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What is that mean suddenly increase in TSH with treatment ?

Hi,
I'm starting taking thyroxin from last July with ascending dose till reaching 25 mg
my TSH test last month was 1,27 and this week it increased to 4,855 the range till 4.78 and F T4 is 1,14 and its' range to 0,75- 1,56 what happened?
9 Responses
Avatar universal
Except at extreme levels TSH is totally inadequate as a diagnostic for thyroid status.  When taking thyroid medication, TSH is even less useful since  studies have shown that taking  thyroid med once daily in place of the usual continuous low flow of natural thyroid hormone in the untreated state creates a different equilibrium among TSH/FT4/FT3.  Studies have also shown that taking adequate thyroid med typically results in a suppressed TSH, which does not indicate hyperthyroidism unless there are attendant hyper symptoms due to excessive levels of Free T4 and Free T3.

TSH is affected by a number of variables, so I don't really know why your TSH changed from last month, nor would I be concerned about it.   In treating a hypothyroid patient the med dosage should be adjusted to relieve hypo symptoms, rather than based on lab test results, since there are no tests that are adequate measures of a person's thyroid status.     Hypothyroidism is not just "inadequate thyroid hormone", but instead it is correctly defined as "insufficient T3 effect in tissue throughout the body due to inadequate supply of, or response to, thyroid hormone".    So hypothyroidism is inadequate TISSUE T3 EFFECT.   Hypothyroidism can result from defects in any part of the complex chain of events required to produce T3 effect.   So obviously it is vital to know what your Free T3 level is, along with Free T4.  

Even more important than lab tests for Free T4 and Free T3 is an evaluation for symptoms that occur more frequently with hypothyroidism than otherwise.  So please tell us about any symptoms you have.    Also please confirm that your dosage is 25 mcg not 25 mg.  

A good thyroid doctor will will treat a hypothyroid patient clinically, for symptoms, by testing and adjusting Free T4 and Free T3 levels as needed to relieve hypo symptoms, without being influenced by resultant TSH levels.  Symptom relief should be all important, not just lab test results, and especially not TSH.  Typically we have found that symptom relief required Free T4 at least at med-range and Free T3 in the upper third of its range, and adjusted from there as needed to relieve symptoms.  In addition hypo patients are frequently deficient in Vitamin D, B12 and ferritin, which affect the response to thyroid hormone.  So if not tested for those you should do so and then supplement as needed to optimize.  D should be at least 50 ng/mL, B12 in the upper end of its range and ferritin should be at least 100.

If you want to confirm what I have said, click on my name and then scroll down to my Journal and read at least the one page Overview of a full paper on Diagnosis and Treatment of Hypothyroidism:  A Patient's Perspective.  
1 Comments
Yes, you are right the dose is 25  mcg  
Vit. D last August was 30.22 ferritin was 15 cholesterol was 233 serum triglyce rides 303 LDL 132 HDL 41 VLDL cholesterol 61
The new symptom I recognised is headache  
What does it mean?
Avatar universal
You mentioned a new symptom.  What other symptoms do you have?  When you were diagnosed as hypothyroid and started on 25 mcg of T4, what was the identified cause for your hypothyroidism?    

Your Vitamin D is much too low.  You need to supplement with about 2000 IU of D3 daily.  Your ferritin is terribly low.   You probably will need to  supplement with 75-100 mg of a good iron supplement like ferrous fumarate, ferrous sulphate, or ferrous bisglycinate, along with 500 mg of Vitamin C to help absorption and any stomach related issues with the iron.  I would start with about half of the expected final dose.   You also need to get tested for B12.  
1 Comments
it isn't my first time to speak to you before on July
i'm a female 32 years having hashimotos' thyroditis  i started med on july with half dose of 25mcg then elevated to 25 mcg last September
Avatar universal
It is important to note that serum thyroid hormone levels are the sum of both natural thyroid and thyroid medication.   When starting thyroid medication, the TSH  drops resulting in less output of natural thyroid hormone.  The net effect is that your Free T4 and Free T3 levels don't change significantly until TSH becomes essentially suppressed.   After that, further increases in your thyroid medication will start to raise your FT4 and FT3 levels.  The 25 mcg dose you are taking is so small that I would not expect you to notice any difference in how you feel.  Only when you get your Free T4 and Free T3 into the upper half of their ranges, would I expect significant symptom relief.  

Your FT4 is at 48 % of its range currently.   Since you mentioned prior posts, I went back and noticed that your Free T4 previously was at 50% of its range, and Free T3 at 35% of its range.   So as I expected, your FT4 level has not changed with the small dose of T4 med, plus your FT3 was not re-tested.  FT4 and FT3 should be tested every time you go in for tests.    

