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Trial

Its been a couple years since I have been here.  I did a trial in 2013 with someone that was dosing based on tsh and I eventually gave up.  Now looking back I have discovered that I probably was not absorbing the medication.  I also know that supplementing with iodine likely sabotaged any progress I was making since is causes tsh to rise in addition to tanking my iron.  These are my observations based on the last two years of monthly labwork.

Fast forward to today still struggling with almost all of the hypo symptoms the top 5 being fatigue, no libido, constipation, weight issues, and dry skin.  I am working on bringing up my mineral levels and fixing my copper/zinc imbalance.  My most recent labs.  I already know the issue with the t3 lab, I am not looking for comentary about it.  This is what I have available to me and it gives me an idea of where I am at.

tsh 2.24 .10 -5.5
t4 .9 .8-1.7
t3 64 50 - 170

I now have a doctor who is very open minded the only issue is that this is not his expertise.  I am definelty okay with that.  This is great because he will basically let me go whatever route I want as long as it is reasonable.  He is open to t3 and/or ndt.  Basically I can chose.  I do not really want to supress my tsh because I am hoping that with mineral balancing and working on my gut that I will not have to rely on medication for the rest of life if at all possible. I feel like I need to add in some cytomel because I am just so consistantly low.  Any advice is greatly appreciated.
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Avatar universal
The issue of relying on thyroid meds for the rest of your life is dependent on the cause for you being hypo enough to be on meds.  What was the diagnosed cause for that?  Then we can discuss your lab results and medication.  
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Nothing has been diagnosed.  I believe it to be low cortisol. I did a saliva test that showed my morning cortisol is insanely low.  I do not know why I have low cortisol.
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With those symptoms and test results It is most likely central hypothyroidism, which is a dysfunction in the hypothalamus/pituitary system causing inadequate TSH to stimulate the thyroid gland.  As a result both your Free T4 and T3 are much too low in the ranges.  Low cortisol would not cause those conditions.  To the contrary, low thyroid hormone levels can eventually exhaust the adrenal function, causing low cortisol.  

A good thyroid doctor will treat a hypo patient clinically by testing and adjusting Free T4 and Free T3 levels as needed to relieve symptoms, without being constrained by resultant TSH.  However, you may well need to address your low cortisol before even starting on thyroid med.  

I would suggest that you get tested for Both Free T4 and Free T3 each time you go in for tests.  Also, you should get tested for Vitamin D, B12, ferritin, and DHEA.  
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Avatar universal
I am very fortunate to have an open minded doctor.  My cortisol has improved since I started mineral balancing and is a work in progress.  I am also supporting my adrenals with adrenal cortex.  I think the thyroid should be addressed as well, It cannot be good to have such low thyroid hormones.  My hair is falling out, I am tired, and I need to be able to function.
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There are two basic types of hypothyroidism:  with primary hypothyroidism the thyroid gland is unable to produce adequate hormone, usually due to Hashimoto's Thyroiditis.  With central hypothyroidism there is a dysfunction in the hypothalamus/pituitary system that results in inadequate TSH to stimulate production of enough thyroid hormone.  Given your history, I expect that you have central hypothyroidism.  So mineral balancing and working on your gut is not going to do it for you.  You need thyroid med adequate to raise your Free T4 and Free T3 enough to relieve symptoms.  Many of us say that required Free T4 around the middle of its range, at minimum, and Free T3 in the upper third of its range, or as needed to relieve symptoms.

So you need to get your doctor to start you on thyroid med and increase dosage as needed to relieve symptoms.  In addition, don't overlook the importance of Vitamin D, B12 and ferritin, as mentioned above.  
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Avatar universal
Okay I understand.  It brings me back to my orignial question.  Is it best to do a combo or just start out with t4 med.  Is there anything I can do to increase absorbtion?  I am taking ACV.

It just bothers me that I do now know why my TSH does accurately reflect what is going on with my levels.
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There are hypo patients who are successful with T4 only.  If that works, it is easier to administer, since you only take it once a day.  T3 acts quicker so it is best to split the dose and take half in the morning and half in the afternoon.  

