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Low TSH, low normal FT4

Over the last few years my TSH has dropped from around 1 to .6 to .5 to .4 and it is now .29 which is outside of the normal range (0.34-4.82). FT4 was evaluated and is 10.7 pmol/l, a drop from around 13 1.5-2 years ago. This is still within the normal range (10-20 pmol/l), however I am having some symptoms: fatigue, short term memory issues big time are the two big ones. I'm waiting to hear back from the doctor about where we go next, but also just looking to hear others' stories if they have been somewhere similar. I am tempted to ask about assessing my pituitary just to be safe, though I feel a bit silly to do so.

Thanks.
5 Responses
Avatar universal
Do not hesitate to ask about pituitary function.  Your symptoms along with diminishing TSH and the low FT4 seems likely to be central hypothyroidism.   With central there is a dysfunction in the hypothalamus/pituitary system resulting in TSH levels that are too low to adequately stimulate the thyroid gland.  

Besides pituitary function testing you need to get some additional tests done.  I recommend that you should always test for both Free T4 and Free T3 each time.  In addition, hypothyroid patients are frequently deficient in Vitamin D, B12 and ferritin, so you should get those done and then supplement as needed to optimize.  D should be at least 50 ng/mL, B12 in the upper part of its range and ferritin should be at least 100.  Also, due to the potential pituitary issue, you should be tested for cortisol.  

When you have additional test results, please post here along with reference ranges and we will be happy to help interpret and advise further.  
3 Comments
Thank you so much! I’m waiting on my B12 results, but it looks like I’ve just got back my Ferritin: 35 (15-130) - up from 26 eight months ago because I am taking 150mg of iron daily. It looks like FT3 was run also and is 3.6 (3.5-6.5). The doctors don’t like to run vitamin D here, but I know from past results that I tend to run quite low so I supplement 2000-5000 IU’s daily.
Is it common in central hypothyroidism to see diminishing TSH over the course of years?
Oh and my B12 just came back: 282 (150-600).
Avatar universal
I have no experience or knowledge gained from others' to say about a diminishing TSH with central hypothyroidism.  I can say that you have a number of deficiencies in your test results.  Just because a test result is within the so-called "normal" range does not mean it is adequate for you.  First because the ranges are far too broad due to the erroneous assumptions used to establish them.  If you want to confirm this and understand why the ranges are not functional for many people, have a look at Item no. 3 on page 4 of the following link.

https://tinyurl.com/y7sfp5r8

In trying to assess a person's thyroid status, TSH is an adequate indicator only when at extreme levels.  The main value for TSH is usually just to distinguish primary from central hypothyroidism.  the most important consideration is symptoms and you have mentioned several that are frequently related to hypothyroidism.   When typical hypo symptoms are present, and Free T4 and Free T3 are in the lower part of their ranges, then hypothyroidism is likely.  Your FT4 was only at 30% of its range, and your Free T3 only at 3 % of its range.  

Since the correct definition for hypothyroidism is "insufficient tissue T3 effect due to inadequate supply of, or response to, thyroid hormone", we also have to look at variables that are major contributors to the response to thyroid hormone.  that is why it is important to look at cortisol, Vitamin D, B12 and ferritin.  Cortisol should be neither high nor low.  Vitamin D needs to be at least 50 ng/mL, B12 in the upper end of its range and ferritin should be at least 100.  Your D should be okay with supplementing as you do daily.  We'll know more about B12 from the test result.  I can't understand how you could be taking 150 mg of iron daily and still be deficient in ferritin.    Are you sure that is 150 mg or mcg?

By the way, hypothyroidism has been shown to reduce cerebral blood flow to 4 key areas of the brain, including the area affecting cognitive ability.  There was also a study that concluded that cognitive impairment from hypothyroidism was reversible.  

The most important thing you need is a good thyroid doctor.  By that I mean one that will diagnose and treat based on symptoms, instead of  just based on TSH and FT4 compared to the flawed reference ranges.    So you are going to have to find out if your doctor is willing to do that.  If not, then you will need to find one that will do so.

1 Comments
Hi Gimel,
Thanks again for your thorough reply. Knowing there is a possibility that the memory and fatigue issues might be reversible is fantastic news.

