High TPO in new very symptomatic patient. Advice for treatment? List for PCP?

[williegates]

Hey there, I'm the husband.  

My wife was fine in July.  Then in August, everything went to hell.  She has a TON of symptoms - from weight to lack of energy to fluid retention.  

We initially thought it was psychological, so we've been treating it like this since Aug with almost no changes.  Horrible time it has been.  After feeling defeated, I just started reading for hours and I wised up at some point that it could be a symptom and not just depression/suicidality.  I thought maybe Estrogen Dominance.  

A test of her Estrogen/Progesterone levels show a ratio of 12.  The low end is 100 and the high end is 500.  Hers was 12.  Top top top end of scale for Estrogen and bottom low end of scale for Prog.

Before waiting two months to see a OBGYN, I researched the ED for hours and hours, frequently seeing ED caused by thyroid dysfunction.  I thought the same thing as with the depression --- what if the ED is ALSO a symptom and not a cause.....

So I chased that one down, nagged the hell out of the doc, and got her to call in a full Thyroid panel for the wife.  Bam.  Got it.  TPOA is supposed to be under 9UI/mL....it's 301.  

So the biggest concern is the insane fatigue and depression she has.  It's killing her.  I worry about her snapping one of these days.  I really do.  She says she will tell me if it gets there, but she's sobbing just getting up out of bed some days after 14 hours in bed, then going down and sitting on the couch and falling asleep sitting up.  It's scary and depressing for me too.  

The reason why I post is we have one of those PCP docs that if you tell him you want something, he will most the time just do it.  And while I would much rather get her in to see a specialist Endo, the three in network are booked solid until JULY !!  So I'm not okay with just letting the wife suffer for five months waiting to see a specialist.  

So MY QUESTION IS----What can we throw at this to start trying to narrow in on a treatment...at least at the level of the PCP so we can get her some relief (because we've tried every antidepressant in the book and none help)?  My research says start with 15-30mg Armour (slowly stepping up) with of course exercise and diet positive changes.  Most of her levels are fine except for TPOA is off the charts, but she is HIGHLY and DEBILITATINGLY symptomatic.

Happy to add info or labs if you need/ask.  Appreciate the help.  

My plan that I've created on my own up to this point lol was just to have PCP (A) give referral to Endo in July, (B) referral for ultrasound of thyroid, (C) start the Armour "exploratory" trial.  (D) Already starting her on Centrum once a day, (E) Just ordered Selenium 200mcg 1xday and (F) just ordered Methyl B12 5000mcg 1xday.  

Anything else?  Does that sound great or terrible lol?  Appreciate your help.

[williegates]

Thank you for your information.  It is more informative than most of my doctors have been to be honest.  So sad really, that so many doctors don't care enough to treat the person.  

So far it's been a struggle.  My PCP is completely useless.  I (as the husband) see the same PCP.  My wife has her three month appointment next week, so during my three month appointment this week, I explained everything I have explained in the last posts about Wife even though it was my appointment.  I ran this by him to see if he was going to be of any help, and, if so, how much help he was going to be.  I told him in the end that Wife is probably going to need
((A)) a referral to an ultrasound,
((B)) tests for D, B12, DHEA-S, and Ferritin, and,
((C)) start standard treatment for her many symptoms by prescribing 30mg of Armour/NDT.  
((D)) I also told him I had ordered (out of my own pocket) a test for Diurnal Cortisol x4 (which arrived yesterday evening, will be administered Sunday, and will be shipped back on Monday (2/10/2020) to hopefully get results back by Friday (2/14/2020) and that she may need Hydrocortisone supplementation of 30mg-35mg evenly distributed throughout the day to treat those specifically applicable symptoms as well.  
((E)) I also explained the TSH levels -- the old ones from 20 years ago (0.50-4.50), the new ones from the American Kidney Association found more accurate over the last 10 years (0.50-2.50), and the ones found best for Hashimoto's patients by reports where those with Autoimmune Thyroiditis have been found most symptom-free (0.50-1.00).  

