Lab Results Interpretation - Am I Confused or is My Doctor?

[Purplemuse]

I just got back test results for treatment of Hypothyroidism and my doc wants to lower my T4 medication (levothyroxine). These are my test results as written in results:

TSH, reflex 0.04 / Range: 0.27 - 4.20 uIU/mL
Free T4 .89 (L) / 0.27 - 4.20 uIU/mL
Free T3 2.93 / Range: 2.57 - 4.43 pg/mL

With a normal T3 result, shouldn't my medications be left alone regardless of T4 and TSH levels?
What I understand is a below range (L) TSH level means the thyroid is producing too much T4, a "low" or below normal range free T4 means that there is not enough T4 being produced by the thyroid and a normal free T3 means that regardless of the other the numbers there is "normal" amount of free T3 being bound to cells to maintain a normal metabolism.

What she is telling me is that my TSH is too low (meaning it is working too hard)
My T4 is low - therefore is also working too hard
My T3 is normal
and therefore wants to lower my medications

I have been taking 75MCG of levothyroxine and 25MCG of liothyronine since December. Her preference is that I quit taking the T3, but because she knows I am reluctant to do that, she lowered my dosage of levo. to 50MCG (back to what it was prior to December).

My feeling is if my T3 is normal, then leave my T3 medications alone

Three months ago (February) (with the same meds I am on now) she only measured my TSH which was .33 (low normal)

Prior to that (December) they were TSH: 3.43 (Range: 0.27 - 4.20 uIU/mL), T4 0.76 (L) (0.27 - 4.20 uIU/mL)  T3 3.43 (Range:2.57 - 4.43 pg/mL). I was VERY symptomatic at that point with significant hair loss, weight gain, depression, fatigue, constipation and excessive menstrual bleeding, so the meds were increased.

Currently my mood is fine, I am experiencing none of the previous symptoms, I have had much more energy than I have since before becoming hypothyroid (so much so that I began to exercise in April and since then have been able to lose 17 lbs (NOT effortlessly as a hyperthyroid might suggest, but walking 8 miles a day and changing my diet substantially (low carb), I have fought hard for every lb of loss. I still need to lose another 5 lbs to be back to my weight prior to my thyroid crashing. Which is why I am reluctant to make a med change back to doses which previously were ineffective. I worked very, very hard for this weight loss and do not want to gain it back.

So, am I the one confused by these results, or is it my Dr (a 2nd year GP resident)?

[artfemme]

I doubt it very much. It generally takes 1 week to 10 days for T4 to build up in your system. Is it possible that you were having a thyroid storm ? Have you been tested for Hashimoto's antibodies ?

This thread is 2 years old already. It would be much better if you posed this as a question on the forum. I only saw this because I got an email alert as I rarely come on this site anymore. More people will respond if you post it as a stand alone comment. If you do that please post your current labs including the lab ranges. For an example of how to do that, check the very first post up at the top for the format. Then click "Ask a Question" to get to the forum.

Good luck.

[paprisuman]

is it possible to reduced TSH from 21.6 uIU/mL to 4.20 uIU/mL by taking 1 Thyroxin tablet of 100 mcg??

[artfemme]

Dear Purplemuse

These are the most current scientific papers I've found that relate to combined T4/T3 therapy. Both of the papers from the EJE have recently been published here in US and accepted by the NIH. I printed them out and took them in to my doctor. The American Thyroid Association has been basing their TSH-centric methods on a paper on T4/T3 written a couple of years ago by a doctor at UCLA, using a very limited sample of patients and standardized rather than personalized dosing with medication. ATA LOVED this paper because it backed up the stance they had already taken. However the more recent articles below, all meta-analyses, refute the UCLA study and supersede it. they also happen to agree with the personal experience of many of our members.

Very impressed with how well you have educated yourself already. I had FIVE endos do to me what your doc is trying to do to you. They ping- ponged my metabolism all over the place, prolly wrecked it. I finally got my PCP to take over my care and basically do what I told her to do based on the results of blood tests I got every 5 or 6 weeks for over a year and finally my FREE levels are up where they should be and I feel better.

