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Hypothyroidism, Esophageal Issues, and Low Pulse Rate

Hello. I am a 46-year-old male, and I have autoimmune hypothyroidism. This post is a bit long. So, please bear with me.

In late June 2019, I started taking Synthroid 137 (2 times per week) and Synthroid 125 (5 times per week).

In mid-August 2019, I had some blood tests, and the results were as follows:

FT4 = 1.59 (normal range = 0.82 - 1.77)

FT3 = 3.3 (normal range = 2.0 - 4.4)

TSH = 0.064 (normal range = 0.450 - 4.500)

Vitamin D, 25-Hydroxy = 21.0 (normal range = 30.0 - 100.0)

Vitamin B12 = 867 (normal range = 232 - 1245)

My endo was concerned about the low Vitamin D level. So, she ordered a bone-density scan. The scan showed osteopenia in 2 places (lumbar spine and left femoral neck).

The endo strongly suggested that I take Vitamin D supplements. I started taking Jarrow Formulas Vitamin D3 (In Extra Virgin Olive Oil) 1000 IU softgels. I took one per day, every day.

Shortly after I started taking Vitamin D, I started feeling pain on the right side of my neck (including the right side of my thyroid). Also, I started having trouble swallowing food (especially macaroni).

In mid-November 2019, I took another round of blood tests, and the results were as follows:

FT4 = 1.46 (normal range = 0.82 - 1.77)

FT3 = 3.2 (normal range = 2.0 - 4.4)

TSH = 0.084 (normal range = 0.450 - 4.500)

Vitamin D, 25-Hydroxy = 31.6 (normal range = 30.0 - 100.0)

Vitamin B12 = 655 (normal range = 232 - 1245)

The Vitamin B12 and the FT4 decreased significantly. The FT3 decreased slightly. And the Vitamin D was now normal.

In mid-December 2019, I had had enough of the neck pain and the trouble swallowing food, and I stopped taking Vitamin D. Shortly after I stopped taking Vitamin D, I started feeling somewhat better with respect to the neck pain and the trouble swallowing food.

Unfortunately, the neck pain and the trouble swallowing food did not go away entirely. Also, I developed acid reflux and a cough. My PCP suggested that I take Omeprazole or Pepcid. But those medications posed a risk of kidney failure. So, I took 10-mg Famotidine tablets (1 per day, for 3 days). On each day, the tablet suppressed the acid reflux. However, on one day, after I took the tablet, I temporarily had more trouble swallowing food than usual. On a different day, I experienced chest pains after taking the tablet.

My PCP ordered a barium x-ray of the esophagus. The x-ray showed that there was an esophageal web. This explained the trouble swallowing food. Sometimes, an esophageal web is caused by iron deficiency. However, my iron level was normal, as the following blood test showed:

Ferritin = 265 (normal range = 24 - 336)

In mid-February 2020, my endo ordered more thyroid tests, and the results were as follows:

FT4 = 1.55 (normal range = 0.82 - 1.77)

FT3 = 3.0 (normal range = 2.0 - 4.4)

TSH = 0.075 (normal range = 0.450 - 4.500)

Vitamin D, 25-Hydroxy = 22.0 (normal range = 30.0 - 100.0)

Vitamin B12 = 862 (normal range = 232 - 1245)

Calcium = 8.9 (normal range = 8.7 - 10.2)

The FT4, Vitamin B12, and Vitamin D levels came back to what they had been before I had taken Vitamin D supplements. However, the FT3 continued going down (from 3.2 to 3.0).

Also, the endo pronounced my Calcium level as normal. However, over the last 10 years, my Calcium level has decreased significantly. Here are my Calcium results over the last 10 years:

July 2009
(when I was first diagnosed
with autoimmune hypothyroidism): Calcium = 9.6 (normal range = 8.5 - 10.3)

December 2013: Calcium = 9.3 (normal range = 8.5 - 10.3)

July 2018: Calcium = 9.0 (normal range = 8.5 - 10.3)

February 2020: Calcium = 8.9 (normal range = 8.7 - 10.2)

Furthermore, about a day ago, I visited my endo, and my vital signs were taken. My pulse rate was about 50 beats per minute. My usual pulse rate is in the 60s or 70s. My pulse rate 3 weeks ago (when I met with my PCP) was 68.

The endo ordered an EKG (electrocradiogram). The EKG report stated "sinus bradycardia", "minimal voltage criteria for LVH, may be normal variant", and "borderline EKG". One possible cause of bradycardia (lower-than normal pulse rate) is hypothyroidism. Also, I have been feeling somewhat lethargic and lightheaded.

