Teenage daughter with possible hypothyroid

Question

Hello.  My 17 year daughter has had a lot of health issues for the past 9 months.  Over Christmas break last year she was very ill with what we assumed was the flu - even though she tested negative.  Extremely high fever of 104 for 5 days, swollen glands, lethargic.  It took her several weeks to feel like even going back to school.  Ever since then she has been "off".  Very depressed, lack of feeling, anxiety, CONSTIPATION, stomach aches, tired (but hard time sleeping at night), always cold, super dry skin (you'd think it was the middle of winter!)  To sum it up - it's been a very challenging 9 months.  She has seen her pediatrician about 4 times and we've battled the constipation, ruled out an ovarian cyst, and even an EKG (panic attacks).  FINALLY we did blood work last week and her TSH level came back high at 11.8 but her T4 level was ok at 1.13.  She will have blood work done again in a few days and in the meantime she had a pelvic xray to make sure she had no intestinal blockage.   I should note that my husband has been on Synthroid for 24 years and his mother & sister also take it.

My question is, can she be experiencing all the classic symptoms of hypothyroid with an ok T4 level?  Would synthroid help her or does she need estrogen (I think I read that somewhere).  Also, could that horrible illness she had back in late December/early January have triggered something?  The mother in points to that being the exact time all this happened.  I keep telling the drs. that it like she got sick and truly has never gotten better.  It's like she is still sick but without the fever.  The depression and the constipation are the worst.

Any info would be truly appreciated.

Thanks!

Red_Star · Answer

I have positive parietal cell antibodies and intrinsic factor antibodies - which is a diagnosis of autoimmune pernicious anaemia. It was my first of four autoimmune diseases to show up; hashimoto's thyroiditis my last...hopefully!

gimel · Answer

Not sure that the OCP issue fits with her blood test results.  Note in the following link: The results suggest that the three DNG-containing and the LNG-containing low-dose OCs may increase T3, T4 and cortisol due to an elevated binding to serum globulins, while the free proportion of the hormones is not or only slightly changed. Therefore, these OCs have only minor effects on thyroid function, adrenal and blood pressure serum parameters.

https://www.ncbi.nlm.nih.gov/pubmed/12742558

At any rate, the doctor seems to be moving in the right direction by giving her thyroid med.  Please let us know how things progress for her.

gimel · Answer

Sorry, meant OCP???

gimel · Answer

OCB?

gimel · Answer

Yes, on the Thyroglobulin antibodies test being similar to the TPO ab test.  Most of the time Hashi's shows up with the TPO ab test.  Other times the TG ab test and sometimes both.  

Did the Endo have any explanation for why FT3 and TT4 were high, along with Hashi's and a high TSH, but no nodules on the thyroid gland to account for the high thyroid hormone levels?

What dosage of Synthroid is she taking?

tcrgemini · Answer

Update...  after a horrible week the endocrinologist got her in yesterday.  Immediately diagnosed as Hashimotos.  Ordered more blood work and an ultrasound.  Just got the result for a test I hadn't seen before:

Anti-Thyroglob Abs	
207 IU/mL (result)
<115 IU/mL (range)

Is this like the TPO test?  Another anti body which points to Hashi?

Her ultrasound today showed enflammed thyroid, no nodules.  She does have a huge swollen gland that the endo didn't seemed concerned about.  Said to see an ENT if it did not go down.  

Putting her back on synthroid and to do blood work again in 3 month.  We plan on continuing the daily probiotic and miralax to continue helping with digestion and constipation.   Also am encouraging her to advocate on behalf of herself d speak up when she know things don't "feel right" with her body.

Thanks for all the info I've found on this page!

gimel · Answer

The TPO ab test being positive for autoimmune disorder points to another possibility:  Hashimoto's Thyroiditis.  With Hashi's the thyroid gland is erroneously identified as foreign to the body and antibodies are produced to attack and eventually destroy the gland.  During the attack on the thyroid gland sometimes nodules are formed that leak hormone faster than normal and cause excess levels of Free T4 and Free T3.  That part fits her situation except that when this occurs, hyper symptoms are present, not hypo.  Plus, with the higher levels of FT4 and FT3, the TSH would be expected to be suppressed to low end of range.  So, to me this still seems like THR.  It would be worthwhile to get an ultrasound of her thyroid gland to check for nodules.  