I was able to convince her to do this because she saw the radical physical changes I went through every time the endos lowered my meds; because certain of my metabolic labs, like cholesterol, were wildly out of line from my usual and I told her that if I was right about T3 and TSH, that would normalize without change in diet or exercise (it did, very quickly); and because I kept bombarding her with papers like the ones below so she had no excuse for dismissing what I told her since there was science to back me up.

Also, just a reminder, NEVER take T3 before having your blood drawn, it will skew your test. Always remember that T3 is 4X stronger than T4, so a reduction of even 5mcg is a lot. If I were you, I'd raise T4 and see if it raises your T3 rather than lowering the T3 ad hoc. Also a good idea to have your Vit D and Vit B12 checked, at a bare minimum.

All the best !


http://www.eje-online.org/content/161/6/955.full
http://www.eje-online.org/content/161/6/895.full
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3148220/

[gimel]

If you would like, I will be happy to call the doctor's office and try to get answers that will reveal whether the doctor is one that has "The Immaculate TSH Belief", and/or uses "Reference Range Endocrinology", as opposed to treating clinically.  If you want me to do this, just send the doctors name by PM.

[Purplemuse]

I forgot to tell you all that I emailed my doc and talked to her about reducing my T3 med to 5 -10MCG, and she said she didn't think there was any dosage lower than 25 that I should quit taking it altogether. Then she added that if I needed discuss this more that I should come in and see another Dr that she had no further appts available the rest of the month.

I checked and she outright lied to me, there are smaller dosages of liothyronine.
I am done with her. We can disagree and I can respect that, but I will not be lied to and treated like I am "one of those" kinds of patients (who act like they know more than their Drs do).

[Purplemuse]

All those endos are at the University of Iowa and that is where I am already seeing my GP.

I have decided to leave my meds alone and see this person - so that the picture they see is the same one my GP sees.

If I don't like this man I will seek yet another doctor, and yes. I will find one, even if I have to drive an hour there and back. I want to feel well, but more importantly, I want to feel that my doctor trusts me to know my own body enough to say "this is not normal and this is" and then he/she help me find that normal despite what the TSH number is.

Is that too freaking much to ask in a University town with 1,000 of Doctor and and another 1,000 soon-to-be doctor residents and fellows?

[gimel]

I brought up this list of Endos in your general area.  I see that all in Iowa City are in one location, therefore an unlikely place to find a good thyroid doctor, based on your prior experience.  The others listed are 50 or more miles away.  Do any of those have any interest for you?

http://www.healthgrades.com/provider-search-directory/search?q=Diabetes%2c+Metabolism+%26+Endocrinology&loc=Iowa+City%2c+IA+52242&search.type=specialty&prof.type=provider&f.specialty=49&f.distance=100.00&pagenumber=1&perpage=20&sortby=bestmatch&f.distance.display=middle&o.city=Iowa+City&o.st=IA&o.zip=52242&o.lat=41.661583&o.lon=-91.552513

[Purplemuse]

I just did a search for a certified naturopath here in Iowa City and this is what I found in my search! Unbelievable.

Due to the lack of licensure in Iowa and the Iowa Board of Medicines present position against practicing Naturopathic Medicine without a license, It is currently illegal to practice Naturopathic Medicine in the state of Iowa without risking our ability to get licensed in the future.

If you are interested in seeing a Naturopathic Physician for your health care please support us in getting the profession licensed in Iowa during the Spring 2012 Legislative Session.  

[Purplemuse]

I just received an email suggesting that I "choose a best answer".

I think this has been a wonderful discussion and you all have been very helpful and there are many "best answers" contributed here.

I can't choose a single comment, you each have given me encouragement, validation and very helpful suggestions. Thank you.

[Purplemuse]

Those are some really valid questions to ask and it would save me much time since it is a month away and then if I have to look it may take another month. That would be really disheartening and discouraging to me, so I think I will take your suggestion and do just that.

[gimel]

I really hate to see a thyroid patient pin their hopes on a new doctor and then have to wait a long time before finding out if he is a good thyroid doctor or not.

As an alternative, many times when trying to help a member find a good thyroid doctor, I call the prospective doctor's office and mention that I am looking for a good thyroid doctor for a friend, but before any appointment, I would like to ask a nurse two questions  That usually always gets a nurse on the line.

