Low TSH, T3+T4 in range, High TGAB, unsure what the issue is.

[Smithyis1337]

Hi everyone,

So I am posting on regarding my girlfriends (21yo if age matters) recent thyroid blood tests. We will be seeing the Doctor in a few days to discuss them but thought having a heads-up before hand would be useful. Results are as follows:

TSH: 0.0039  (0.3500 - 4.9400)
FT4: 13.28  (9.00-19.05)
FT3: 4.76  (2.63-5.70)
TGAB: 206.86  (0.00-4.00)
TPO-AB: 2.94 (0.00-5.61)

Her symptoms are as follows: Fatigue, foggy memory, heavy periods, arrhythmia which can sometimes lead to bad chest pain, shortness of breath, dry skin, depression, anxiety and insomnia.

I was thinking Hashimoto's disease even though she has hyper symptoms not hypo. She has had these symptoms for several months (around April/May time). Any input on this from someone knowledgeable or who has had similar results/problems would be great!

[gimel]

Wow, your friend's ferritin and Vitamin D are terribly low.  Ferritin needs to be at least 100 and D should be at least 50 ng/mL.   From one source, "Iron deficiency is shown to significantly reduce T4 to T3 conversion, increase reverse T3 levels, and block the thermogenic (metabolism boosting) properties of thyroid hormone (238-242). Thus, iron deficiency, as indicated by an iron saturation below 25 or a ferritin below 70, will result in diminished intracellular T3 levels."   In addition, low ferritin can cause the following symptoms.

    Minor aches
    Fatigue
    Weakness
    Heart palpitations
    Increased pulse
    Loss of energy
    Loss of libido
    Confusion
    Irritability
    Shortness of breath

"Vitamin D deficiency doesn’t always cause symptoms. When it does, some of the symptoms may include:

    difficulty thinking clearly
    bone pain
    frequent bone fractures
    muscle weakness
    soft bones that may result in deformities
    unexplained fatigue"

So, in spite of her low TSH indicating the possibility of Graves' and her TG ab result indicating Hashimoto's Thyroiditis, with her current levels of FT4 and FT3, the most immediate problems appear to be the low ferritin and low Vitamin D.  So she needs to supplement with about 5000 IU of D3 daily, and also supplement with at least 65 mg of a good iron supplement, and perhaps even get the doctor to give her an iron injection to get the level up faster.  Some good forms of iron include ferrous fumarate, ferrous bisglycinate, and ferrous sulfate.  Alon with the iron supplement she should take about 500 mg of Vitamin C to help prevent stomach distress from the iron.  In addition she needs to be tested for Vitamin B12 and supplement as needed to get into the upper end of the range, to hlep with fatigue.  

What time of day was the blood draw for the cortisol test?  I am not familiar with ultrasound testing for parathyroids.  Has she been tested for calcium and PTH?

[Smithyis1337]

Thank you again for your replies! I had the same conclusion and so did the Doctor, however I felt the doctors advice was inadequate. She recommended 500IU a day of Vitamin D3 daily and 27mg of Ferrous fumarate. I argued with the Doctor saying for her weight (121lb) she should take between 5000IU and 10000IU to reach a level of 50-60, in the end she relented and said we could do as we wished but 500IU was still her advice. She was recommended taking an EKG to see if the heart palpitations have got better but we didn't see the point in this.We probably won't see this Doctor again.

We have found somewhere to get her TSI tested do you still think we should? We can tack a B12 test on there for sure as well.

The Cortisol was drawn in the morning, around 9am. No test for Calcium was recommended but I have read it is good idea if you suspect parathyroid issues,

[gimel]

If you need any info to help influence the doctor  to get what is needed, you can use the following link.  I highly recommend reading at least the first two pages and more if you want to get into the discussion and scientific evidence for all that is recommended.

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

[Smithyis1337]

Thanks for the information, I read it all! Doctors tomorrow, so we will ask about the tests and if he knows somewhere we can get them done. If not we will find somewhere ourselves.

[Smithyis1337]

Hi Gimel, we have my girlfriends results back:

Ferratin:  8  (10-150)
Cortisol: 10.4 (2.9-17.9)
Vitamin D: 17.2  (<20 Severe Deficiency, 20-30 Deficiency, 30+ Normal, 150+ High)

The clinic does not do a TSI or reverse T3 test, we will keep looking for a lab that does but we don't know what the TSI test is called in Russian. We will discuss it with the doctor to see if he can recommend a lab to use.

Thyroid Ultrasound: Enlarged thyroid but will be getting more information from the doctor today about it. She has however been advised to come back for a parathyroid ultrasound.

So I can see she has extremely low Iron and Vit-D, my understanding is that this could be causing her hyper symptoms, most notably arrhythmia. It would also indicate to me that being prescribed T4 alone will not be enough as her body won't be able to convert it to T3 easily?

Any insights are welcome as always!

[gimel]

When assessing a potential thyroid problem, the most important consideration is symptoms.   Your friend has a number that are most often related to hypothyroidism; however, some can also be related to hyperthyroidism.  Her lab results show FT4 at about 42 % of the range, and her FT3 result is about 70% of the range.  Those levels are not typical of a person with hypothyroidism, although there are many other factors, and serum thyroid levels do not always reflect tissue thyroid levels, which determine a person's thyroid state.  Her TSH is typical of hyperthyroidism in a person not taking thyroid medication, and could be an indication of Graves'Disease.  The test for TPO ab is negative, while the TG ab test shows the likelihood of Hashimoto's Thyroiditis.  So she has a mixed bag of test results.  

So I think your friend needs to get some additional testing done to check for Graves'.  The test for that is the Thyroxine Stimulating Immunoglobulin test (TSI).  In addition to the TSI, it would also be a good idea to do an ultrasound test of the thyroid gland to check for nodules.  With Hashi's in particular, nodules can form that then leak thyroid hormone faster than normal.  Also, it would be a good idea to test for Vitamin D, ferritin, and cortisol.  The doctor may not agree, but it would also be a good idea to test for Reverse T3 (and a Free T3 from the same blood draw).  Studies have shown Reverse T3 and the ratio of FT3 to RT3 to be a good indicator of tissue thyroid levels and effects.  

If you are able to get these tests done, please post results and reference ranges and we will be happy to help interpret and advise further.  

[Smithyis1337]

Thanks a lot for this comment! We will certainly bring up these additional tests when we see the doctor. If we can find somewhere to get these tests done then we will (sometimes it's not so easy in Russia to find places to do things, even here in Moscow).

Again, thanks for your insight.

[gimel]

With her TSH result I think it would be a good idea to get the TSI test, and also a B12 test.

Why was parathyroid a possible issue to the doctor?

[Smithyis1337]

Ok, we are booking in the TSI and B12 test today. The doctor herself didnt mention anything about parathyroid, the person that suggested it was the  Ultrasound...tech(? not sure if that is the right word sorry)

I will be back here to bother you for advice when we get  the next results. Thanks!