Thyroid test, to believe it or not?

[balkanFX]

Hi everybody,
My little 4 1/2 year old daughter had some blood teststs done in July and another one in September. The reason for the test was an exsess body hair, legs, arms, back but none in the androgenic areas. The July Thyroid test results were TSH=1.9 ,FT4=13.4 ,FT3= 5.6 . The doc said all was OK. The second test in September came out as TSH=0.16 , FT4=13.6 , FT3=6 . We haven't see the doc yet.
It is my suspicion that somehow she is making a bit more FT3, just enough in exsess to alter the the body hair normal cycles of growth, regretion and rest.
The FT4 and FT3 do not look too much different but the TSH is way out of line on the second test. I would like to point out that as she is only 4 and a half, she is really expected to have higher TSH, maybe in the region of 2 to 3. She is not exactly a typical Hyper.., but I can say that she tolerates cold a lot better than her brother and night time the blanket is allways off.
From researching I got idea that the FT4/ FT3 should be around 2.5 or slightly more. Ideal should be 2.5 . Her's is, the first one 2.39 and the second 2.26 , indicating she is converting a bit too much or is she?
I agree that by just looking at the reference ranges you can't always say if one has problematic thyroid or TSH (pituitary). Everybody is different to extent and Thyroid hormone values could be at different spot for everyone, slight variation up or down within the ref range and we have a problem.

I would like to hear your opinion as I am desperately hoping to resolve the original symptom.

PS. My thyroid seems OK, but my birth family have history of thyroid problems, hyper and hypo.

Thanks for taking the time to read this.    

[balkanFX]

Thanks Barb135,
Yes the antibodies atack the thyroid, but in the case of TSH-R-Ab or sometime written TSHR-Ab, they also mimic the availability of TSH and make the thyroid produce T4 and T3 without the intervention of  the actual TSH. Those antibodies are not stable and could fluctuate, giving you sometimes false higher than before TSH. It is an important indicator that could change the way the thyroid function is interpreted by an endo who knows what he is doing.

[Barb135]

I, too, am very sorry that the endo wasn't more sympathetic.  That had to be a hard appt for you.  

Keep in mind that TSH is not a good indicator of thyroid levels.... My TSH has been < 0.01 for the past 4 years, but my FT3 and FT 4 have both been from low to mid range.  

TSH stimulates the thyroid; antibodies don't; they destroy it.  

I agree with goolarra, have you looked online for further tests?  One site you might check is www.healthcheckusa.com........ there are a lot of tests you can order from them.......  they will provide a lab order for you to take to your local laboratory; you get the tests done, with results in 2-3 days.

And at the risk of sounding like a parrot, what did the endo suggest for further follow up?   If s/he had no recommendations, I'd suggest that you try to find another........

[balkanFX]

Hi there, the endo did not acknowledge the problem at all. I am absolutely destroyed that I allowed my daughter to be bled again for we will know knothing different after the test.  
Regarding the low TSH and TSH-R-Ab, yes you are 100% right, the only thing I would like to clarify is that if we are in the beginnign stages the thyroid stimulated by the antibodies could be making just a little bit more hormones, not huge amounts yet. Pituitary sences that it only needs to send a little bit TSH to get the hormones where they need to be and this is how you can have TSH-R-Ab, have crazy low TSH and perfectly normal FT4 and FT3.

[goolarra]

I'm so sorry you didn't get more satisfaction from the endo.  I think we've all been where you are now.

Usually, if TRab antibodies are present, TSH is low, and FT3 and FT4 are high (unless the disease has not progressed to that point, in which case FT3 and FT4 can be in range).  TRab stimulate thyroid cells, acting in place of TSH and ordering the production of excess thyroid hormone.  TSI (thyroid stimulating immunoglobulin) is the definitive test for Graves'.  

You have to understand that TRab does not have a direct effect on TSH.  The only way TRab can affect TSH is by stimulating the overproduction of FT3 and FT4 in the thyroid, thus raising serum FT3 and FT4 levels.  It's the higher FT3 and FT4 levels that suppress TSH.  In effect, the thyroid is now under the control of TRab, rather than the pituitary (through TSH).  

TSH causes no symptoms.  It's only a messenger from your pituitary to your thyroid to tell it to produce more T4 and T3.  It's volatile, even varies with the time of day the blood is drawn.  FT3 and FT4 levels are much more important.

I'm sorry your endo wouldn't order more tests.  Certainly, a TSI is a cheap and simple way to confirm Graves'.  Is there the possibility of seeing another doctor?  Perhaps your PCP would order the tests you requested that were denied.  Even if your PCP didn't know how to deal with the test results, it's often beneficial to be able to go to your specialist with labs confirming your theories.

Almost everything is available online.  Have you thought of getting tests that way?