Then I ask if the doctor is willing to treat a hypo patient clinically by testing and adjusting Free T3 and Free T4 as necessary to relieve symptoms, without being constrained by resultant TSH levels.  I also ask if the doctor is willing to prescribe T3 type meds rather than just T4 types.  If either answer is no, then I just keep looking for a good thyroid doctor.

Check your new doctor out by asking these 2 questions and you might save yourself a lot of waiting and frustration if he should turn out to be a suspect rather than a prospect.

[Purplemuse]

I got a call back and I will be seeing an endocrine doctor on August 7th. Hopefully, this person won't be one of those who just looks at the TSH levels. Iowa City is a pretty liberal community so I will look to see if there are naturopaths here somewhere. Surely there are, might have to go out of town to find one, I will do some research and if this doc doesn't work out, that will be my next step.

[gimel]

Sorry, Shell Rock won't work.  When I looked closer at the distance, it is about 2 hours away from you.  

[payton382]

In my experience, every Naturopath I've been to (4 of them) have all looked at and treated the Free's.  They all took TSH into account but it was never their driving force and some almost ignore it compared to where my Free's are at.  They all prescribed and were pro whatever works; compounds, T4 only, desiccated, and T3 only.  They were all always concerned with symptoms no matter what my levels were.  They also would test me for whatever I asked.  3 of the 4 took my insurance.  

I know not everyone likes going to ND's and honestly my ND only manages my thyroid.  My Internal Medicine Doctor does everything else but keeps my latest thyroid labs that I bring in from the ND and my medication dosage in my history.  

I live in Washington but close to Portland, Oregon so I don't know if ND's are just more liberal around here or what because I'm not sure everyone else has had the same experience I have.

As far as your mom and sister having hyper and you having hypo, I think that's pretty normal.  My grandma had Grave's Diseasse, my mom had Hashimoto's, and I had Grave's so I'm expecting at least one of my girls to have something.      

[Purplemuse]

I looked through the website for the Internal Medicine Clinic at the U and there are those who specialize in endocrinology / thyroid. So I filled out a form requesting an appointment and gave a bit of the information in the form as to why I want to be seen  (hypothyroidism still unstable after several years of treatment, second opinion), and noted that I had no idea if my condition is primary or secondary.

They already called and I have an appointment to be seen on August 7th. Unfortunately, that won't help me with this most recent medication issue, but it is hopeful. Who knows what my levels will be at that point.

I did email my doc and suggest cutting the T3 back stating that it made sense to reduce the hormone that I have some detectable amount of in my blood and leave the T4 alone since it is barely registering. I did that yesterday.

She hasn't responded. I think I may well have pissed her off. Wait until she finds out I am seeking a second opinion! It would be too bad because I do like her and wouldn't like to change doctors altogether. I just think it's time to let someone else handle the thyroid stuff.

Thank you for all your responses. I can't tell you how much I appreciate feeling validated with my concerns. I was beginning to think that I had misunderstood all that I have read about my illness and how it is treated.

I am assuming since my GP tested for T's 3 & 4 at the same University that this doctor will too. I suppose my first question should be - do you medicate solely on the basis of TSH levels, or do you look at the FT's as well? I would also like to know whether this is primary or secondary. No one has bothered to find out why my thryroid started crapping out in the first place.

My mom had to have hers irradiated and my oldest sister had to have hers removed. They both were hyperthyroid. So it seems odd that I went the other way. Though I am the one who tends to have the autoimmune-related, what I call, "weird **** syndrome". I do think they ought to make this an official diagnosis. :)

How did you all find the doctors who finally helped you? Do your doctors involve you in your treatment like you are a partner in your own health? I wish I could find one of those. I know they exist... or perhaps I watch too many medical shows on Hulu! :)

[Purplemuse]

where is shell rock?

[Jackie419]

I had to find a new doctor, called one and asked receptionist/nurse to ask the doctor if she tests FT3, FT4 before even making the appointment and was told the doctor did test those things. Only to find out over a month later at 1st appt (and last) that she does NOT test FT3 at all, and was looking at my TSH only. I was livid. Pain in the arse to keep looking for another doc that does it right, but I HAVE to, and you certainly do too, or you will never feel well....good luck to you.