My PCP was absolutely worthless beyond belief.  So said.  He's 70-something years old and stuck in his old ways I believe.  I believe mentally he's not there to forge any new roads or learn any new information or treat individuals more than just check three-month boxes of "I saw patient, will see in another 3 months, blah blah blah....".  The answers were all bad...sigh....

This is what responses I got from him:
((A)) "A referral is best given by an endocrinologist" (even though I said it would be mid-May or June before I could get Wife into see one),
((B)) "Those tests have little impact and little to do with your thyroid...they are more promoted online for those 'natural rose petal extract anti-vax naturalist PAs who really have no business prescribing anything most the time with their snake-oil ideas (while laughing off my idea)." (This is even though I explained I read Mayo Clinic studies where incorrect levels of some of them produced hyper- and hypo-thyroid symptoms).
((C)) "If her TSH is within range, prescribing her needless hormones could kill her...bad idea....." (I don't believe that for a sec...in fact lol, I may have irritated him at that point because I made a passing comment about how "if the depression and anxiety of not being treated doesn't kill her first.").

CONTINUED (ONE OF TWO POSTS)

[gimel]

Responding to your list.

2A.  Weight gain/difficult to lose weight.      Hypothyroid patients typically  have below normal Resting Metabolic Rate.  The actual RMR depends on the severity of hypothyroidism.    There is a company I know about that developed a test for tendon reflex time as a measure of a patient's thyroid status.   It has been known for a long time that tendon reflex time correlated well with hypothyroid symptoms., but it was never utilized due to lack of reliable test equipment, I think.   This company established a tendon reflex time threshold for euthyroidism.  Patients that had a longer tendon reflex time and symptoms typical of hypothyroidism and relatively low FT4 and FT3 were treated as needed to achieve their recommended level of tendon reflex time.   They reported that the change in RMR averaged about 400 calories per day.    To assess the effect on a person you can use the formula for RMR, by which you could estimate that over an extended period, 400 calories per day increase would    cause a female to lose 400 divided by 4.35, which is about 92 pounds, assuming that diet and exercise habits
went unchanged.  

2B.  I know of no reason that T3 would need to be added to the Armour for absorption.   If the person was not getting an adequate effect, it was probably due to an inadequate dose, maybe because the dose was being determined by TSH levels, not by symptoms.

4A.  the 10,000 dose of Vitamin D every day is way too much, so she had a reaction.  If her D is as low as you mentioned, then I suggest 3000 IU daily and then re-test later.  D needs to be at least 50 ng/mL.    If not tested for B12 and ferritin it needs to be done and then supplemented to get B12 in the upper part of its range, and ferritin needs to be at least 100.  Ferritin is important for conversion of T4 to T3 and low ferritin can cause symptoms.  It is also necessary for good hair growth.

5.  Yes, two Centrum tablets plus K2.  I take 45 mcg of K2 daily.  

6.  I am sending you a PM with some doctor info.   To access, just click on your name and then from your personal page click on messages.  

[williegates]

Thank you, gimel.  Appreciate all the information and guidance.

((1)) Get Ultrasound -- will do.  Thank you.

((2)) Armor/NDT. Will do.  Start at 30mg, increase every two weeks by 30mg. After 8 weeks while at the dosage which produces the most minimal level of symptoms, check all the thyroid levels.
     ((A)) "Depending on weight"-- she is 240 pounds and in otherwise good health except for weight and thyroid/cortisol issues.
     ((B))  While reading about this issue and people's experiences, I noticed many people have had no effect from NDT by itself and need 10mcg of Cytomel to assure absorption of NDT.  Do you not recommend this? Or do you recommend after a certain amount of time with no results from only NDT?

((3)) Check 4-stage Cortisol levels. Will do. Thanks for the ZRLabs recommendation.  Found the test panel.  I will try to convince my doc to call it in, but he's a stubborn old guy who has only certain uses, and exploring new frontiers are not some of those uses lol.  I will post those results once I get them, either from my old doc or from my own labs.

