18552345 tn?1472243264

New Lab Results--Please help!

I'm in tears trying to figure out why my lab results are not getting any better. My t4 is not budging but the tsh has dropped dramatically. What is going on? :(

August 22nd-  6 weeks on new increase of 75 mcg Synthyroid  & 10 mcg generic cytomel (split 5 hrs apart)

TSH- 0.732  (0.340-5.600)
Free T4- .62 (.57-1.25)
Free T3- 2.8 (2.2-4.3)
Ferritin- 35 ( 11-307)  I take one iron supplement per day.

June 29th- 56 mcg Synthyroid & 10 mcg generic cytomel ( taken 5 hrs apart)

TSH- 3.087 (0.340-5.6)
Free T4- 0.59 (.57-1.25)
Free T3- 2.9 (2.2-4.3)
Ferritin- 24 (11-307)

20 Responses
Avatar universal
No need for tears.  What you are experiencing is quite common when starting on thyroid med, until the dose is high enough.  The reason your Free T4 and Free T3 levels have not increased is that serum thyroid levels are the sum of both natural thyroid hormone and also thyroid med.   When taking thyroid med, the hypothalamus/pituitary response is to reduce the TSH output.  As you can see that has happened.  Since TSH stimulates output of thyroid hormone, less TSH means less natural thyroid hormone production.  When thyroid med is increased to the point that TSH is suppressed to the low end of the range or below and is no longer stimulating output of natural thyroid hormone, further thyroid med will cause Free T4 and Free T3 to start increasing.  

So to get your Free T4 and Free T3 optimized, you need to further increase your dosages.  Be aware that many doctors don't realize that a suppressed TSH is a frequent occurrence when taking adequate thyroid med.  Many of them interpret suppressed TSH as being hyperthyroid.  That is not the case, unless the patient actually has hyperthyroid symptoms due to excessive levels of Free T4 and Free T3.  You can read about this in Item no. 10, page 13 in the following link.


I also suggest reading at least the first two pages of the paper.  
Avatar universal
The real question is how do you feel?

I thought is that every bit of the additional T4 is being used and also the T3.  So essentially the amount you increased was "absorbed" and used by your body.  It is possible your tissue thyroid level increased and your pituitary is noticing that and telling your thyroid to slow down (reduced TSH).

Having said that, both of your FT4 and FT3 levels seem pretty darn low.  Your FT4 is still close to rock bottom (only 7.35%) when the rule of thumb is to be at or slightly above 50%.  YOur FT3 is only 28.6% when the rule of thumb is to be at least 50% if not closer to 66% of the range.  So it looks like you have a long road to go.  IF you don't feel well.

I would have to also ask do you take your T4 medication at least 1 hour away from eating and do you avoid Calcium for at least 4 hours either side of taking the T4?

You may be having an absorption issue.
18552345 tn?1472243264
Than you both for all your help! I truly appreciate it!

I take my 75 mcg of  synthroid and first dose of 5 mcg's of cytomel at 6 am with a full glass of water. I eat breakfast around 9am. I take last dose of cytomel at noon.

Here are my past results:

Lab results in March 2016:

56 mcg of levothyroxine and 10 mcg cytomel

TSH- 1.080

FREE T4- 0.78  (0.57 - 1.25)

FREE T3-  2.5   (2.0 - 4.4)

Ferritin- 64

B-12- 1095 (211-946)  (Was told to back off supplement)

Lab results in January 2016:

56 mcg of levothyroxine and 10 mcg cytomel

TSH- 1.444

FREE T4- 0.62 (0.57 - 1.25)

FREE T3-  3.0 (2.2 - 4.3)

Ferritin- 28

18552345 tn?1472243264
I feel a little better with the increase from 56 to 75 mcg but still feel fatiqued, brain fog and gained about 10 lbs. My hair did stop falling out but is slow growing.

May I ask for doctor recommendations in the Seattle, Washington area?

I'm so grateful for all the help. Thank you!
Avatar universal
By the improvement of your symptoms i would say you are on the right track.

How long have you been on your current dosage of T4?  

If it has been over about 6 weeks I would recommend you get retested and if there is not much improvement in the lab numbers, I would probably recommend that you ask your Dr. for another increase in your T4.
18552345 tn?1472243264
I have been on the new dose of 75 mcg since July 7th. I just had new labs done this week.
Avatar universal
I would really like to see your new test results but I am sure you will still need further increases in your med to optimize your Free T4 and Free T3.  You also need to know your Vitamin D and supplement to optimize to at least 50.  Your need to slightly reduce your B2 supplement, and also raise your ferritin level to at least 70, and some sources say 100.

