Trying to figure out some (hypo?)thyroid results...

[NervousFishbone]

Dear all,

I wonder if you could help me as I am struggling with some Thyroid results. For a couple of years now I have been struggling with anxiety, indigestion, muscle tension in jaw/face, and headaches (and recently my hair is thinning). The way I feel has always seemed kind of irrational to me. It all started when I was under a good deal of stress, in my work life and personal life (including a bad car accident).

After couple of years of avenues like therapy/meditation, etc., I am feeling frustrated and tired. However, this year some new info has emerged, and I am trying to figure out its significance.

Earlier this year I went to a food allergist and he threw in a thyroid panel. My TSH levels were (borderline?) high (5.5) but the T3 and T4 were ok. I went to my regular doc with these results. She ordered a more detailed test, which showed these results:

TSH 4.71 (.55-4.78)
T4 Free 1.35 (.89-1.76)
TPO AB 17.2 (<35.0 IU/mL)
T3 Free 2.9 (2.3-4.2)

My doctor said that to her the results attested to a hashimotos event history.

At that time I pursued a second opinion, as these results did not to me seem all that conclusive. My sister's friend is a doctor, and he said:

"Negative tpo antibodies so he doesn't have hashimotos. I imagine the doc is making the diagnosis based on the tsh being close to upper limit. However it is still normal so based on these lab data only ... there is no thyroid problem. At most a repeat test is needed. In my opinion no thyroid meds are needed. Second opinion sounds sensible because the diagnosis appears silly and Ill thought out."

I went to another doctor then, and got a second test. I'm Irish and the second test was in Ireland, where you can get TSH assessed for free. He did not look at TPO. The TSH was 7.5 (interesting I would have been on vacation at this point, eating buckets of gluten, and experiencing very bad facial tension/headache symptoms - even mild dizziness at points.

These results persuaded me a thyroid issue might be more likely. I quite eating gluten. I feel when I quit eating gluten/grains (basically went pale) my symptoms improve to a notable degree.

More recently I have been seeing a functional medicine specialist, and we got a full blood test (looking at much more than Thyroid) and found the following Thyroid-relevant results:

*Note: In the below, I am "off" gluten:

Free T4 1.31 (0.82-1.77)
TSH 2.38 (0.45-4.5)
Antithyroglobulin <1.0 (0.0-0.9)
Reverse T3 11.7 (9.2-24.1)
T4 6.8 (4.5-12)
T3 uptake 36 (24-39)
Free Thyroxine Index 2.4 (1.2-4.9)
TPO AB 11 (0-34)
Triiodothyronine, Free 3.0 (2.0-4.4)

[gimel]

Sorry for the confusion.  I just wanted to alert you  that a low dose of thyroid med will not do much except get you started in the right direction.

Think of your total serum thyroid levels as being comprised of both natural  thyroid hormone and thyroid hormone from meds.   Taking thyroid med can actually result in a hypothalamus/pituitary reaction that reduces TSH and thus reduces your output of natural thyroid hormone.   That is why I mentioned not to expect much from the small, starter dose.  I didn't want you to be anticipating great things from the starter dose.  It may take a while for the dosage to be slowly ramped up as necessary to reach your optimal levels and relieve symptoms.  Slow and sure is the best approach.  

Some hypo patients taking significant doses of thyroid med find that their TSH actually becomes suppressed below the range before total serum thyroid hormone levels can start to rise.  Be aware that contrary to what many doctors will tell you, suppressed TSH does not automatically mean hyperthyroidism, unless you do have hyper symptoms due to excess Free T3 and Free T4 levels.  

That is why I say so often that a  good thyroid doctor will treat a hypo patient clinically by testing and adjusting Free T3 and Free T4 as necessary to relieve symptoms, without being constrained by resultant TSH levels.  You can get some good insight into clinical treatment from this letter written by a good thyroid doctor for patients that he sometimes consults with after initial tests and evaluation.  The letter is then sent to the participating doctor of the patient to help guide treatment.  In the letter, please note the statement, "the ultimate criterion for dose adjustment must always be the clinical response of the patient."

http://hormonerestoration.com/files/ThyroidPMD.pdf

[NervousFishbone]

Can I just get you to clarify "it will only reduce your TSH a bit and thus your own natural thryoid hormone production." Are you saying it will actually *reduce* my natural thyroid production?

[gimel]

I'd go with the first opinion, that got you the prescription.  I should point out, however, that it is a very low starting dose, and very likely that it will only reduce your TSH a bit and thus your own natural thryoid hormone production.  Net effect from low starting doses is usually not very much in the way of increasing serum thyroid levels.  I think the main benefit will be that you have started on the path to raising your Free T3 level, and that will encourage the doctor to continue with that, as long as you continue to emphasize your symptoms and your Free T3 and Free T4 levels.    

[NervousFishbone]

Folks, I have a sort of further, logistical question.

I have doc here in the city (the doc who ran my second numbers, above). She's an MD but works in a 'complimentary medicine' center. She actually did prescribe me a low dose (25mcg, I think) of Levothyroxine.

However, the second opinion I got pooh-poohed this so much that I never filled the prescription. But I am literally about to head off home to Ireland for 3.5 weeks. I have no time to go back to my doc.

My question is this: would it be worth picking up the Levothyroxine prescription and trying it for the next month, before going back to my doc?