((4)) Get levels checked of DHEA-S, Vitamin B12, and Ferritin.  
     ((A)) I found a Vitamin D level test from July 4, 2019 and the level was 19.  I asked the wife about it, and she said the doc had tried to tell her to supplement 10,000 units of Vitamin D.  She said after about 3 or 4 days of taking it, she felt extremely moody and "bitchy" and it made her feel like she was turning into a "raging *****" (her words lol).  So she stopped taking it and that feeling/symptoms went away.  

((5)) Centrum.  Keep taking it.  Will do.  There IS a possibility of osteoporosis because she took the birth control for quite a few years back in 99-03, the birth control that causes bone loss that they said not to take anymore and she stopped.  She used to be 5 foot 6 and ended up after 5-7 years being 5 foot 4, which her doc at the time said was probably bone loss from the birth control.  
     ((A)) I noticed you said TWO Centrum Silvers.  First, I got the normal Centrum 300 tabs from Amazon.  My wife is 40 so I didn't want her to feel terribly old and so I got the normal stuff.  Should she be taking TWO a day instead of ONE?  FYI, I will also get her some Vitamin K1 supplements ordered.

((6)) Thanks for the heads up about the endo.  I just don't want to waste my time waiting four or five months for a specialist who isn't going to help at all.  That would really really really **** me off lol.  A lot.  I appreciate the recommend to a decent doc.  It's so hard to find one and then wait four months to find out if the guy is worth a crap..sigh...  We live in El Reno, Oklahoma....That's about 15 minutes west of Oklahoma City, Oklahoma.  Anywhere in Edmond, Norman, Moore, Oklahoma City, etc would be fine.  Tulsa is about two hours away and too far for regular visits. Appreciate wholeheartedly the recommendation.

[gimel]

The list I gave you included both typical hypothyroid as well as hypocortisol  related symptoms.  Obviously your wife is hypothyroid.  It is not well known that female hypothyroid patients frequently have hypocortisolism also.   She also seems to have a number of low cortisol symptoms.  

I suggest that you slightly modify your plan as follows.  

>Get the ultrasound test of the thyroid gland as planned.

>As for medication, following is the recommendation of an outstanding hormone doctor.    "To initiate TRT with NDT in patients who are healthy and less than 50yrs. old, I start with 1/2gr of NDT (30mgs) and increase by 1/2gr every two weeks up to 1.5 to 2grs, depending on body weight. In elderly or ill patients or those with suspected hypocortisolism, I start with just 1/4gr and increase by 1/4gr every two weeks up to just 1 to 1.5grs daily. After 8 weeks on the full dose I check the TSH, FT4 and FT3. I reserve rT3 testing for difficult cases. I instruct patients to have their blood drawn in the morning, prior to taking the thyroid dose, and not much later than their usual dose time. This yields the 24hr trough levels—the lowest FT4 and FT3, and highest TSH levels that exist during a day. "  It is very important to defer morning dose of thyroid med until after the blood draw, in order to avoid false high results.  

>Get a diurnal saliva cortisol (free cortisol) panel of 4 tests done over the day.    Doctors usually will not order this, but instead want to do a morning serum cortisol (total cortisol) test, which is not nearly as revealing.  If the doctor won't order a saliva cortisol test, you can order a kit from ZRT Labs and do it yourselves.   If you do this, understand that being in the lower half  of the range along with multiple symptoms of hypocortisolism is confirmative, even if the doctor doesn't agree.   If you can get agreement to treat, then a total of 6 or 7  of the five mg pills of hydrocortisone should do it for her.  

> I don't think you need to do all those tests at this time.   I do suggest a DHEA-S, Vitamin D, B12 and ferritin.  Hypothyroid patients are frequently deficient in those.   D should be at least 50 ng/mL, B12 in the upper part of its range, and ferritin should be at least 100.  I think a B12 supplement should be more like 500 - 1000.mcg daily.