I am sending a PM with doctor info.  To access, just click on your name and then from your personal page, click on messages.
18552345 tn?1472243264
Hi Gimel,

Here are the new labs done on August 22nd.
75 mcg synthroid and 10 mcg generic cytomel

TSH- 0.732  (0.340-5.600)
Free T4- .62 (.57-1.25)
Free T3- 2.8 (2.2-4.3)
Ferritin- 35 ( 11-307)  I take one iron supplement per day.
Avatar universal
Sorry, I misunderstood that you were getting new labs.  So my previous comments stand.  As stated by flyingfool your Free T4 is only at 7 % of its range and Free T3 at 29 % which is far too low for many people.  You need to further increase your Free T4 and Free T3 levels by increasing both your T4 and T3 meds.  In addition you need to know your Vitamin D and B12 levels and supplement as needed to optimize.  D should be 50 min., and B12 in the upper end of its range.  Also as mentioned your ferritin is much too low, so you need to increase your dose.  In my experience I increased by iron supplement from 25mg to 50 to 75 over the span of about 4 weeks to get my level optimal.

Do you think your current doctor might agree to do all this?
18552345 tn?1472243264
Thank you for all your help. I'm so tired of getting the runaround from my dr.

I was diagnosed in 2012 with a TSH of 7.49 and have never been the same since being on medication. I miss my old self with all the energy and the head full of hair. :(

My doctor only concentrates on the TSH level--frustrating!
Do you think I should ask him to increase the synthroid to 88 mcg? I know I probably need an increase of the cytomel but should I wait until the t4 goes up first?

I'm struggling to keep my ferritin up with one supplement a day. I will increase like you advised.

Thank you for your time.
18552345 tn?1472243264
Thank you for all your help.

Do you think I should ask my doctor to increase the Synthroid to 88 mcg? What about the cytomel dosage? Would an increase to 15 mcg be too much?

Avatar universal
With your low levels there should be no problem with increasing both.  At your FT4/FT3 levels an increase of 15 is hardly anything.    I would ask the doctor to increase by 50 mcg of T4 and 10 mcg of T3.  If you could get that approved, then I would increase in two steps of 25/5 about a month apart, in order to allow your body to accommodate.  

You do need to work on the ferritin and also get tested for Vitamin D and B12.
Avatar universal
I agree with gimel that you need to increase thyroid meds. It is not surprising, but very unfortunate your doc is focusing on your tsh. As gimel stated, tsh does and should go down as optimal ft4 and ft3 are reached. The fact that your tsh is still so high (for taking meds), indicates the need to increase them. My doc kept increasing thyroid med until my ft4 was in the 75% of high normal range. I also have taken natural Armour Thyroid for many years vs synthroid and cytomel. I am pleased your doc knows to supplement synthroid (for ft4) with cytomel (for ft3). Most do not. I did have to take synthroid/levothyroxin and cytomel for a year or so when Armour was not being manufactured. I prefer the Armour Thyroid myself. I feel better on it and it is not a synthetic med, but that's just me. Armour Thyroid also provides both T4 and t3, so it is a one pill a day.

Best of luck to you! Your tsh is nothing to worry about, but you may want to provide medical information for your doc to review, or switch doctors.
18552345 tn?1472243264
Thank you for your time and effort.

My endo is on emergency leave and will not be back until Oct. I will be seeing a Adult Nurse Practitioner for my appt next week who is taking his place while he's away. I'm hoping she increases both my medications without getting worried about my low tsh. I need to provide medical information like Michiganrunner advised.

In the past, I tried to talk to my doctor regarding Armour and he stated it's old school and it's not necessary to use anymore. Plus, he mentioned the t3/t4 levels are never consistent with each batch. I'm still interested in Armour, but my only concern is that I'm allergic to pork.

Avatar universal
If you will go to the link included within this link, you will find scientific evidence of almost anything you need.  


Specifically Item 10 on page 13 covers suppressed TSH and lists 3 references to scientific studies (79,80 and 81).  I also highly recommend reading reference 36, which summarizes a study of patients clinically classified as hypothyroid , euthryoid, and hyperthyroid.  The TSH range for each group was quite similar, showing that TSH is totally inadequate to distinguish among the three groups and certainly not a diagnostic to dose a thyroid patient.  As previously mentioned,  a suppressed TSH when taking thyroid med means nothing, unless you also have hyper symptoms due to excessive levels of FT4 and FT3.  
18552345 tn?1472243264
Thank you so much, Gimel.

I'm truly grateful for all the information you and the other members have provided for me. It has given me hope to feel better with this condition.
I'd like to make a couple of suggestions.