Did the endo have any suggestions at all as to who you should see to explain your daughter's symptoms?

[balkanFX]

OK, seen a peadiatric endo who was so dismissive about my worry, that I am still in a state of rage/madness/dissapointment/disgust. He agreed to repeat the thyroid function test including the TSH, FT4 and FT3, but would not include TSH-R-Ab (TSH Receptor Antibodies). I tried to explain that if there are some of those antibodies, it would explain why the TSH could have apeared so low TSH 0.16 whilst the FT4 and FT3 remained in the normal ranges. For a healthy child of the age of 4-5 you should expect TSH levels close to 2.5. I thought I was talking to a wall or more like I was talking but words were not reaching the endo.

I wanted some more tests like a 24h urine steroid profile, indicating the levels of cortisol and androgens for the duration of 24h, but I was refused.

It is painfull to look forward to something and be so hopefull and then get shafted and laughed upon as if I was a nutcase.

You can not take little kids to the lab so often, what I needed was one visit maximum coverage of of suspicious areas.

God help me have enough strength to see this problem resolved !

[balkanFX]

Thanks "goolarra", we are seeing an endo soon and will discuss an Ultrasound. That ratio, was just made up by me based on observations of ref ranges that include the medians. You are probably right, that it has no significance.
Thanks agin for your time so far.

[goolarra]

I agree that the ranges, AT THEIR EXTREMITIES, only tell you when you are severely out of line.  However, if your results are solidly around midrange, then I think you are safe to assume that the levels are basically "normal".

Yes, endocrine systems are sensitive to deviation, but they also change constantly in response to bodily demands.  It's fairly telling that we, medicated thyroid patients, take a pill usually once a day, so our levels are more or less constant.  We function pretty well despite our lack of ability to respond to higher and lower levels of demand (and fluctuating FT3 and FT4 levels because of that).  Yes, I think we all have a personal reference range, for most of us within the population reference range, where we feel comfortable.  However, our personal comfort level is still a range, not a specific number.

I agree with Barb that a toxic nodule would likely produce higher FT3 levels, and that it's a bit of a long shot.  However, I thought a U/S might help to eliminate one of the possibilities and set your mind at ease.  Since FT3 is a "snapshot", spikes can be hard to pin down..

I also think you're putting too much emphasis on the ratio of FT4 to FT3, or perhaps I should say that you are putting too much emphasis on that being exactly 2.5.  To me, that's a little like saying that everyone's FT4 should be exactly 1.3 all the time.   Surely, that ratio is also subject to "range".  I've never seen a discussion on this forum of the ratio of FT4 to FT3 in those precise terms.  We often discuss it in broad strokes...FT3 should be higher in it's range than FT4 is in it's, or slow conversion is indicated (if symptoms prevail)  Furthermore, if the 2.5 ratio IS valid, I would guess that your daughter's results of 2.39 and 2.2 ARE "around" 2.5..

I ran the ratio on the midpoint of both my ranges, and the number came out to 4.1.  Now, as a rule of thumb, we often say that FT4 should be midrange, and FT3 upper half to upper third of range.  Comparing midrange on FT4 with the lower end of the top third on FT3, you still get a ratio of 3.6.  That 2.5 number doesn't seem to be holding water.

Once again, I agree with you about ranges for the most part, but I DO think that they are quite reliable around midpoint.  Yes, if you're close to one or the other limit, you probably have a problem, but if you're square in the middle...less certain.  Your daughter's pretty much in the middle, allowing for daily variations.

[balkanFX]

Forgot the link, sorry, here it is: http://vimeo.com/3927642
and also: http://vimeo.com/3161062

[balkanFX]

Thanks "Barb135"
Yes, I agree with you. I need to keep an open mind as to what might be causing the symptom we are concerned about.
Regarding Ref Ranges, I agree that they are needed but in their current way too broad range, they become if not useless then pretty much close to it. OK, I am being a bit extreme, I agree. The point I am trying to make is that if you visit an endo and he specificaly base his opinion on wether the values are within the range or out, then it is pretty likely that you would not be diagnosed with having a problem unless you have suffered for years and or it is way too late maybe, and have very few options left to correct the problem.

I came accross this website that has a video representation by Dr Bryan Walsh, subject is Thyroid Physiology. You can have a look also at what he says about the "Problem with Modern Blood Chemistries".

[Barb135]

Are you referring to a ratio of FT4/FT3 being at 2.5?

While I can agree that the reference ranges are not designed to give a completely clean bill of health, I can't agree that they are totally useless, either.  What good would a lab result be without something, with which to reference it? Because each lab uses different methods of testing and units of measure, the ranges will change accordingly.