A lot of hypo patients taking T4 med find that their body does not adequately convert the T4 toT3, resulting in low Free T3 and lingering hypo symptoms.  There are no available data to quantify the percentages of patients who are successful with T4 only versus those who are not.  If you start with T4 and find lack of conversion, then you can add a source of T3, either an NDT type like Armour, or a T3 only med like Cytomel.  Even if you start with Armour, you can add a separate source of either T4 or T3, if more of either is needed.  I admit that based on my personal experience I am  biased toward using a combo of both T4 and T3.  But it has to be your decision, along with your doctor.  

Hypo patients frequently are low in stomach acid, resulting in poor absorption of vitamins/nutrients.  That is why they so frequently too low in the ranges for Vitamin D, B12 and ferritin.  As you raise your FT4 and FT3 levels absorption will improve.  

TSH is affected by so many things that there is no reason to expect that TSH will accurately reflect levels of Free T4 and Free T3.  Even less that TSH will correlate with symptoms.  If you have a look at this link it shows the very best correlation I have ever found of TSH on Free T4 and Free T3.

http://www.clinchem.org/content/55/7/1380/F2.large.jpg

If the correlation were perfect it would show a straight line.  The widespread scatter of the data clearly shows how poorly TSH correlates with either.  Unfortunately doctors like to portray it otherwise.  
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Avatar universal
The problem I was having before is that my T4 did not go up much, I got up to 125 mcg of levo.  It did not convert to anything that is why I think it just did not get absorbed.  I checked RT3 and no problem there and T3 never really improved, only got me back to where I started.  

My ferritin has always been low ish, but supplementing iodine tanked it from 63 to 38.  Not sure where I am at this very moment and its too soon to test again. I have not tested Vit D in a while but do take cod liver oil daily.  B12 has never been an issue for me.

I am leaning toward the combo syntheic route.  I do not want to take too much T3.  I am hoping to get pregnant in the next year.  I recently had a baby and noticed that my levels peaked at the third trimester then slowly went back down towards the end and totally tanked 10 days after I had the baby.  That baffles me even more.  
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Besides the concern for absorption, there may be another answer for the Free T4 not going up with dosage.  Serum thyroid levels are a sum of both endogenous (natural thyroid hormone) and exogenous (thyroid med) sources.  As you take thyroid med, that causes your TSH level to drop.  This reduces the output from the thyroid gland and the total effect may be zero until the dosage is increased enough that the TSH level is essentially suppressed and serum thyroid levels are totally dependent on increasing dosages of thyroid med.  

B12 is best when in the very upper end of its range.  D should be about 55-60 and ferritin should be about 70 minimum.  If you are not familiar with postpartum thyroiditis, have a look at this link.

http://www.mayoclinic.org/diseases-conditions/postpartum-thyroiditis/basics/definition/con-20035474
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Avatar universal
I am back up to 125 of Levo
FT4 1.2
T3 70
TSH .10
Vit D 34
B12 698 range >200

Is it time to add in some cytomel?  Also when I went from 100 to 125 I have been having issues with headaches, not sure if it is related.


If low cortisol did not cause the low thyroid hormones, how come during pregnancy I had reasonable levels of hormone?

Everything I have read indicates low cortisol as the cause of low thyroid hormone.  Do you have any sources for this info?  Would be great to finally have a root cause.

Thank you so much for all of your info!
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Avatar universal
Please post the reference ranges for the FT4 and T3 results, as shown on the lab report.  

Were you tested for ferritin also?

I'd be very interested in any info that says low cortisol causes low thyroid.  There may be a tendency for the two to occur together due to low thyroid levels eventually stressing the adrenals to the point that they produce less cortisol.

Here is a good link on the info I gave you.  Following is a quote from the link.
http://www.thyroidscience.com/hypotheses/warmingham.2010/warmingham.intro.7.2010.htm

"When a hypothyroid patient (whose circulating pool of thyroid hormone is too low) begins taking exogenous thyroid hormone, a negative feedback system reduces the pituitary gland's output of TSH. This decreases the thyroid gland's output of endogenous thyroid hormone, and despite the patient's exogenous thyroid hormone's contribution to his or her total circulating thyroid pool, that pool does not increase—not until the TSH is suppressed and the thyroid gland is contributing no more thyroid hormone to the total circulating pool. At that point, adding more exogenous thyroid hormone will finally increase the circulating pool of thyroid hormone. The increase must occur for thyroid hormone therapy to be effective. The patient's suppressed TSH, then, does not indicate that the patient is over-treated with thyroid hormone; instead, it indicates that the patient's low total thyroid hormone pool will finally rise to potentially adequate levels."