First, keep in mind that a normal thyroid will produce about 90 - 100 mcg of T4 and about 6 mcg of T3 in a day. So your daily intake should somewhat similar, and also take into account that you do not absorb 100% of your meds. As your current meds are now high enough to suppress your TSH, thyroid hormone production from your own thyroid has been "turned-off" and therefore you need to take a "full replacement dose". You can see that your 75 mcg T4 plus 10 mcg of T3 could be a little on the low side.

However I would caution you about increasing your meds too much. You can feel just as crappy if your take too much, as too little. To help you get into the ball park here is my experience. I currently take 94 mcg Synthroid plus 15 mcg T3, and I get good lab results. Previously I tried 100 T4 + 15 T3 but FT4 was slightly high. And I also tried 88 T4 + 15 T3 but both FT4 and FT3 were too low and I definitely felt hypo.

It is good that you have a doctor who is willing to try a T4-T3 combo, but he/she may now become (unnecessarily) concerned about your low TSH. It is possibly the fast acting cytomel that is making your TSH go low. If he refuses to increase your meds, you could suggest perhaps switching over to slow release T3.

I use Synthroid plus slow release T3 (SRT3); rather than cytomel. SRT3 can be made by a "compounding pharmacy"; they call it Liothyronine Slow-Release Capsules and they can make the capsules to any strength specified by  your doctor. I get 5 mcg capsules. With slow release T3 your FT3 does not spike as high in the hours following your taking the pill; consequently your TSH does not go as low. My TSH is now slightly over 1.0.

An ND from Portland, Oregon wrote a good paper describing how he is successfully using T4 plus SRT3. It is easy to find and has a lot of good info for people using a T4-T3 combo. However I categorically disagree with his mathematics shown in the paper for calculating amounts of T4 and T3. The paper is "Hypothyroidism: Optimizing Medication with Slow-Release Compounded Thyroid Replacement".
Avatar universal
I agree that an increase is needed.

I do wonder however about an absorption issue.  As the dose keeps increasing yet the blood labs show little to no improvement.  It is possible that the most recent changes are as a result of the medication taking the place of the thyroid gland. And the reduced TSH shut down production from your thyroid gland.   If this is the case, then at some point you'd see a corresponding increase in blood lab levels and also reduction of symptoms.
18552345 tn?1472243264
Thank you so much for your time, everyone!

I was looking through last years test results and I remember feeling pretty good when my TSH was suppressed below normal range.

Here are my April 2015 test results:

75 mcg of Levothyroxine with 10 mcg of generic Cytomel

TSH- 0.132  (0.340-5.60) LOW
Free T3- 3.1 (2.2-4.3)
Free T4- 0.92 (0.57-1.25)
Ferritin- 44 (11-307)

My doctor said the TSH went too low and adjusted my Levo from 75mcg to 50 mcg (Mon-Fri) and 75 mcg (Sat and Sun). :(

After the dosage change, I started feeling crappy again.
Avatar universal
Just to be clear I am totally on board with the concept of using a slow release T3 thyroid med; however, they are more costly than regular med and I have not seen scientific evidence that anyone has a compounding method that guarantees slow, even release over a 12 hour period.  Further, when I read a site written by the doctor you mention,  I found this.  

"The amount of slow-release T3 prescribed, whether formulated
in combination with T4 or taken separately from T4 , should be
about 25% more than the mathematical equivalencies would suggest.
This is because T4 blunts the utilization of T 3 to some extent.
The compounded slow-release form seems to allow for less total
drug absorption. This can vary considerably from patient to patient.
The best approach is to monitor serum levels of free T4 , free
T3 , and TSH in patients taking T4 and slow-release T3 replacement
6 to 8 weeks after every dose adjustment. Further dose adjustments
can then be made if necessary. Since T 3 has a short
half-life and serum levels tend to peak 3 to 4 hours after dosing of
compounded slow-release T3 , we instruct patients to not take their
morning slow-release medication until after their blood draw."

So two things there.  One is that slow release versions are more expensive and the doctor suggests using 25% more to assure similar absorption, which will add more cost.  Two is that if it truly is slow release over an extended period up to 12 hours, then why the need to mention that it peaks 3-4 hours after dosing and that the morning dose should be deferred until after blood draw?   I don't understand that.
18552345 tn?1472243264
I went to my appointment this morning with the ARNP that is taking over while my endo is away on emergency leave. She told me that my TSH of 0.732 is to low to increase the Synthroid. She also said that she would have to decrease the Synthroid by 12.5 mcg to increase the Cytomel to 15 mcg.
She could careless about my symptoms or the literature I brought to her. I told her she is not decreasing my Synthroid. She basically said there is nothing else she could do for me. I'm so frustrated!

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