I feel that if I at least tried it, she'd might be more credibly willing to try me on armour.

Thoughts?

Thanks all for your responses already.

[NervousFishbone]

Thanks a lot for your feedback. I will try to get this taken care of early next month (I'll be on the road next few weeks and no real way to see my doc in that time, unfortunately).

[gimel]

The two tests for Hashi's were negative.  That does not absolutely rule out Hashi's; however, confirmation is somewhat irrelevant at this point.  The main benefit to knowing about Hashi's is that it identifies the cause of being hypothyroid and then you would know if your thyroid gland function would continue to diminish over time.  In addition your Free T3 to Reverse T3 ratio meets the level generally regarded as necessary.  So, nothing to be concerned about there.  

Of course the most important issue for you right now is the symptoms you mentioned.   Your symptoms are sometimes related to being too low in the range for Free T3.  Many of our members say that symptom relief required Free T3 in the upper third of its range, along with Free T4 around the middle of its range.  So it would be a good idea to discuss with your doctor a trial of a T3 med to start increasing your Free T3 level and monitor its effect on your symptoms.  The doctor might want to alternatively try you on a T4 med to see if raising your Free T4 level will adequately raise your Free T3 level.  That might work, but it would take months to get a good evaluation of the effect.  T3 is much faster acting so a small dose should have an effect in weeks, rather than months.  

Also, your doctor may get hung up on your TSH level being within range.  That is not so important because TSH is a pituitary hormone that is affected by many things.  Doctors like to think it accurately reflects levels of the biologically active thyroid hormones, Free T3 and free T4; however, TSH cannot be shown to correlate well with either Free T3 or Free T4, much less correlate well with symptoms.  Free T3 is the thyroid test that correlates best with symptoms, as shown by scientific studies.  

In conjunction with the above, since hypo patients are frequently too low in the ranges for Vitamin D, B12 and ferritin, I also suggest that you should test for those.  Since ferritin and selenium affect conversion of T4 toT3, it would also be good to check your selenium level.  

[NervousFishbone]

Thank you. You explained that quite clearly. One thing, you mentioned testing for Reverse T3. In the last (4th) test results above, my Reverse T3 was tested at:

Reverse T3 11.7 (9.2-24.1)

So it would seem to be at quite low end of range, and probably not dominant? In which case, you would be saying it is an efficiency issue?

Tho you are saying in either case goal is to reduce stress, and add little amount of T3?

Just for sake of my research and future consultations with doctors or whatever, are you saying this is a kind of hypothyroidism but probably NOT hashimotos? Those antibodies would have to be a lot higher for that, no? (Tho both times that was tested, I had not been eating gluten for a while). I ask simply as I am getting mixed interpretations on this point.

Anecdotally, I can tell you that white flour-based products consumed for any extended period do seem to make me feel significantly worse (tension, dizziness, anxiety, etc.). I am okay with small amounts of caffeine, but more can make me feel worse, too. Sugary things make me feel bad. And hangovers from alcohol seem to be quite bad, too. I am currently off gluten and trying to avoid the other things in large or frequent amounts.

Finally, based on the above, do you still contend I need T3? If so, is this something one can only get through a doctor?

[flyingfool]

TSH test is a screening test at best.  over 10 years ago the American Acadame of Clinical Endocrinologist stated that any TSH above a 3.0 should be considered for treatment of being Hypo (low thyroid).

your tests clearly and repeatedly have been above 3.0 suggesting being hypo.

Better tests for determining your thyroid condition are the Free T4 test and Free T3 test.  you have had both of those done and they are within normal range.  HOWEVER.  normal range's are set inadequately.  Many if not most people feel well when substaintially up within the range.  specicifally,

having BOTH of the following.

1) Free T4 FT4 to be in the MIDDLE of the range if not slightly higher (50% or more of the range)

AND- that means in addition

2) Free T3 (FT3) to be in the UPPER 1/3 of the range (66.7%) of the range.

You test results are:

FT4 =51.5% so it is indeed over the rule of thumb 50%

FT3  = 41.7% which is substaintially BELOW the rule of thumb 66.7%

This would indicate that you may have an issue with your body's ability to convert the FT4 into usable FT3.  That would mean that it would make sense that you may want to consider adding in a source of T3 medication.

your body at the cellular level ONLY uses the Free T3 hormone. So with your being low in the FT3, that would mean that at the tissue or cellular level you are deficient of thyroid.  Even though there is enough Free T4 in the blood to be converted.  So there simply is an issue going on with the conversion. Not hugely uncommon condition.

As your tests seem to indicate a FT3 conversion issue, you may want to ahve your Reverse T3 tested as well.

This is because during the conversion process the Free T4 can only be converted into either usable Free T3, or it is converted into Reverse T3. Which is a mirror image molecule that is biologically inactive.  Testing for Reverse T3 may help dedtermine whether or not you have a reverse T3 domanance issue, or if you have an efficiency issue, that is not enough of the conversion is taking place at all.

Stress either emotionally or physically can cause the Reverse T3 to be elevated.  In either case the solution other than reducing the stress is to add some T3 medication SLOWLY.

Just my thoughts for now!

[NervousFishbone]

Sorry, posted too quickly. Some typos there:

*Paleo, not "pale"

Anyway, thanks all for your thoughts. Much appreciated.

Sincerely,

NervousFishbone