The recent thyroid tests are outdated and not very useful, so I am not sure that doctor is up to speed on thyroid issues.  As for an Endo, most of them specialize in diabetes, not thyroid.  Also, many of them have the "Immaculate TSH Belief" and only pay attention to that, which is wrong.  If they go beyond TSH is is usually only to test for Free T4 and then use "Reference Range Endocrinology", by which they will tell you that a thyroid test that falls anywhere within its range is adequate.  That is also wrong.  The ranges are far too broad to be functional across the entire range, for everyone.  You don't necessarily need an Endo, just a good thyroid doctor.  
If interested I have the name of a doctor in your area that has been recommended as a good thyroid doctor, by another member.

gimel · Answer

I have not seen nearly as much test data on the TRab test as I have on the TSI test.  It is reported that while the gold standard for thyroid-stimulating immunoglobulins is the bioassay (see TSI / Thyroid-Stimulating Immunoglobulin [TSI], Serum), the thyrotropin receptor antibody test has a shorter turnaround time, less analytical variability, and is less expensive.  So as I see the result as favorable for not having Graves" Disease.  In addition, I read that "In healthy individuals and in patients with thyroid disease without diagnosis of Graves disease, the upper limit of antithyrotropin receptor (anti-TSHR) values are 1.22 IU/L and 1.58 IU/L, respectively (97.5th percentiles).  So, as I understand it, even against those lower limits her result is favorable.  Further, if her relatively higher thyroid hormone levels were the result of Graves', the TSH would not be elevated as well.

With all those symptoms that are typically related to hypothyroidism, and your daughter's high Total T3, mid-range Free T4, and high TSH, it still seems to point to the possibility of Thyroid Hormone Resistance (THR).  So giving her thyroid med and monitoring the effect on her Free T4 and Free T3 levels, and ultimately her symptoms, will be very important.  The doctor will likely start her on a small dose that may not be enough to notice any significant difference, so the doctor should not make a hasty decision to stop the med based on test results only, but continue to increase the dose, and monitor the effect closely.  What she needs is enough thyroid med to raise her Free T4 and Free T3 levels as necessary to eliminate the signs/symptoms of hypothyroidism, but not so much as to create signs/symptoms of hyperthyroidism.  To quote an excellent thyroid doctor, medication dosage is irrelevant, only the physiological effect matters."

I have certainly found this to be true for myself.  With my thyroid test results you wold never have believed I became hypothyroid again last year.  Fortunately that same excellent thyroid doctor diagnosed THR and raised my med dosages until symptoms disappeared.  Not many doctors would have understood and adequately increased my meds.  The point here is that you will likely have to be persistent with your daughter's doctor to get her to where she needs to be.

gimel · Answer

It seems that there is a heredity aspect with thyroid issues.

If your daughter's GP is willing to prescribe Synthroid, it is worth trying.  Just make sure the doctor is willing gradually raise her dosage enough  to relieve her symptoms, since adjusting her dosage based on test results would be very misleading.  

Please keep in touch and let us know how she is doing.

gimel · Answer

As for the negative ANA result, it is reported to have only a 5% false negative rate, so that is good evidence that her high TSH is not related to an autoimmune system problem.  

Regarding the range, the closest range I can find is for Total T3, which was 87-190 ng/dL, which converts to .87-1.90 ng/m, which is fairly close to the range you show.   So it may be Total T3, not Free T3.  If that is the case, Total T3 is not nearly as revealing as Free T3; however, even if it is Total T3, I would be surprised to find that Free T3 was low in its range.  So that is still puzzling as to your daughter's symptoms, with those test results.  The only situation I have run across with the patient having hypo symptoms,  and relatively high Free T4 and Free T3, but also elevated TSH, is a relatively unusual occurrence called Thyroid Hormone Resistance.  

There is not a lot of info available on THR, and I don't know enough about it to be sure that is the problem, but here is a link that provides some information that is quite similar.  

http://www.endotext.org/question/does-this-person-have-thyroid-hormone-resistance/

Although the patient in the case had gone through RAI and was taking high dose of thyroid med, she was experiencing high FT4 and elevated TSH, as follows.

10/12/01 SHBG 49.1 (18-114) , PROLACTIN 50.0 (1.6-27.1) , T3 165 (58-184) ,FREE T4 1.80 (0.68-1.76) ,TSH 10.55 (0.3506) 

Even more interesting was this:  "(12/15/01)I just got back another interesting piece of information. I had the case patient's daughter tested. Her TSH is 1.92 (0.35-6), her free T4 is 2.08 (0.68-1.76) and her total T3 is 236 (58-184). She is not on any thyroid hormone and has never had any form of thyroid treatment. This looks to me like thyroid hormone resistance in this family."

So, I am not exactly sure what to suggest here, other than for her to be seen by a really good Endocrinologist who recognizes that Thyroid Hormone Resistance is a rare but real condition that may need to be considered.  If you will tell us your location, perhaps someone can suggest a doctor in your area, that has been recommended bo other thyroid patients.  