I am positive that the iron is 150mg. I have no idea why it is climbing as slowly as it is. My B12 came back at 282 (150-600).

I also just received a note from my doctor stating that the bloodwork looked basically normal save the TSH value and my iron stores. She wants to repeat the TSH in one month.
Avatar universal
Your doctor is just delaying action that you need.   Waiting is not going to help  clarify anything.   It is already clear that you need to be on thyroid medication adequate to raise your FT4 and FT3.  Note the following conclusion from an outstanding thyroid doctor.   "The free T3 is not as helpful in untreated persons as the free T4 because in the light of a rather low FT4 the body will convert more T4 to T3 to maintain thyroid effect as well as is possible. So the person with a rather low FT4 and high-in-range FT3 may still be hypothyroid. However, if the FT4 is below 1.3 and the FT3 is also rather low, say below 3.4 (range 2 to 4.4 at LabCorp) then its likely that hypothyroidism is the cause of a person's symptoms."  Of course the reference ranges and results are in different measurements than yours, but the inference is clear.  

Does it really make any sense to say that a FT4 or FT3 test that is at the very bottom of the range (like yours) is equally acceptable as one that is 100% higher, at the very top of the range?  No it does not.  The ranges are not based on results from adults with no thyroid pathology.  The ranges are  based on all test results at a given lab, with the only results excluded being those with high TSH.    In addition everyone has different thyroid parameters at which they function best.   So you are going to have to change your doctor's mind by giving him relevant information and asking him to read and reevaluate his diagnosis and treatment protocols.  A good start would be to click on my name and then scroll down to my Journal and red at least the one page overview of the full paper I linked for you previously.  If that overview and the full paper does not change your doctor's approach, then you will need to find a good thyroid doctor that will diagnose and treat clinically, based on symptoms rather than by TSH and FT4 compared to demonstrably flawed reference ranges.  

Also, if you cannot get your ferritin level up by the supplement you  mentioned then the doctor might be willing to give you iron infusions.   Ferritin needs to be at least 100.
2 Comments
Thank you Gimel. I am reading what you posted and have booked a follow up with my doctor for next week to communicate to her that I would like to probe further rather than take a wait and see approach.
By way of an update: I spoke with my doctor and she has referred me to an endocrinologist. It can take some time to get in, so in the instance I have to wait more than one month to see the endo, we will repeat the thyroid testing prior to seeing the endo. Otherwise, we'll wait and let the endo order whatever testing.
Avatar universal
Just being an Endocrinologist does not assure being a good thyroid doctor.  Many Endos specialize in diabetes.  Many also have the "Immaculate TSH Belief", by which they really only pay attention to TSH for both diagnosis and treatment.  That does not work for most hypothyroid patients.   To best prepare for the next step, I highly recommend that you read through the info I gave you above and take a copy with you to the doctor and ask him to read it and consider clinical diagnosis and treatment, based primarily on symptoms, rather than just TSH and Free T4.  

Please let us know how things progress for you.
3 Comments
Hello. I don't want to hijack your post, but I just created a similar post a few moments ago. If you have a moment, please feel free to read my post and respond. I would love it if you would. :-) A huge difference between me and lsninja is that I have Hashimoto's and I take T3 and T4. My TSH is now suppressed and my free's are dropping. My understanding with pituitary issues is that you can have just one pituitary hormone be deficient (such as TSH, since it comes from the pituitary gland), while all of the others are normal. I've had my other pituitary hormones test in the past and they were normal.

For those of us who have had lowish TSH all of our lives, lowish free's, go on meds and TSH gets suppressed much more than someone who is regular hypo, if there is an inclination for there to be a pituitary problem, do the TSH levels fluctuate a little up and down or even decline over time? Or, is this low TSH/low free's a product of very high antibodies and is just par for the Hashimoto's course?

I will also read your linked info.
Hi Gimel,
It’s asked to complete another TSH, FT4, FT3 and TSH antibody. My numbers have shifted a bit, particularly the FT3. TSH: .47; FT4: 10.9 and FT3: 4.2. I am still waiting on the antibody test. But these numbers look better?
Please post the reference ranges shown on the lab report for those tests.  Are you going to be able to get tested for Vitamin D, ferritin, and cortisol?
Avatar universal
I had already responded to your other message.
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