Even if your daughter's TSH still comes back that low in subsequent testing, I'd still not look at it specifically as a thyroid issue.  I'd be more inclined to look at other possibilities, first, since her FT's don't indicate that she's hyper.  

If your daughter had a nodule that's over producing, chances are pretty great that her FT3 and/or FT4 levels would be higher than they are.  Additionally, from my reading, nodules secreting hormones independent of the thyroid, are outside the regulatory influence of the pituitary gland, therefore, would not necessarily cause the TSH to drop that low.

Like you, I'm not a doctor

[balkanFX]

Thanks "Barb135" and "goolarra",
I think both tests have their inconsistencies and leave room to question some of the results. I also agree that one of the biggest problems with those labs is the useless ref. ranges. They are not designed to give you a clean bill of health but to simply state if you are severely out of line. Thyroid as well as other endocrine systems are very sencetive to even a small deviation from the normal set point for each person. Also if I keep going to different lab each time I am suspicious, I am afraid would probably end up in the same position. I have decided to go for another test at the same lab and see what the values are going to be. If TSH is still that low and FT3 and FT4 within the mid range then I can assume we are dealing possibly with a subclinical hyper or symply a nodule that is over producing T4 or T3 and causing the TSH to go low. Another bother is that in my researsh and it is not supported by any documents, but symply by observations the FT4 / FT3 should be around 2.5 or slighly more for a healthy individual. The link I provided in my previous post, which could be viewed in PDF prefferably, could help in establishing that relationship. But then again, I am not a doctor and what I am talking could be completely nonsence.
Thanks for your opinions so far.

[goolarra]

I agree with you on both points:  The ranges are very broad (broader than for adults, which is bad news), and two labs in the same city, using the same equipment, should have more similar (the same?) ranges.

I eyeballed the range for your daughter's age group on the link you provided.  Since it's a chart, I came up with roughly 4.25-7.5 as the range that 95% fall into.  Interestingly, that's very close to the range from the second lab (4.28-7.23).  If, indeed, both labs use the same methodology, I'd feel fairly confident applying that range to both labs.

That would put your daughter's result of 5.6 at the 44th percentile and the second result of 6.0 at the 58th percentile, which would indicate that she's hovering right around midrange, which is good.

The upshot of all this is that both FT3 and FT4 have been not only in range, but well away from the extremes of the ranges in both cases.  The only result out of range is the TSH of 0.16.  As gimel pointed out above, TSH is volatile, even the time of day the blood was drawn can effect it.  Though you might want to keep a watchful eye on thyroid labs, I really am having a hard time seeing a thyroid problem in your daughter's labs.  

I'd suggest a thyroid ultrasound to rule out any autonymous nodules.  However, I think I'd continue to pursue other possible causes of your daughter's symptoms.  

This, of course, is just my opinion as a layperson, not a medical professional.  

[Barb135]

You could particularly hurt a 4 yr old such as your daughter, if not careful, and it's unlikely the above technique will do much, as I've seen the same instructions posted for other issues.

[balkanFX]

I guess this would have to be done by someone who know exactly what, where and with what force need to push. Surely, if you get a bit carried away you could hurt anybody. I will try that on the wife. Interesting post, thanks.

[hava]

Some alternative, you may wish to try.
Thyroid point – press the fleshy bit on palm between  the base of thumb and wrist on both hands. If you feel sharp pain when you press, then you have a possible thyroid problem.
If the pain is felt,then do the the following in a fun way, without mentioning thyroid.
Press the thyroid point several times, massage the whole hand, do clapping everyday(so the point gets pressed on both hands).
Opening and closing the fists tight, with the fingers landing on the thyroid point will help as well.
Turn the head left, right, up and down slowly(in a fun way), so the thyroid gland gets stimulated.
The child may prevent you touching the hand, if the pain is sharp, so handle with care.
When the thyroid point pain goes down, you may start to notice the difference, in the child.
October 24, 2011

[balkanFX]

Sorry, I did not mean to repeat posting the link, but when I did it went way up the thread, here it is again:http://www.biomedcentral.com/1472-6823/8/15

[balkanFX]

Sorry, forgot to paste the link, here it is: http://www.biomedcentral.com/1472-6823/8/15

[balkanFX]

Thanks "goolarra" and "Barb135" for your help so far.

"goolarra" thanks for the percentage explanation, I will keep an eye in the future on those levels.
My understanding so far was that the diagnostic machines the modern labs are using nowaday are more or less callibrated to give accurate mesurment of the actual value in given units of, lets say FT3, TSH and so on. However those diagnostic machines, like for example  "Abbott ARCHITECT ci8200" do not come with a recomended ref ranges as they could be used in any part of the world where the iodine consumpsion could be different. It's down to the lab to either commission their own private statistical researsh or use one of the already completed ones by an independant bodys utilizing that particular diagnostic machine. This is why in my opinion two hospital within the same town using the same diagnostic machine could quote so much broader or narrower ref ranges. I have not read this or been told about it, it was just my assumption.

