conversion problem? what to pursue next?

[RCinNY]

Hi, all.  I've had worsening fatigue and morning headaches/lightheadedness/nausea for years now, which still might be caused by a few things still not ruled out.

I did find a responsive endocrinologist who agreed it was worth giving me a trial Rx of Levo (25 daily).  After 6 weeks, my labs changed as follows...
TSH: 3.49 --> 2.28 (0.40 - 4.50, but we know better)
FT4:  1.2 --> 1.9 (0.8 - 1.8)
FT3:  2.9 --> 2.66 (2.3 - 4.2)

My symptoms haven't improved at all, but I understand it could be an unresolved, unrelated issue (and I do suspect my sleep apnea therapy needs to be altered somehow).  I have a follow-up endo appt. scheduled in a couple of weeks but before I go, I was curious about what next to ask about and whether there are other labs I've had done that could possibly explain these.  I guess it could be a lab error, but I've read about T4-T3 conversion issues, but the threads can branch off in lots of ways and get confusing.

Thanks for any advice.
RC :)

[RCinNY]

I just wanted to follow up on this to see if you think I'm on the right track.  After 6 months on 50 mcg (up from 25) levothyroxine, my TSH and T3 haven't budged much (low 2's and high 2's respectively), and, no surprise, T4 is way over the maximum now (low 2's).

The levothyroxine didn't seem to be having much influence on the fatigue.  I seem to have a couple of decent weeks then a block of time when I'm just dragging (and missing work time).  I'm still on cymbalta, an anti-depressant, which is keeping generalized anxiety under control.  My psychiatrist has me on adderall (20 mg) for 3 months now, and so far it seems to be the only thing that gets me out of bed.

It's hard to tell how much of this is mental vs. something biological (such as a thyroid issue).  My numbers before treatment were never so far out of whack and the levo. doesn't seem to be doing much.  Just when my endo and I were going to give up, I asked about the T3 not climbing, and she thought to give me cytomel (5 mcg daily) as one last thing to try.  I'm only on the second day of it, so it's probably too soon to tell.

It seems like it's this or bust, as far as the thyroid goes, right?  I'm sure everyone is different, but I can't seem to tell whether my #s are more indicative of someone with a serviceable thyroid grasping at straws or whether I'm in a small minority (a fairly young male who doesn't convert that well).

Thanks for any thoughts you might have to share.

[RCinNY]

Thanks, Barb.

Yes, those are the correct #s.  Fatigue, morning headaches are the worst symptoms, which I realize could be caused by so many things.  For over two years, I've been to several dr's, trying to find the cause or rule out possibilities, one by one.  Reading online, it seems I have a whole bunch of labs that are normal but borderline.  (I do have constipation and a bit of weight gain, but those are probably lifestyle-related.  No issues with sugar.)

As for the thyroid, for years the TSH has been about 3.5, with normal FT4 (I think this is the first year someone thought to check for *F* T3).  I've always been a low-energy person but never quite this bad.  I had a bout with alopecia about 7 years ago, and when a thyroid work-up was done then, I tested positive for an antibody.  So it was always in the back of my mind that something might not be quite right with the thyroid.  Maybe it's OK to leave it alone and monitor, IDK. Both primary dr's I had over the years recommended that approach, but the endo could tell I was desperate and she said it was 50/50 that a low-dose trial could work (i.e., solve the problem).

As for the FT3, it didn't occur to me that it could just be a time lag before it would catch up.  I since read (this morning) that B12 helps with conversion.  There, too, my B12 typically comes up low-normal.  I was taking a supplement (levels were at the top of the range with it) during the first test.  I since gave up on my vitamins, probably out of frustration since they didn't appear to be doing anything for me.  So that could explain the drop, although the FT3 was never that great in the first place.

[Barb135]

Your TSH was 3.49 and it dropped to 2.28 after 6 weeks of treatment with 25 mcg of levo, etc?  Just want to make sure we're on the same page...

It's entirely possible to have a conversion problem; many of us do, but I don't think 6 weeks on levo is enough time to determine that, since  FT3 often lags behind FT4 for some time before it finally starts tracking upward.  It also takes time for the body to adjust to taking thyroid hormones.  

On the other hand, FT3 tends to correlate best with symptoms and yours is very low in the range, so could be a source of symptoms. You can talk to the endo about adding a small dose of T3 med and see if he's receptive.  T3 med is best started at a very small dosage - no more than 5 mcg/day and is best split into 2 dosages/day - 2.5 mcg in the am and 2.5 mcg around noon/early pm.  

You could try taking the levo every other day for an average of 12.5/day, since your FT4 is already over range and it's customary to decrease T4 med when adding a T3 med.  

Fatigue is really the only thyroid related symptom you mention, but with your initial labs, it's worth a try, if the endo is receptive - most would not be.  

Do you have any other symptoms of hypothyroidism, such as constipation, cold intolerance, weight gain, muscle/joint pain, puffiness in the face, hands, feet, etc?

Have you been tested for diabetes/blood sugar issues?  Either hyper or hypoglycemia can cause the symptoms you mentioned.