One other thing, hypothyroid patients are frequently deficient in Vitamin D, B12 and ferritin.  You have already found her B12 to be low.  I suggest that you also get her D and ferritin tested and supplement as needed to optimize.  D should be at least 50 ng/mL and ferritin should be at least 100.

gimel · Answer

Something just doesn't compute.  Your daughter has a lot of symptoms that are typical of being hypothyroid.  Her Free T4 is close to mid-range, which is good.  I am puzzled by the Free T3 range.  I have seen quite a number of different ranges, but never one like that.  Could you please double check it and also list the measurement units for it, like pg/mL or whatever it shows?

gimel · Answer

Test results and associated ranges vary from lab to lab.  So, results should always be compared to ranges from same lab.  

What are the reference ranges shown on the lab report for the Free t4 and Free T3?

Red_Star · Answer

I had hypothyroid symptoms with my free T4 in range.  My free T4 dropped in the range to 13 pmol/L (lab range is 10 - 20 and my sweet spot is 16) but never went below range as I started thyroid medication.

gimel · Answer

It sounds like your daughter has some type of thyroiditis.  There are two that I would suspect.  Hashimoto's is the most common type, but several of your daughters original symptoms sound more like DeQuervain's.  Following is some info on that one.  

De Quervain's thyroiditis (also called subacute or granulomatous thyroiditis) was first described in 1904 and is much less common than Hashimoto's thyroiditis. The thyroid gland generally swells rapidly and is very painful and tender.

The gland discharges thyroid hormone into the blood and the patients become hyperthyroid; however, the gland quits taking up iodine (radioactive iodine uptake is very low), and the hyperthyroidism generally resolves over the next several weeks.

Patients frequently become ill with fever and prefer to be in bed.
Thyroid antibodies are not present in the blood, but the sedimentation rate (which measures inflammation) is very high.
Although this type of thyroiditis resembles an infection within the thyroid gland, no infectious agent has ever been identified, and antibiotics are of no use.
Treatment is usually bed rest and aspirin to reduce inflammation.
Occasionally cortisone (steroids, which reduce inflammation) and thyroid hormone (to "rest" the thyroid gland) may be used in prolonged cases.
Nearly all patients recover, and the thyroid gland returns to normal after several weeks or months.
A few patients will become hypothyroid once the inflammation settles down and therefore will need to stay on thyroid hormone replacement indefinitely.
Recurrences are uncommon.




Regardless of the cause, it sounds like your daughter is suffering with hypothyroidism and needs to be on thyroid medication.  Her TSH level of 11 is frequently identified as overt hypothyroidism.  Her Free T4 result being within range does not preclude hypothyroidism.  In trying to assess thyroid status, the most important consideration is symptoms, followed by Free T4 and Free T3.   Even though there are a number of variables that affect tissue thyroid hormone levels and effects, if there are symptoms typical of hypothyroidism and FT4 and FT3 are below mid-range, that is a strong indication of hypothyroidism.  Since she is seeing the doctor in a few days, I highly recommend reading at least the first two pages of the following link, 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

On page 2 note sugg. 4 that lists recommended tests.  She should be tested for Free T4 and Free T3 every time she goes in for tests.  Free T3 is metabolized by all the cells of the body to produce needed energy.  It would also be good to test for Reverse T3, cortisol, TPO ab, TG ab (if TPO ab is negative), Vitamin D, B12 and ferritin.  If you read the paper you can find the reasons why all are important.  Reading it will also prepare you to insist on these tests if the doctor resists.  

A good thyroid doctor will treat a hypothyroid patient clinically, by testing and adjusting Free T4 and Free T3 as needed to relieve symptoms, without being influenced by resultant TSH results.  Symptom relief should be all important, not just test results, and especially not TSH results.  So when she sees the doctor you need to find out if the doctor is going to be willing to treat clinically, as described.  Also find out if the doctor is willing to prescribe T3 type meds like Armour Thyroid and Cytomel.  If either answer is no, then you will need to find a good thyroid doctor that will do both.  If that turns out to be the case, then let us know your location and we can try to suggest a doctor in your area that has been recommended by other thyroid patients.  

Based on extensive experience I suspect that your husband and his mother and sister are likely being inadequately treated for their hypothyroidism, and would benefit from reading the link and trying to get treated clinically, as described.

Teenage daughter with possible hypothyroid

Thyroid levels

Elevated TG antibodies

new blood numbers

thyroiditis with normal test blood

Thyroid levels

Elevated TG antibodies

new blood numbers

thyroiditis with normal test blood

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