I am not a doctor, and you know those labs do not like to give info to outsiders. Anyhow, thanks very much for your help so far.

Below is a link of one such research. You can see how it stacks up to similar researched done by other diagnostic machines like "Advia Centaur"

[goolarra]

When you have different reference ranges (sometimes they vary because they're expressed in different units, sometimes it has to do with the labs' methods and/or equipment), you can convert the numbers to a percentage of range to compare them.

The math for the first labs:

Upper limit of range - lower limit of range (10.2 - 5.2 = 5.0)
Result - lower limit of range (5.6 - 5.2 = 0.4)
Divide second result by first X 100 (0.4 / 5.0 X 100 = 8%)

For the second:
7.23 - 4.28 = 2.95
6.0 - 4.28 = 1.72
1.72 / 2.95 X 100 = 58%

As a rule of thumb (which like all rules is broken by many of us), FT4 should be about midrange (50%).  Your daughter's were at 32% and 27%, respectively for the two tests.  This is a little low.

FT3's rule of thumb is upper half to upper third of range.  At 8%, her FT3 was dismally low, but at 58% looked excellent.  However, this kind of variation is fairly unusual.  That's why I'm questioning the range from one or both labs...it seems too inconsistent to me, and we already know there was some confusion.

I'm not thinking paranoia at all...I'd verify both those lab ranges again.  I agree with Barb...get another test at a lab you trust and make sure you get ranges accurately adjusted for your daughter's age.

I'd also once again suggest a thyroid ultrasound.

[balkanFX]

Hi "goolarra",
Could you please explain how did you work out those persentages of FT3, 8% and 58%, and what is their significance. The FT3 went up from 5.6 to 6, and the FT4 from 12.4 to 12.6 ???

Thanks

[Barb135]

TSH is variable for a variety of reasons (this is why TSH is useless as a diagnostic), so without follow up tests to see where your daughter is now, you won't know.  I would doubt that the result is a typo, but anything's possible.  

Thyroid blood work should always be done in the same manner - in other words, if it's done once fasting, it should always be done fasting; and it should always be done near the same time of day

I really think you need to take your daughter to a different lab, for the same tests.  

[balkanFX]

The first test was a 12h fasting one the second was a normal one with a breakfast. I just wonder it that somehow could have pushed the TSH so low down from 1.9 to 0.16 . FT4 and FT3 did not move so much though. Risking to sound even crazy, it crossed my mind that the second test TSH value could have been a human typing error, just puting the decimal point in the wrong place. If it was 1.6, then maybe would have made sence. I know what you might be thinking, - "paranoia".

[goolarra]

I agree that a third set of labs wouldn't hurt.   I'd have a discussion with the lab beforehand to make sure they have ranges adjusted for age and that those ranges get on the lab report that goes to the doctor.

"As far as I am concerned every good endo should know where the values should be, if not from medical schol then atleast from experience. After all they study to become endos for more than 10 years."  Unfortunately, it's not that simple since the values that "should be" are very individual for all of us.  Most people have to have levels adjusted to fairly high in the ranges; I'm quite comfortable barely in the lower end of the ranges.  Add to that that different labs, using different methods, have different "normal" populations, and range becomes even more illusive.

I have to say that were I convinced that this was a thyroid problem, I really wouldn't know how to suggest you go about treating it.  FT4 is a little on the low side in both labs.  FT3 (still questionable, in my opinion) varied from 8% to 58% of range.  Yet, you feel that her symptoms are hyper, which is not supported in those labs.  I really wouldn't know whether to suggest treatment for hypo or hyper.  I feel that the results are not definitive enough to medicate (at this time).

I believe gimel suggested above that you have an ultrasound, and I'd agree with that to rule out the possibility of a hyperfunctioning nodule.  Hyperfunctioning nodules put out T3 independent of the influence of TSH.  T3 is produced in spurts, so FT3 levels can vary wildly.  Has anyone in either of your families ever been diagnosed with Plummer's Disease?      

[Barb135]

Since you seem very distrustful of the lab that did the analysis, maybe you could try to get the tests done at a different lab?

The second set of tests was done in Sept, which would be close to 6 weeks ago, so assuming that you'd want to keep a close eye on the situation, it would be about time to retest to see where all of your daughter's levels are now.  If possible, this should be done at a lab you trust.  You might even want to talk to the lab prior in order to insure quality.

You mentioned that both your and your wife's family have a history of thyroid disease.  Have either you or your wife been diagnosed with a thyroid issue?  Has the hypertrichosis showed up in any other family members with thyroid disease?