Also here is a link on how TSH is suppressed with adequate thyroid med, and a following quote from the link.

http://www.ncbi.nlm.nih.gov/pubmed/12481949

"Suppression of TSH by thyroid replacement to levels below 0.1 mU/L predicted euthyroidism in 92% of cases, compared to 34% when TSH was above 1 mU/L (p < 0.0001). In conclusion, in central hypothyroidism baseline TSH is usually within normal values, and is further suppressed by exogenous thyroid hormone as in primary hypothyroidism, but to lower levels. Thus, insufficient replacement may be reflected by inappropriately elevated TSH levels, and may lead to dosage increment."
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Avatar universal
TSH .15 .10 - 5.5
FT4 1.2 .8  - 1.7
T3 70 50 - 170

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No current ferritin.
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Free T4 should be at the middle of its range, at minimum.  Your Free T4 is just a bit shy of the middle of the range.  If these tests were from before the increase in T4 med, then that should be good.  Your Total T3 is at less than 17% of its range.  If that is indicative of your Free T3, then you do need to add some T3 to your meds and raise the level as needed to relieve your hypo symptoms.  Is the doctor willing to prescribe T3 med?  Can you get your doctor to test for Free T3 and Free T4 every time you go in for tests, so you can track the effect of med changes?  

Your Vitamin D is much too low.  Optimal is about 55-60.  B12 should be in the upper end of its range, which would be about 850-900.  You need to know your ferritin level.  Can you get the doctor to test for that?  Low ferritin can cause hair problems like you mentioned.  It would also be good to know your cortisol level.  Best test for that is a diurnal saliva cortisol test done at 4 times during the day.  Doctors don't think that is needed and usually run a morning serum cortisol test, which is harder to interpret due to the variation in cortisol level during the day.  
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Avatar universal
I have not increased anything since this lab.  Was not sure if I should add more levo first or wait a little longer at this dose.

My dr will give me cytomel.  He will nit test free t3, so I am basing dosage off symotoms and T3.  

My last ferritin was in september, it was 36.

How much vit d to bring that up? Started with 6000 iu, not sure if that is enough.
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Avatar universal
In that case, a slight increase in T4 would be beneficial.  What possible reason does the doctor have for not testing Free T3.  If it is because he doesn't think it is an accurate test, perhaps I can find evidence otherwise.  

Assuming that you started on the 6000 IU after the test result of 34, then I expect that the 6000 would be more than needed. Probable 2000-3000 IU daily should be adequate.You can tell after your next test.  With a ferritin level of 40 I started on 25 mg of ferrous fumarate (ferrous bisglycinate is also good) and increased to 50 mg.  My ferritin increased to 78.

Dosage should always be based on symptoms first and Free T4 and Free T3 second.  
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Avatar universal
I am so very tired.  The lab itself does not do it.  I am sure if I push he will send it outside of kaiser lab, he has done that for me in the past.  I am sure I am not even close to being optimal.  I cannot believe my t3 level has not gone up much.

There is so much conflicting info about supplementing vit d and iron.  The last time I tried to take iron it only made me more constipated and levels did not move.
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That is why it would be better for you to take ferrous bisglycinate, and if needed add some Vitamin C and magnesium.  
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I took solgars gentle iron in addition to mg and vit c.
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How much Solgars?
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So I added some T3, 5 in the morning and 5 and noon.  I felt awesome for about 5 days.  Now I feel like crap again.  Do I keep adding until the symptoms are gone?  Will I keep having to add more and more?  Is this typical?  I am due for labs on Monday.
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I just saw you asked how much solgars, 25mg and it made me terribly constipated.

I added in another 5mcg of cytomel and feeling better.  This was my labwork.

FT4 1.3 .8  - 1.7
T3 94 50 - 170

I have an appointment with my doc on Wednesday to see about getting FT3 and RT3 for next month.

Its amazing how the cytomel has given me back my life, I actually have a personality again. Guessing I will need a couple of increases and going to listen to my body,
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