From the symptoms you previously mentioned I am sure you have seen no improvement with the small dose of T4 med.  You need to get your doctor to continue to increase your med dosage in order to try and get your FT3 into the upper third of its range, and adjusted from there as needed to relieve symptoms.  In order to get FT3 high enough when taking T4 med, you really need to make sure your ferritin is over 100 in order to improve conversion of T4 to T3.   Even then you might find it necessary to add a source of T3 to your med  in order to get Free T3 high enough in its range.  

Have you supplemented with Vitamin D and iron since your July test results?

Also, please post the reference range shown on the lab report for the prior cortisol test result.  
3 Comments
My mother takes 25 mcg daily. It makes a difference. Her hair has started to curl again now too after about a year I think (Hashi's straightened her hair).
Hard to argue against without any details; however, isn't it  possible that the change was due to something else she did since 25 mcg  makes little/no difference in Free T4 levels and may slightly reduce Free T3 levels.   At any rate, I would argue forever that 25 mcg of T4 makes no significant difference to a hypothyroid patient.  It is only a starter dose.  
Depends on the person to what relieves symptoms. 50 mcg makes her hyper but 25 mcg is just right.
Avatar universal
Yes each person is different, but I think you should look at her FT4 and FT3 before starting med and with each dose and see if there was any significant change.   Also very important to know her free cortisol levels since a small dose can create a positive initial effect with low cortisol, but have reactions when further raising the dosage.   Hypocortisolism is far more common than recognized, and especially among women.   In fact even the ATAAACE Guidelines say that any cortisol deficiency should be corrected before starting on thyroid med.
3 Comments
this is my lab test results
free T3 2.89 range 1.7:4.2
free T4 1.1 range 0.75:1.56
TSH 5.314 range 1.55:
this is my new lab test results 
free T3 2.89 range 1.7:4.2 
free T4 1.1 range 0.75:1.56 
TSH 5.314 range 0.55: 4.78
ACTH 24.7 range <65
cortisol 9 am 10.2 range 4.3:22.4
prolactin 14.13 range 5.18: 26.53
glucated Hb 5.1 normal range 4.5:5.7 serum potassium 4.1 range 3.5:5.1
sodium 139 range 136:146
the previous test ranges of lipid profile
cholestrol 233 range borderline 200:239
HDL 41 range up to 40 high risk, over 60 low risk
LDL 131 range borderline 130:159
triglycerides 303 range 200:499 high
serum VLDL cholesterol 61 range up to 30
T cholesterol/ HDL cholesterol 5.68 range < 4.44
LDL/HDL 3.2 range <3.22
i am already taking vit D monthly 50000 i u
and feroglubin supplement daily
i'll visit my doctor properly next week
what do you see?
this is my new lab test results 
free T3 2.89 range 1.7:4.2 
free T4 1.1 range 0.75:1.56 
TSH 5.314 range 0.55: 4.78
ACTH 24.7 range <65
cortisol 9 am 10.2 range 4.3:22.4
prolactin 14.13 range 5.18: 26.53
glucated Hb 5.1 normal range 4.5:5.7 serum potassium 4.1 range 3.5:5.1
sodium 139 range 136:146
the previous test ranges of lipid profile
cholestrol 233 range borderline 200:239
HDL 41 range up to 40 high risk, over 60 low risk
LDL 131 range borderline 130:159
triglycerides 303 range 200:499 high
serum VLDL cholesterol 61 range up to 30
T cholesterol/ HDL cholesterol 5.68 range < 4.44
LDL/HDL 3.2 range <3.22
i am already taking vit D monthly 50000 i u
and feroglubin supplement daily
i'll visit my doctor properly next week
what do you see?
Avatar universal
When were those tests done?  Did you take any thyroid med in the morning before the blood draw ?  Have you been supplementing with Vitamin D, B12 and iron (for the low ferritin)?  Please list all the symptoms you have currently.  If you still have the lab report, what was the reference range shown for the cortisol test?
3 Comments
thyroid tests were last Sunday.
ACTH,k,Na,glucated Hb and cortisol were last Thursday.
lipid profile was last September.
yes i did, i took thyroxin every day mostly at 6 am before blood draw.
yes, i have supplementing for vit. D, B12 and iron.
the sumptoms i'm feeling now are: muscle pain specially in the back,legs and  shoulders
headache
nervous
can't tolerante loud voices and noise .
most of the symptoms decreased when i started medication.
cortisol 9 am result is 10.2
range from 4.3:22.4 
also there is  no weight loss and i feel the thyroid gland enlarged a little bit
abdominal swelling
distributed long menstrual cycle form 10 days  
Avatar universal
As mentioned, your small dose of T4 med is not going to really change anything  regarding your FT4 and FT3 levels.    Your test results for FT4 and FT3 are 47.6% and 43%, of their ranges respectively, which is not too bad.  There is room for increasing, mainly your FT3 level; however, I am more suspicious that your symptoms are due to different causes.  Specifically,  I think your cortisol is too low.  Note the following list of the different symptoms of hypocortisolism.