[gimel]

Would you be willing to travel as far as Shell Rock?

[Barb135]

Just goes to show you that University doctors can be wrong, too!!  Don't forget that even though some endos might specialize in diabetes they can still treat thyroid.  My endo also specializes in diabetes, but in some ways I believe that's to my advantage, because I can pretty much drive my own treatment.

When you call the different doctors, make sure you ask if they test both FT3 and FT4, if they treat based on those vs TSH, if they are willing to prescribe T3 medication.  

[Purplemuse]

Can anyone tell me how to post a question to the Thyroid Doc in the Experts area? I can't seem to find instructions in how to do that?

[Purplemuse]

This is a Dr at the U of I!

I did a search for endocrine Drs in my area - most specialize in Diabetes, but some listed specialization in "Metabolic Disorders" - which includes Thyroid issues too I would think. Not a single one outside the Internal Medicine clinic at the U. I am going to call them to see if I can come see someone without my Dr making a referral first.

My first preference would have been to see an Endocrin Doc outside the U (since many are reluctant to go against colleagues)  - but there isn't a single one!

[Purplemuse]

Thank you I have saved this to print out.

[gimel]

Thought you'd find this scientific study to be interesting info for your doctor.  Although I'm sure their minds are made up and nothing will change them.

From a study published in the British Medical Journal Volume 293.  Here is the link and a couple of quotes from the link.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1341585/pdf/bmjcred00253-0040.pdf

"When you are being treated with thyroid hormone, the TSH should be very low as long as the T3 and T4 are not too high. More often than not, doctors will lower a patient's thyroid medication based on the TSH being "too low" without measuring the actual levels of the hormones directly. This goes back to our training when we are taught that a low TSH is a sign of an overactive thyroid gland; this is true but NOT IN A PATIENT TAKING THYROID MEDICATIONS. A low TSH should be the goal of treatment, not a sign of overtreatment as long as there are no signs or symptoms of overtreatment.



"It is clear from table IV,
however, that serum thyroid hormone and thyroid stimulating
hormone concentrations cannot be used with any degree of con-
fidence to classify patients as receiving satisfactory, insufficient, or
excessive amounts of thyroxine replacement. There is little dif-
ference between the ability of concentrations of total and analogue
free thyroxine to detect over-replacement; the poor diagnostic
sensitivity and high false positive rate associated with such measure-
ments render them virtually useless in clinical practice. Concentra-
tions of total triiodothyronine, analogue free triiodothyronine, and
thyroid stimulating hormoneareindicating over-replacement.tions of total triiodothyronine, analogue free triiodothyronine, and
thyroid stimulating hormone are also incapable of satisfactorily
indicating over-replacement. The tests perform equally badly in detecting under-replacement."

"Our findings emphasise the need for laboratories to make their
users aware that the reference ranges for serum thyroxine, free
thyroxine, and thyroid stimulating hormone concentrations in
patients receiving thyroxine replacement are considerably different
from the conventional ranges; they should also point out the
limitations of these ranges."

This study was further strong evidence that when taking thyroid meds, test results, especially TSH, are too variable and not reliable to use for dosing a hypo patient.  Conclusion was that clinical treatment is the best for the patient.  This was very clear in their statement that, "We consider that biochemical tests of thyroid function are of little, if any, value clinically in patients receiving thyroxine replacement. Most patients are rendered euthyroid by a daily dose of 100 or 150 ,mcg of thyroxine. Further adjustments to the dose should be made according to the patient's clinical response."

Of course treating a hypo patient clinically would require the doctor to actually listen to the patient and determine what may be causing symptoms, rather than just running tests and then diagnosing by whether the results fall within the so-called "normal' ranges that we all know are flawed.  A computer could diagnose and treat a hypo patient equally as well as many doctors who have the "Immaculate TSH Belief" and only want to use "Reference Range Endocrinology".  

[Barb135]

Just in case another voice can add encouragement -- get a new doctor, yours will keep you ill, because she's looking only at TSH.  

I had a doctor that did that and I truly thought he was going to kill  me.  BTW, my TSH lives in the basement at a whopping < 0.01, so I've been through your struggle; in fact, still go through it.  

Iowa City has some excellent, innovative doctors; have you tried contacting anyone at the University?