High TSH, High T4 with Insomnia/Anxiety

[tuckyville]

I was diagnosed with Hashimotos 20 years back and have struggled off and on with some of the symptoms especially insomnia and anxiety.  Have been on 150mcg for many years.  Recently had a switch back to Synthroid but then switched back to generic.  Am taking separate medicine for insomnia/anxiety but think that my thyroid issues are really the root of things.  Tried NDT twice and T3 in the distant past but was not able to tolerate them (hyper symptoms).  Last two test results:

11/2015 - (after being back on Synthroid for a few months after a long period on generic)
TSH 3.05 (.45 - 4.5)
FT3 2.7 (2.0 - 4.4)
FT4 1.87 (.82 - 1.77)

2/2016 - (after prior results, switched back to generic which apparently has less of a kick)
TSH 4.26 (.45 - 4.5)
FT3 2.9 (2.0 - 4.4)
FT4 1.63 (.82 - 1.77)

My doctor says my Reverse T3 ratio (separate test) is too low but the supplements she suggested were also activating to me as are other supplements for the most part (Vitamin D and B12, both of which I am low in - I try to get my Vitamin D from outdoor exposure).  Doc also says she looks to get TSH below 2.

I have read a few posts that say that that TSH can be irrelevant as an indicator once you are on supplemental thyroid medicine.  At the time of the 11/2015 test I was really having trouble sleeping and that continues through the second test and today (going for another test in the near future).  What I am wondering is whether for the time being I would do better at a lower dose of T4 (maybe getting myself to an average dose of 135 or 130 mcg) as whenever my T4 number is near or above the range, I experience insomnia and anxiety the most (this was the case historically for me as well). I know I need to get my T3 levels up but my main concern at the present moment is being able to sleep well consistently as not doing so is a driver of my anxiety.  I have no problems getting to sleep, but I wake very early.  Have had a salivary cortisol in the distant past which showed high AM cortisol but have not been able to lower it through the many supplements geared towards that approach.

I'm really trying to figure out if lowering my T4 dosage for a time might help me by bringing down my T4 number which I've previously correlated to my insomnia/anxiety.  Then, after I do that, I can see about tackling my T3 and maybe getting that higher in the range.

Thank you in advance for any thoughts.

[gimel]

Obviously your test results are consistent with being hypothyroid.  Your Free T4 is higher than necessary, but your Free T3 is too low in the range, which is quite common when taking only T4 med.  With your Free T3 to Reverse T3 ratio, you really do need to reduce your RT3 level and increase the FT3 level; however, in view of the reactions to NDT and T3 in the past (which can be associated with cortisol and/or ferritin), I suggest that you hold off on that until you find out about your current cortisol and ferritin levels.  

High RT3 has been postulated to be due to a broad spectrum of abnormalities such as: leptin resistance: inflammation; dieting; nutrient deficiencies such as low iron, selenium, zinc, chromium, vitamin B6 and B12, vitamin D and iodine; low testosterone; low human growth hormone; insulin dependent diabetes; pain; stress; environmental toxins; free radical load; hemorrhagic shock;, liver disease' kidney disease; severe or systemic illness; severe injury' surgery; and toxic metal exposure.  Clearly the number of variables makes it difficult to test enough to pin down potential cause(s); however, note that low Vitamin D is included.  

So, one suggestion is to increase your Vitamin D level.  I can't understand why you would have a reaction to D supplementation like described.  In the following study it concluded that low D is a possible cause for IBD.  So somehow you need to raise your D level to about 50.  I expect that it will take about 3000-4000 IU daily of D3.  You can also take more magnesium and Vitamin C to offset any adverse effect.  

http://www.ncbi.nlm.nih.gov/pubmed/24236989

I also think that the Free T3 level you do have is likely not adequately getting into cells of your body due to the high ferritin level and high cortisol (if you still are high).  This would further add to your hypo condition.  

Unless you are supplementing with iron, I suggest that you should be tested for ferritin again and a full iron test panel (serum iron, TIBC, and % saturation).  Along with that I suggest that you get new tests for cortisol.  I suggest a morning serum cortisol, and a diurnal saliva cortisol panel of 4 tests.  It may be that your sleep issues are related to cortisol level.  Once you have these test results it will help greatly to determine further action.  

I also have a side question that I have sent to you in a PM.  Please click on your name and then from your personal page, click on messages.

[gimel]

Before getting into a full discussion, please post your Reverse T3 result, and identify when it was done.  Also, please post your Vitamin D and B12 result.  How long ago was the AM cortisol test done, and when you say it was high, does that mean it was over the range limit or just high in the range?  Have you ever tested for ferritin?  

[tuckyville]

Thank you Gimel for your response.  My Reverse T3 reading for the 2/2016 testing was 23.6 (9.2-24.1 range).  My doc included a calculation showing that my RT3 Ratio was 12.3 and she says it should be over 20.  For the same testing date, B12 was 406 (211-946 Range), Folate was 14.6 (> 3.0), Ferritin was 367 (30-400), Selenium was 187 (79-326) and Zinc was  69 (56-134).  I did not have Vitamin D tested at this time but it has been consistently in the 25-27 (30-100) range for past testing which I know is low, however, when I supplement with it (or B12) I end up with worse sleep issues.  I try to get Sun now outdoors (Summer here).  Salivary cortisol is very old (2009) but I was out of range for the 6-8 AM reading with a 52 (13-24 range) and 19 for the 11-Noon (5-10 range).  The other two readings were at the top of the range but not above it for total cortisol burden of 83 (23-42 range). Other hormones were tested as well at this time and Estradiol was high out of range at 17 (1-3 for men my age) and Free Testosterone 114 (50-80 for my age). Progesterone was high but in range at 92 (5-95). I tried a number of suggested supplements after these results and have tried them again more recently (without additional salivary cortisol testing) to see if that could help with the early AM wakenings but they did not help and one may have exacerbated tings). I thought they would help as I saw a bunch of postings where early AM wakenings were tied to high cortisol and I was hoping the supplements would blunt the cortisol but they didn't either time as far as I could tell.  On the sleep side I am otherwise following a decent regimen and have eliminated other potential issues that I can think of (only one cup of coffee AM no other caffeine, no nicotine in over 6 months, exercise 3 times/week minimum, diet improvements, etc.).

[tuckyville]

One other issue for me with Vitamin D supplementation - it binds me up and I have IBS-C.  I know constipation is generally an issue with hypo so it is all related. I take 50 mg Magnesium Glycinate three times a day and try to have a decent amount of fiber/water in my diet.  But if I add Vitamin D to the mix as a supplement that throws everything off and binds me up - so it both affects my sleep and exacerbates the IBS-C issue.