Thyroid Disorders Community
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Avatar universal

synthroid/cytomel after thyroidectomy

I am one year post op (complete thyroidectomy).  I have continued to have symptoms of hyper no matter
what my dose was adjusted to.  This week my doctor added cytomel but didn't lower my synthroid.  
I already see some benefits from the cytomel but also felt some syptoms that indicate hyper for me.
Do you always lower the synthroid when giving cytomel?  I'm on 88mcg of synthroid (low for my weight)
and 10 mcg of cytomel.
9 Responses
Avatar universal
Did you really mean hyper,  not hypo?  Why would the doctor be adding Cytomel, if you have hyper symptoms?  Please post  whatever lab test results you have you, along with reference ranges used by that lab.
Avatar universal
I have had consistently low t3 labs (low to low normal).  We had tried 125 mcg synthroid
then 112 then 100 and now 88mcg. I was finally in normal range but having problems
(constipation!, fluid retention, low energy, sore feet)
I just started the cytomel this week and have already seen some improvements but
wondered if doc needed to lower my synthroid since anything above 88 mcg makes' me
hyper.  I don't have my labs with me but will post them later. The doctor didn't know
much about cytomel but is great and listening and trying to help.
Avatar universal
Sorry, but I'm having difficulty understanding some things.  Are you basing your description of being hyper on your  TSH levels, or on actual hyper symptoms?  What are all the symptoms that you have?  We really do need to look at your lab results and reference ranges for each test.  

Trying to read between the lines, it sounds like to me that you are still having hypo symptoms because you're not getting enough meds, after your TT, but the doctor is maybe telling you that you are becoming hyper, based on your TSH level.  So, your T4 med was lowered, and instead, you were given Cytomel, which is a T3 med, that is more potent and faster acting than a T4 med.  If that is the case, it makes no sense.

TSH is a pituitary hormone, not a thyroid hormone.  It is affected by many variables, including the time of day when blood is drawn.  TSH is totally inadequate as a diagnostic, by which to determine medication and dosage.  At best it is an indicator, along with more important indicators, which are symptoms and the levels of the actual, biologically active thyroid hormones free T3 and free T4.  By free, it means that the hormone is not bound up with protein molecules, and is thereby biologically active.  FT3 is the most important to now because it is four times as potent as FT4  and FT3 correlates best with hypo symptoms.  TSH does not correlate very well at all with hypo symptoms.

So, in my opinion, the very best way to treat a thyroid patient is to test and adjust the levels of the actual biologically active thyroid hormones, FT3 and FT4 with whatever meds are required to alleviate symptoms, without being restrained by TSH levels.  TSH levels are frequently suppressed to the low end of its range and even below when taking thyroid meds.  This does not mean you are hyper.  Only hyper symptoms mean you are hyper.  And symptoms should be all important.

Hope this will give you some food for thought.  Please post those labs and reference ranges so that our many experienced members can provide some worthwhile feedback.
Avatar universal
Thank you for your comments!  I have been on synthroid 88mcg for 3 months now and
actually had my best labs so far-  tsh .632 (470-4.830),  t4 1.7 (.75-2.00), triiiodothytonine 2.7 (2.0-4.4)  I had my thryoid removed because of toxic multinodular goiter.  My symptoms have been severe constipation, afternoon tiredness, fluid retention, weight gain, sore feet - I have never had the classis hyper symptoms but
had all hypo symptoms - before and after surgery.  My tsh before being treated with
ATD's and before surgery was .002. hence the hyper diagnosis.
By the way, I cut my synthroid in half this morn. and took the cytomel...I feel very
normal today.  I hoping!! this (cytomel) is the answer for me!  What do you think?
Avatar universal
Yes, you do have the classic hypo symptoms, plus your free T3 is low in its range.  So adding in some T3 med is in the right direction.  I'm not sure I would have reduced the Synthroid so much.  The 10mcg of Cytomel is approx. the equivalent of 40 mcg of Synthroid: however, Synthroid levels will decrease very slowly.  So in 4-6 weeks you might all of a sudden notice that you are having more symptoms again. as your T4 goes down.  I don't know how your doctor is figuring into your med change and what kind of direction he gave you.  You definitely needed more freeT3 to help with those symptoms.  I think if it were me I would keep the Synthroid level the same and if possible split the Cytomel into 4 peices and take 1/4 in the am. and 1/4 in late afternoon.  I'd do this for several weeks and see how you react.  Then if all okay then I would go to 1/2 in a.m. and 1/2 in late afternoon, and then after 2-3 more weeks I would get retested for FT3 and FT4.  

Since the ranges for FT3 and FT4 are very broad and need to be adjusted like TSH was, patients frequently find that they need for FT3 to be in the upper part of the range , and FT4 at least midrange, in order to get symptom relief.   So you can keep that in mind as you progress.
Avatar universal
I think you are right on the synthroid dosage.  I felt very good this morning but started
running down in the p.m. and took the other half.  My doctor doesn't seem to know
a whole lot about dosing the cytomel.  She looked at some papers that I brought in
about trying cytomel and it suggested 5 mcg x 2.  On my labs 3 months ago, my
t3 was 2.2 (I was on 100 mcg levothyroxine) but my t3 has risen to the present point
of 2.7 without cytomel.  I get confused about these numbers at times.  I thought my
t3 should  be mid-range and my t4 in the upper range.  Since I couldn't tolerate higher
doses of synthroid before, I worried that the cytomel would have the same effect
as say the 100mcg dose if I didn't lower the synthroid.  Is that too confusing?  
I will try what you suggested about the cytomel tomorrow though.  Would that be just
to give my body an adjusted period to it?  
Avatar universal
Free T3 is the most active thyroid hormone.  I am personally convinced that the ranges for the "Frees" are wrong, since they have never been adjusted like TSH was over 6 years ago.  Having a bit of a background in statistical analysis, I think if the range for FT3 were adjusted comparable to TSH, the range would go from 2.6-4.2 pg/ml up to 3.3-4.3.  My logic for that ties in with what we hear from so many hypo patients that continue to suffer symptoms until their FT3 is in the upper part of the range.  FT 4 in the middle of its range is probably adequate to go with the FT3 in the upper part.  The most important thing is to test and adjust FT3 and FT4 with whatever meds are required to alleviate symptoms, without being constrained by the resultant TSH level.  Whatever levels are required to relieve symptoms, that's what we are all looking for and it varies from person to person.  

When you say you couldn't tolerate higher doses of Synthroid before, do you mean that you had hyper symptoms as a result, or just a low TSH?  If it was just a low TSH, then that is not unusual for TSH to be suppressed when on thyroid meds.  You are hyper only if having hyper symptoms, although many doctors react as though you are confirmed hyper and reduce your meds.  Dosing a patient by TSH is just wrong.  How can the absence of a pituitary hormone that does not affect metabolism or other body functions be such a concern?  Somehow they think it is signaling hypothyroidism, yet you probably didn't have hyper symptoms.  Very puzzling.

Regarding the Cytomel, yes, if you don't reduce the Synthroid, then splitting the dose and extending the time is just to make sure that you do not have an unwanted  reaction to it.  Just being cautious.  Slow and steady changes are recommended, especially as you approach higher levels.
Avatar universal
Sorry, just noticed my mistake.   I meant to say in the second paragraph.  Somehow they think it is signaling hyperthyroidism, yet you probably didn't have hyper symptoms.
Avatar universal
I know that this is many year old, but coming across this sounds much like myself currently two years out from my TT.  I hope someone sees this to comment on any progress.
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