So, with my FT3 continuing to go down, with my Calcium levels significantly decreasing during the past 10 years, and with bradycardia developing, what is my endo doing? She is DECREASING my Synthroid dosage because she is concerned that the low TSH (0.075) means that my bones are in danger. She could make the bradycardia worse.

The endo wanted to decrease my dosage to Synthroid 125 (7 times per week). However, I talked her into a smaller decrease (Synthroid 125, 6 times per week), (Synthroid 137, 1 time per week).

By the way, the endo said that she believes that the FT3 value is unreliable.

So, what's going on here? Why is my FT3 decreasing? Why is my Calcium decreasing? Why do I have bradycardia (lower-than-normal pulse rate)?

Is my endo correct to decrease my dosage? Or should I find a new endo?

Thank you for any information.

1 Responses
649848 tn?1534633700
It sounds like you have more than one thing going on, but unfortunately, it's pretty much mostly related to being hypothyroid.  

Acid reflux is a very common symptom of hypothyroidism, as is sinus bradycardia.  I, personally, have had them both since I was diagnosed... I, too, have Hashimoto's (autoimmune hypothyroidism) and suppressed TSH, along with osteopenia, which causes my doctors to believe I'm hyper and that the low TSH will/is causing bone deterioration.  I've also been plagued with low vitamin D and I have Pernicious Anemia which is autoimmune low Vitamin B-12, which requires injection of B-12 since I don't absorb it via the gut.  My ferritin level has also, typically, run close to 300, and although Ferritin is the iron storage hormone, it doesn't always indicate adequate iron levels; higher ferritin levels can also indicate inflammation in the body.  

Low calcium levels could indicate a parathyroid problem or simply a diet issue in which you aren't getting enough calcium.  Symptoms of calcium deficiency include muscle/joint pain, cramps, fatigue, skin/nail problems, alopecia, osteopenia/osteoporosis, PMS (obviously would not apply to you), dental problems, tingling around the mouth, in the feet, hands, etc.  

So, what to do?  First off, no - your doctor should not be reducing your dosage because of your low TSH.  TSH does nothing but stimulate the thyroid, it does not cause osteopenia or osteoporosis, nor does it cause or alleviate symptoms.  Doctors who believe it does are misinformed and are doing their patients a huge disservice.  

I believe in previous postings, we've stated that most of us feel best when Free T4 is at/near mid range - yours, at 1.55, is at 76% of its range.  Most of us, also feel best with Free T3 in the upper half to upper third of its range.  Yours is right at 50% of its range.  Your Free T4 is really higher than it needs to be, but your Free T3 is lower than it should be since Free T3  is the hormone that's used by nearly every cell in the body.  It appears that you aren't converting the Free T4 to Free T3 adequately.  If I recall, it's been suggested in past posts that you might need to add a T3 medication to your daily regimen if your doctor would agree to this.  Judging from her view that Free T3 is not a reliable test, I'd guess that she doesn't believe in T3 medication or the possibility that one might not convert adequately.  If that's the case, my first recommendation would be a new doctor.  

Along with that, you do need to be taking Vitamin D to get/keep your level up.  Just getting it into the "normal" range isn't good enough.  Vitamin D needs to be at least 60 in order to be effective - some say it should be higher than that.  Vitamin D is necessary for proper metabolism of thyroid hormones.  It's also necessary for proper absorption of calcium, which could be contributing to osteopenia at such a young age.  

Magnesium is also required for proper absorption of calcium for proper bone formation, as vitamin K2.  

Although your calcium level is "normal", you might discuss taking supplements with your doctor because calcium is responsible, not only for bone health, but it plays a role in the electrical responses in the heart health as well.  Studies show low calcium may contribute to heart arrhythmia (irregular heartbeat).  

I'd also recommend a complete iron panel to make sure your iron level is really adequate, since iron is also necessary for proper conversion of Free T4 to Free T3.  Iron deficiency also causes fatigue and other symptoms, so you'll want to make sure you do have sufficient iron.  Simply being in range isn't good enough for many of the vitamins/minerals.  For many of them, we need to be at least mid range, if not toward the upper end of the ranges because the ranges are so broad that being in the bottom of the ranges is like being deficient.
Hi, Barb.

