Is it possible to display symptoms of hypo and hyper thryoidism at the same time?

[makkus]

I am 50 YO male, ex-smoker (quit beginning of last May), MI survivor (3 stent implants - 2 2004, 1 2010), history of hypertension, familial history of hypothyroidism, Hashimoto's disease, Grave's disease, and goiters.  Hospitalized Nov 5 2015 due to extremely high BP (204/102 in ambulance), rapid pounding heart, extreme shortness of breath,  shakiness, muscle weakness, and hand tremors.  Due to prior coronary history a blocked artery was suspected but angiogram revealed only a partial blockage, which was not repaired.

Diagnosed Hyperthyroidism and suspected Graves Disease Nov 7 2015.  Thyroid ultrasound revealed one lobe more than twice normal size, and overall very heterogeneous echotexture.  Allergic reactions to Methimazole (bad) and PTU (not as bad), so had to have total Thyroidectomy Feb 9 2016, parathyroids left intact.  Started on 125mcg Synthroid, Feb 10.  T3 conversion problem discovered March 21st, so Endo added 25mcg Cytomel as well (1/2 dose for first week then titrated to full dose).  Most recent bloodwork (Apr 6) shows

fT3 6.81 (range 3.90 - 6.70 pmol/L)
fT4 13.3 (range 12.0-22.0 pmol/L)
TSH 1.36 (range 0.27-4.20 mlU/L)
TPO Ab 518 (range 0-34 IU/ml)
Calcium 2.43 (range 2.10-2.55 mmol/L)

Lately I have found that if I take all my thyroid meds in one dose first thing in the morning, as instructed, I am jittery and shaky by 10 or 11 am, then crashing and looking for a nap midafternoon.  BP 124/80 at GP's office yesterday afternoon, but 149/92 at home this morning 1.5 hours after taking my thyroid meds.  I am only just learning about the effect my T3 and T4 levels have on my body, and have been reading forums like this one and STTM, but it seems to me that my fT4 (although technically in the normal range) is too low, and my fT3 is now too high.  Phoned my Endo's office this morning to ask about it, and never got past the receptionist, who says if my TSH is normal that's all she (my Endo) is worried about.  REALLY?   With a KNOWN T3 conversion problem, and post-thyroidectomy?  If I understand all this, with no thyroid for it to affect, isn't my TSH level kind of a moot point?

I would welcome any and all information or insight anyone could offer.

[goolarra]

One quick question before getting into a discussion:  Had you taken your T3 before the blood draw?  If so, how long?

[makkus]

Because I was having boodwork done that day I only took 15mcg at 6:30am.  Blood draw was approx. 1pm.  the remaining 10 mcg I took about 3pm.  

[makkus]

It may also be worthy of mention that I'm taking 2000 iu Vit D and 3000 mg Calcium Carbonate daily.  My B complex and ferritin have not been tested recently, to my knowledge.

[goolarra]

No, it's not a dumb question.  You're right, it really doesn't matter at this point.  I just found it curious that you were diagnosed with Graves' with TPOab so high (TPOab is one of the markers for Hashi's) and no TSI (the marker for Graves') test to back it up.  At this point you are hypo, and that's all we need to know.  I find your diagnosis more of a reflection on your doctor's ability as a thyroid doctor.

I disagree with cmac66.  TSH level is often moot.  TSH is really only useful as a screening test for asymptomatic individuals.  TSH is affected by so many factors in the thyroid/hypothalamus/pituitary feedback loop that it often becomes useless.  A classic example:  Once on meds, many people's TSH goes to close to zero, never to bounce back up; adding T3 also frequently causes TSH to virtually disappear.

Hashi's is a cause of hypothyroidism, the most prevalent cause in the developed world, but Graves' is the cause of hyper, not hypo.  Goiter, inflammation and enlargement of the thyroid, is common in people with both Hashi's and Graves'.    

Remember that TSH causes NO symptoms in and of itself.  If TSH is accurately reflecting FT3 and FT4 levels, then it can be useful.  Too many of us have been treated improperly because TSH didn't reflect our free levels  or our symptoms, and too many doctors are fixated on TSH as the gold standard in thyroid testing, which it isn't.  

[cmac66]

First off,  Hashimotos and graves are causes/results of hypothyroidism and goiters are a symptom of Graves. Yes, you can display signs of hypo and hyper at the same time just as people with theses may exhibit one or more of the related symptoms. Noone experiences them all but they do experience different degrees and different symptoms. Your TSH level is never moot. You still have the hormone in your body even if synthetic and it still effects your body. You are correct in that your TSH may be normal but you can still have problems if your T3 and T4 are off. If not satisfied with your current endocrinologist ask to be referred to another

[goolarra]

I've never heard a valid argument for not splitting it.  I think a lot of doctors think we're not reliable enough to remember to take it twice.  You probably need an increase in your T4 meds, too, but with FT3 so high, you'd want to decrease T3 to compensate.    

[makkus]

Hashi or Graves, how much does that matter now that I'm post-thyroidectomy?  I know that probably seems like a dumb question, but please  understand I am still pretty new to all of this.

[goolarra]

Given your high TPOab, I'd suspect you were in a hyper phase of Hashi's rather than Graves'.  Did they test TSI when you were diagnosed hyper with suspected Graves' in November?

T3 has a very short half-life.  It peaks in your blood a few hours after taking it, and it's pretty much gone a few hours after that.  Most people split their dose of T3 into two half doses, one first thing in the morning along with the T4, the other typically late morning to early afternoon.  You can play with timing to see what works best for you.  25 mcg T3 is a lot all at once, and your symptoms are classic symptoms of too much in a single dose.  T4 doesn't have to be split because its half-life is much longer.

The 15 mcg of T3 you took the morning of the draw probably inflated your FT3 a bit, but the draw was 6 or so hours after taking it, so that would counterbalance the inflation a bit.  The general rule is not to take T3 before the draw.  

You're absolutely right about your FT3 and FT4 levels.  FT4 is 13% of range, and the guideline for FT4 is 50%.  FT3 is above range, and the general rule for that is upper half of range.  We're all different, so take those numbers as a starting point and nothing else.  

Thyroid or no thyroid, conversion issue or none, TSH is not adequate to manage meds on.  FT3 and FT4 are much more important, and both have to be optimal (for you), not just somewhere/anywhere in the ranges.  Symptoms trump FT3 and FT4.  Most people can tolerate FT3 levels in the top half of the range; I, personally, would be spinning off the planet.  

You may need a new doctor.  It's usually pretty hard to convince them that TSH isn't the gold standard they were taught in med school that it is.  I'm also not impressed by your doctor starting you on such a high dose of T3.  Many times 5-10 mcg per day, split, is adequate.  I'm also not impressed that she told you to take it once a day.  T3 just doesn't last that long as you can tell by your hyper symptoms in the morning and crash in the afternoon.

What were your numbers in March when she diagnosed a conversion issue and added 25 mcg T3 to your 125 mcg T4?

[makkus]

I don't have a copy of the bloodwork, but I remember my fT4 being about 16.7, and fT3 being below the normal range on March 7th. which was the last blood draw before my surgical followup app't on the 21st.  I tried to talk to GP yesterday about splitting my dose(s), but she does not want to step on my Endo's toes yet.  Have not heard back yet from my Endo since I called this morning.