Abdominal pain.
Abnormal menstrual periods.
Craving for salty food.
Dehydration.
Depression.
Diarrhea.
Irritability.
Lightheadedness or dizziness when standing up.
Loss of appetite.
Low blood glucose.
Low blood pressure.
Muscle weakness, aches
Nausea.
Patches of dark skin, especially aroundscars, skin folds, and joints.
Sensitivity to cold.
Unexplained weight loss.
Vomiting.
Worsening fatigue (extreme tiredness).

In addition,  That amount of Vitamin is inadequate to raise your level to a minimum of 50 bg/mL.  Also, how much iron is in the ferroglubim.

the fact that your symptoms improved a bit from that small starting dose fits with the scenario of hypocortisolism, since the med may have caused a short term increase in output of cortisol.  If you really want to know about your cortisol, the best test is a diurnal saliva cortisol (free cortisol) test panel of 4 tests done at different times of the day.  Is there any way to get that done?
2 Comments
most of the symptoms are exactly what i feel like
Abdominal pain. 
Abnormal menstrual periods. 
Craving for salty food. 
Depression. 
Irritability. 
Lightheadedness or dizziness when standing up. 
Loss of appetite. 
Muscle weakness
Sensitivity to cold. 
i haven't loss any weight and there is no vomiting or diarrhoea
what can i do? takes vit D 50000 iu weekly and iron in feroglobin is 15mg
Do you think the med dose of thyroxin will increase?
and about the free cortisol i'll do as soon as possible
most of the symptoms are exactly what i feel like
Abdominal pain. 
Abnormal menstrual periods. 
Craving for salty food. 
Depression. 
Irritability. 
Lightheadedness or dizziness when standing up. 
Loss of appetite. 
Muscle weakness
Sensitivity to cold. 
i haven't loss any weight and there is no vomiting or diarrhoea
what can i do? takes vit D 50000 iu weekly and iron in feroglobin is 15mg
Do you think the med dose of thyroxin will increase?
and about the free cortisol i'll do as soon as possible
Avatar universal
For Vitamin D you could just use over the counter D3 at about 3000 IU daily.  The iron amount you take is at most 1/4 of what you will need to get your ferritin to at least 100.  And even that amount may not be enough.    Some good sources of iron are ferrous fumarate, ferrous sulfate, and ferrous bisglycinate.  If you take one of those also take about 500 mg of Vitamin C to help absorption and avoid stomach distress.   You also need to know your B12 and of course get the saliva cortisol tests done.   I see no need to increase your T4 med dosage until you find out about cortisol status.    You might as well initiate a discussion about this with your doctor to find out his thinking and whether he will be willing to treat you if  your saliva cortisol levels are low in the range..  
1756321 tn?1547095325
You still are not optimally treated for Hashi's based on your labs and symptoms.
2 Comments
What should i do?
A bit of trial and error in regards to dosage. You may find different thyroid medications suit you better as well. Also try selenium. I noted certain symptoms vanished in days after I starting eating Brazil nuts and also a decrease in my TPOAb.

Info from Mary Shalom, author of the book Living Well With Hypothyroidism...

"If you're undiagnosed, or a thyroid patient taking thyroid hormone replacement medications, being in the "normal" range does not mean you feel well, or that your treatment is optimized. What levels are considered "optimal*" by many integrative physicians?

~ TSH - Typically less than 2.0
~ Free T4 - Top half of the reference range
~ Free T3 - Top half - top 25th percentile of reference range
~ Reverse T3 - Lower end of normal range
~ Thyroid Peroxidase Antibodies (TPO) - Within reference range
~ Vitamin D - Above 50
~ Ferritin - Above 60 (Above 80 if experiencing hair loss)

* we are all different, one size doesn't fit all, so these are guidelines. Your optimal levels may vary."

Just to add to that, the vitamin D listed above is in ng/mL so above 50 ng/mL converts to above 125 nmol/L.

Avatar universal
Of course I agree with Red_star about your need for higher levels of Free T4 and Free T3, by increasing your thyroid med dosage and supplements.  My only concern was that some people have reactions to increasing thyroid med when they are cortisol deficient.  Cortisol affects thyroid and vice versa. That is why I suggested waiting until you have saliva cortisol results in hand and see what needs to be done in response to that data; however, at your current, very low dosage, an increase should not become a concern.     I still recommend a minimum of 100 for ferritin which was based on a review of guidelines from 29 professional associations.  Here is the link.

https://www.ncbi.nlm.nih.gov/pubmed/26561626
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