interesting to note that the iodine did provide some much needed relief from symptoms.

1383383 tn?1279360481
Forgot to mention (yes, my memory is shot). I took the 5 mcg liothyronine in the morning (single dose) and the 25 mcg levothyroxine at bedtime.

Since I did take these meds individually for an extended timeframe I can give some comparison. The levothyroxine did have some very subtle effects but when all is said and done I would say it was detrimental. The liothyronine did show some definite benefit though not nearly enough.
Avatar universal
Your FT3 and FT4 are clearly hypo.  That's a very unusual range for FT4, but if it's accurate, you are in at 6% of range, and as I said above, most of us find that FT4 has to be around 50% to feel well.  Your FT3 is below range, and that often has to be 50+% of range.  So, it appears you would benefit from taking thyroid hormones.

It's not unusual for symptoms to worsen somewhat after starting meds.  Your body has become used to not having thyroid hormones available, other organs are trying to make up for that, and a whole rebalancing act has to go on in your system.

Levothyroxine (T4) is very slow acting and takes weeks to build in your blood.  It should be taken on an empty stomach (which is why most people take if first thing in the morning and don't eat or drink anything for half to one hour after).  If you take it at night, you should be sure that it's at least 3-4 hours after any food or drink, and if you are very hypo and your digestion has slowed, it could be even longer.

Liothyroinine (T3), on the other hand, is very fast acting and quickly neutralized by your body if not used promptly.  For that reason, many people split the dose into two half doses, taking one first thing in the morning and the other sometime late morning or early afternoon.  Splitting helps minimize the peaks and valleys in T3 levels that you can get otherwise.

If I were you, I think I'd give meds another try.  Until you get both FT3 and FT4 to appropriate levels (or close) for you, you are probably not going to feel a lot better.  If you're not customarily sensitive to meds, you might try starting on a slightly higher dose of T4.  That might get you through that interim period faster.  Whether or not you want to combine that with some T3 is another decision.  Because it is so fast-acting, T3 will make you feel better in a shorter time than T4 will.  However, if you want to try T4-only therapy, which is argueably the easiest and relies on the body's natural conversion process to respond to demand, you can always add T3 in later if you find you convert slowly.

Have you tried taking the T4 in the morning?  I also think you'd do better splitting the T3.  



I'd suggest having iodine levels checked.  If you are deficient (rare in the developed world), your body cannot make thyroid hormone.  
Avatar universal
Have you tried avoiding fluoride? I've read fluoride can interfere with iodine absorption, so even if you take a supplement, it may not work. I've also read some things about NOT taking iodine supplements, so it's probably best to talk to a good doctor (which I know is not easy to find)!

I started avoiding water with fluoride and started using fluoride-free toothpaste, and my hypothyroid levels started "improving", although I now have symptoms of hyperthyroidism, so I am still trying to get it all figured out since my doctor keeps lowering my Synthroid dose. Someone also recently told me to avoid soy and that perhaps coconut oil can help! These are all just some things I have heard. I hope you start feeling better soon.
1383383 tn?1279360481
Thanks for the comments.

I did notice changes when I was on the levothyroxine that seemed to indicate a "re-shuffling of the deck" so to speak. The liothyronine almost immediately went to work and showed definite improvements.

The thing that I find confusing is that I took both of these individually for a period of at least six weeks before having labs done with very different results. Here's the numbers.

Levothyroxine 25mcg only:

TSH   1.80   (0.30-3.00) uIU/mL

FT3   2.33   (2.57-4.43) pg/mL

FT4   0.79   (0.50-3.00) ng/dL

TT4   6.5     (4.5-10.5) ug/dL

No surprise that the FT4 is higher than labs not supplemented with levothyroxine. I did see some ups and downs with this therapy but in the end I thought things were worse. The pain got really bad at four weeks in. Perhaps this was just coincidence.  

Liothyronine 5mcg only:

TSH   2.38   (0.30-3.00) uIU/mL

FT3   2.65   (2.57-4.43) pg/m

FT4   0.59   (0.50-3.00) ng/dL

No surprise again, the FT3 increased marginally. As stated, I saw quick improvement with this therapy (some relief from the pain) but in the end it was unsatisfactory. The one thing interesting here is the change in the other numbers. FT4 down, TSH up.

Levothyroxine 25mcg and Liothyronine 5mcg (these were taken at a different lab):

TSH   1.60   (0.35-5.50) UIU/ML

FT3   2.25   (2.20-4.20) PG/ML

FT4   1.07   (0.70-1.70) NG/DL

TPO Abs   19.9   (0.0-35.0) IU/mL

Perhaps this is why the endocrinologist said I was not hypothyroid after stating that I was "clearly hypothyroid". Just for the record. The labs sent from my doctors office did not have reference ranges (inexcusable). I keep copies of all my own labs now.


I am aware of the fluoride problem (as well as other hallide exposure) and this is one reason I started the iodine. Iodine is supposed to drive out fluoride and bromide (why are these in things we consume anyway). Iodine defeciency does not seem to be a problem. I did an iodine patch test and I ended up washing it off. It did not want to absorb.

I did note a definite improvement with the iodine. Initially I had a lump in my throat but that subsided in a few days. It took about two weeks to really kick in. I had some ups and downs during that period but mostly ups.

Just for the record. My general health is very good. Two years ago I started doing cardio exercises at a local fitness club attempting to build endurance. After struggling along with this for a couple of months I gave up. The more I exercised the worse my endurance became??? The gym regulars were baffled by this. My doctor ordered a pulmonary function test and a cardiac stress test. Everything looked good there. BMI 21.2, no smoking, no alcohol, no "recreational" drugs, fasting glucose levels consistently under 90, blood pressure is typically in the 105 over 72 range but does vary. I have seen it as low as 90 over 50 (problems encountered at this level). I watch my diet carefully to avoid sugars and HFCS. Let me state that weight gain has not been a problem (as is often the case in hypothyroid patients). I do have a recurring problem with mild anemia and have been supplementing with iron. In the past the anemia did respond nicely to the addition of iron (I eat very little meat). Serum iron, ferritin, etc. respond well although CBC is slow to improve.

Don't know if this brings up any other thoughts (other than TMI) but that is why I am posting. Thanks again for the info. When you don't have answer's, it's good to know that others are listening.

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