Regarding the issue of FT4-to-FT3 conversion, someone told me the following: A normal thyroid will produce both FT4 (to be converted to FT3) and FT3. My thyroid is not working properly and is not producing anything. The Synthroid is only FT4 (to be converted to FT3). The Synthroid does not produce the extra FT3 that a normal thyroid would produce. That is why my FT3 level is lower than it should be. My conversion rate is normal, but there is no extra FT3.

As for adding a T3 medicine, I took some Liothyronine (generic version of Cytomel) in 2012. That medication gave me heart trouble, and I haven't taken any T3 medicines since then.

As for Calcium in my diet, I probably do not get enough Calcium in my diet, and my endo suggested that I change my diet, and she gave me a list of foods that contain Calcium (as well as a list of foods that contain Vitamin D). But I have to be careful with these Calcium-containing foods. In 2018, I ate Calcium-containing shrimp for a while (at night, for dinner, long after taking Synthroid), and my FT4 plunged to 1.00, my Vitamin B12 plunged to 304, and my TSH rose to 3.010. However, my FT3 was at 3.0 (up from 2.9 before the shrimp).

As for the complete iron panel, which tests are included in that?

"no - your doctor should not be reducing your dosage because of your low TSH." Well, she believes that low TSH means too much Synthroid, and that too much Synthroid causes bone loss/problems. She kind of laid down the gauntlet on the Synthroid issue. Lower the Synthroid, or find another doctor. So, for now, I have to go along with this. But I might pay for a private iron-panel blood test.

It's true that a normal thyroid produces both T4 and T3; it's also true that if your thyroid isn't working, it produces nothing and if you're only taking Synthroid, you're only getting T4.  It's also true that Synthroid does not produce T3 because it's a T4 medication.  I have no idea how someone decided that your conversion rate is normal under those circumstances.  The first clue that one's conversion is not adequate is normal/high Free T4 and low Free T3 because the theory is that your body "should" be able to convert the Synthroid to produce an adequate supply of T3.  Most/many of us are not able to do that without adding another source of T3, such as Liothyronine, Cytomel or a desiccated hormone such as Armour, NP, NatureThroid, etc.

What type of heart trouble did the Liothyronine give you?  T3 doesn't cause heart trouble unless you take too high a dose.  Actually, taking too low a dose of thyroid medications can cause heart issues, as well, as you can see, since you have sinus bradycardia.  Too low heart rate is just as dangerous as one that's too high.  Also, hypothyroidism can cause irregularities as well.

It might be worth trying a very small dose again.  I'm on Liothyronine, but only 5 mcg/day.  It's not quite enough, but it's all I can get my doctor to prescribe.  Without it, I get heart palps, pounding heart rate and my heart rate goes even lower than it already is (resting is low 50's, but it's known to drop into the low 30's when I sleep).  

I have no idea why your FT4 and Vitamin B-12 would have dropped so low while eating calcium containing foods.  It is necessary to separate calcium supplements or high calcium foods from thyroid meds by at least 4 hours, but if you were taking your med in the morning and eating the foods at night (assuming around dinner time), it shouldn't have had that effect unless you were eating way more than you needed and you weren't absorbing the calcium into your body (i.e. it was just floating around in your blood, binding to the medication or somehow blocking it from entering the cells).  

Just because you tried something once - the T3 med or the calcium and Vitamin D, doesn't mean you shouldn't try them again.  Simply try a different brand, form, dosage, etc.  We don't always have great success with the first thing we try.  

An iron panel includes:      serum iron,  total iron binding capacity (TIBC),  transferrin saturation (%),
    overall ferritin (iron) in the body  
Here's a link to a reasonably priced iron panel if you're paying out of pocket: http://www.healthcheckusa.com/hemochromatosis-iron-tests/iron-panel.aspx

I'm really sorry that your doctor was so adamant about the low TSH meaning too much Synthroid and/or that too much Synthroid causes bone deterioration.  Quite frankly, the one doctor that laid down that gauntlet with me found herself with one less patient.   I'd strongly recommend you begin the search for another doctor.  It doesn't have to be an endo; it can be a primary care physician, as long as they're familiar with treating thyroid conditions.  Many of us find that we get better care from naturopathic doctors, but many of those don't take insurance and/or they demand that blood tests be run by their own labs, etc.  There are beginning to be more that accept insurance and that actually do primary care, so if you can find such a doctor, you might have better luck.  There are even some nurse practitioners that are treating thyroid patients and doing a better job than many doctors.  Look around and see what you can find - if you're willing to switch because your current doctor is going to keep you ill.
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