>Centrum is good.  Depending on whether there is possibility of osteoporosis, I have determined that taking 2 Centrum Silver daily, alon g with a Vitamin K2 will help build bone the natural way.  

I would not pin my hopes on the endocrinologist.   Most of them specialize in diabetes, not thyroid.  Most of them also have the "Immaculate TSH Belief" and use "Reference Range Endocrinology", which does not work well for most patients.   What you need is a  doctor that will diagnose and treat clinically, primarily based on symptoms, with extended testing beyond just TSH and FT4.   If you will tell us your location, perhaps we can suggest a doctor who has been recommended by thyroid patients.  And of course you will want a doctor who understands cortisol.  

If you want to confirm what I have suggested, click on my name and then scroll down to my Journal and read at least the Overview of my paper on Diagnosis and Treatment of Hypothyroidism: a Patient's Perspective.

[williegates]

My plan (that I've created on my own) up to this point is to ask the PCP to do the following:

(A) give referral to Endo that we will see sometime in July....sigh....

(B) referral for ultrasound of thyroid (to ensure no serious abnormalities/growths/cancer/etc)

(C) start the Armour "exploratory" trial.  My research shows Armour is the least symptomatic option statistically.  Normal start is 15mg for 2 weeks, then pull full Thyroid panel, then 15mg added, wait for 2 weeks, then pull blood.  Rinse/repeat until symptoms go away or hyper symptoms appear.. My research tells me Armour should push the TSH level down to .5-1.0 while raising T3/T4 to upper half or third of scale.  This should improve symptoms.  (This is all research, googling, and med paper reading....I could be wrong, but this is my best guess.)

(D) ????

I've gotten on Amazon and bought the following and will be implementing it if not told to stop:

(A) already started her on Centrum once a day

(B) Ordered Selenium 200mcg.  Will be here tomorrow.  Will start her on 1xday as soon as it arrives.

(C) Ordered Methyl B12 5000mcg.  Will be here tomorrow.  Will start her on 1xday as soon as it arrives.

(D) ????


Possible tests to discuss with PCP/GP:

1. SIBO Test
2. Epstein-Barr Test
3. Iodine Level Test
4. Selenium Level Test
5. B12 Level Test
6. Celiac Test
7. Cortisol Test over 24 hour span
8. DHEA Test
9. Fibromyalgia Test (FM/a)
10. Ferritin Level Test
11. ????



Possible other options if Armour doesn't work or works negatively

1. Synthroid/Levothyroxine, start at 25mg, take for 2 weeks, test RT3.  If no improvement in other numbers and/or symptomology and RT3 is high, it's an absorption problem and add Cytomel 10mg.  If not absorption problem and numbers are going in right direction, continue stepping up Synthroid/Levothyroxine @25mg/2 week wait/pull full Thyroid panel....rinse/repeat until either hypo symptoms disappear and/or hyper symptoms appear.

2. (Last resort to rid her of all these horrible symptoms?) Remove thyroid and supplement everything.

3. ????

[williegates]

Thanks for your reply.  Here you go. :)

X    fatigue                                                                                                
X    inability to cope with stress                                                                          
X    cognitive dysfunction                              
no hot flashes
no hypotension, lightheadedness                                                                                                
X   depression
X   anxiety                                                                                                        
(used to a few months ago, not over the last month or two) insomnia/frequent awakening
X   irritability
no low blood pressure                                                                                      
X   body hair loss    
X   nausea, diarrhea or vomiting  
no low blood pressure
(no, opposite in fact) unexplained weight loss
no salt craving
X   mental fog/poor concentration  
X  cold extremities, always feels cold    
X  aches and pains
X  hair loss/dry coarse scalp hair
X  dry skin (use skin creme)
X  weight gain                                                  
no constipation   (have to use laxatives/fiber)                                          
X  high cholesterol                                        
X  ankle swelling
no facial puffiness                                                                          
X  hair dry/brittle/loss                                                                                
no hoarseness