Hypothyroidism or Hashimoto?

[Sportynr13]

In August 2015, I woke up one day with a large lump on my neck. I quickly had an ultrasound and they found multiple thyroid nodules. They chose to monitor it and I had another ultrasound February 2016. This time I had a new physician and I got a FNA ordered. The results came back from the biopsy as benign. I had another ultrasound in July 2016 and it said everything was stable. I just had my annual ultrasound in this past July and it looks like my nodules/cysts on my right lobe have been growing. One grew as much as 5cm.

My main concern is the symptoms I have been experiencing this past year. My entire life I have always been tired, fatigue, hands and feet always cold, and could never lose weight on any diet. Lately I am exhausted, my brain is foggy, increase in anxiety, abnormal body temperature, constipation. I had my TSH, free t3, and free t4 checked and they said everything is normal. I see an endocrinologist next week but wanted to get some insight on what other test should I ask for? I know something isn’t right in my body, I can feel it. Here are my levels:

TSH-1.42 ul U/ml
Free T4, 1.1 ng/dl
Free T3, 3.6 pg/ml

Any help, thoughts, what you experienced would be great! It sucks having to fight for additional tests when I can feel something is wrong. They are currently just chalking my symptoms up to anxiety/depression.

Thanks!

[gimel]

With the multiple nodules found on your thyroid gland, you should be tested for the possibility of Hashimoto's Thyroiditis.  Two tests should be done:  Thyroid Peroxidase antibodies (TPO ab) and Thyroglobulin antibodies (TG ab).  If Hashi's is the cause, it will show up in those tests.  

As mentioned, the most important consideration in evaluating someone for hypothyroidism is symptoms, and you have a number that are typically related to being hypothyroid.  Unfortunately most doctors only pay attention to TSH, and if it is in range, they usually deny the possibility of hypothyroidism.  If TSH is above range, they will test for Free T4.  If FT4 is in range, then it will be diagnosed as subclinical and usually nothing further is done, until test results go out of range.  This is very wrong.  Symptoms, or lack of symptoms, are dependent on tissue thyroid levels and effects, for which there is no direct measure.  Serum thyroid levels may be significantly different from tissue thyroid levels due to a number of variables.  

Even though your TSH is well within range, and your Free T4 is at the top of the range, your Free T3 is only at 50% of its range.  So in view of your symptoms, you need to do further tests to get a better idea of tissue thyroid levels.  Specifically I suggest that you should test for Reverse T3 and Free T3, from the same blood draw.  The ratio of Free T3 to Reverse T3 is a good indicator of tissue thyroid levels.  In addition you need to test for Vitamin D, B12, ferritin, and cortisol.  

A good thyroid doctor will treat a hypothyroid patient clinically, for symptoms, by doing all the recommended testing and then prescribing meds to raise Free T4 and Free T3 levels as needed to relieve symptoms, without being influenced by resultant TSH levels.  Symptom relief should be all important, not just lab results.  

I have to say that based on the experience of many people I am not optimistic that the Endocrinologist will be a good thyroid doctor like you need.  Most seem to have the "Immaculate TSH Belief" and only pay attention to that, which doesn't work for the patient.  When testing beyond TSH they will then use "Reference Range Endocrinology", by which they will tell you that any thyroid test that falls within range means you are normal and don't require treatment.  That is also usually wrong.  

So, in preparation for the appointment, and in order to get the tests you need to confirm the need for treatment, I highly recommend reading at least the first two pages of the following link, and read more if you want to get into the discussion and scientific evidence for all that is recommended.  Then you can raise the right questions with the doctor and hopefully get what you need.  If it doesn't work out that way, then let us know where you are located and perhaps we can suggest a doctor in your area that has been recommended by other thyroid patients.

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

[gimel]

In trying to assess a person's thyroid status, the most important consideration is symptoms, of which you have many that are frequently related to hypothyroidism.  After symptoms, test results are next in importance.  In order to try and evaluate your test results we need you to post the reference ranges shown on the lab report for those results.  

[Sportynr13]

The TSH Reference range is 0.45 - 5.10 uIU/mL
T3-2.8 - 4.4 pg/mL
T4-0.6 - 1.1 ng/dL