Normal TSH and freeT3 low free T4

[beliz20]

I have Celiac disease, diagnosed 8 months ago. (immune response to gluten) I have had forgetfulness, brain fog, fatigue, worsening PMS symptoms like cramps, moods and again fatigue, unable to lose weight, etc.(some of these symptoms can be related to celiac but also some could be hypothyroid) I have other random symptoms but keep coming back to extreme fatigue and body aches mostly for small periods throughout the day. As part of the celiac disease workup I have had my thyroid labs drawn.
TSH  1.7 (.3- 4.8)
Free T3 2.6(2.0-4.0)
and my free T4 is borderline .54 (.50- 1.50).
Thyroglobulin 6.1 (0.0-55.0)
Thyrog Ab <20.0 (0.0-40.0)  
Tpo abs<10.0 (0.0 -35.0)
So my TSH and T3 are normal and my T4 is borderline. My thyroid antibodies are normal. Is a borderline low free t4 and an autoimmune disease enough to send me to an endo? I will be asking my family doc to run the thyroid panel again to see if it rectifies itself, but if I see this confusing result again what should i do? My family doc is open to suggestions but I don't know that she's that aware of thyroid issues. THanks for any advice.

[gimel]

Doesn't have to be an Endo, just a good thyroid doctor.  Endos are frequently enamored with the "Immaculate TSH Belief" and only want to diagnose and medicate based on TSH.  This does not work.   Others are very rigid about using " Reference Range Endocrinology".   This frequently doesn't work either because the ranges are far too broad, since they have never been corrected like was done for TSH over 8 years ago.  

A PCP is not a good thyroid doctor unless willing to treat a patient clinically by testing and adjusting Free T3 and Free T4 as necessary to relieve symptoms, without being constrained by resultant TSH levels.  Symptom relief should be all important, not just test results.

[sunrise204]

I agree and disagree with comments read regarding your situation. Like you, I was borderline with my T4, the primary doctor chose to do nothing.  My symptoms got worse.  In the mean time, I scheduled my annual visit with the gyno doc.  She is fabulous!  During the exam, she noticed that my thyroid was enlarged.  After talking with me, I explained that I had just had a thyroid test and it was borderline.  She said she didn't like what she felt so she was going to repeat tests.(it had only been 3 months at the most).  The second test showed clearly that I had hypothyroid.  Medication was prescribed and I retested 3 months later.  This was over 10 years ago now.  My issue is that the levels have really never been able to be regulated correctly and it took a long time to figure out why.  Testing for me is every 6 weeks now because I have what is called Hoshimoto's disease.  That is basically when you are hypo one month then hyper the next. There really is no known reason why so I go often to get tested and meds change every single time.  It is extremely frustrating for me.  In fact, I have disposed of so much medication recently due to the frequent fluxuation in the dosage.  I want to have the thing removed and take a dosage to maintain.  I am tired a lot and deal with depression all side effects of the disease.  What is interesting to me is that I have a family history of Celiacs and have all of the same issues I have been reading about.  It is scarey.  I had gastric bypass 7 years ago and lost more than my body weight.  I absolutely hate to eat now due to the issues I experience following .  In fact, I don't eat much if any most of the time.  I take weekly B12 shots as absorbing meds is an issue since gastric surgery.  Also, became lacto intolerent following the surgery.  I have leg cramps, aches, throbbing all of the time.  Much of this seems to be written about on these forums in reference to celiacs.  I wonder if Celiacs and Thyroid conditions are connected in some way.  
As for what I disagree with from comments above, it is imperative that you get a good endo doc.  Primary docs are wonderful but they are not experts on medicating for this disease.  At one point I was taking 3 times the dosage necessary for my body weight.  The primary doc finally admitted she was not the expert and felt I would be better off to see an endo doc.  The endo doc was appauled by the amount of meds I was taking on a daily basis.   She adjusted the meds and I stay between certain levels that are much more conducive to my weight.  While the disease I have is difficult, the medication dosage varies in small numbers.  Good Luck!

[beliz20]

Thanks for your feedback. Much appreciated!

[gimel]

From your description of symptoms plus the test results, I'd say that you are hypo, and in need of thyroid meds.  It is good that you were able to get all those tests done, and not just the TSH test that is always done.  As you noted, your FT4 level is borderline.  Your FT3 level is also too low based on what I have found during my extensive web surfing and also from feedback from our members.  Frequently we hear from members that symptom relief for them required that FT3 was adjusted into the upper part of its range and FT4 adjusted  to at least midpoint of its range.  Symptom relief should be all important, not just test results.

If your family doctor is open to suggestions, then personally I'd stick with that doctor, rather than going to an Endo.  Even though you would expect different, many of them have the "Immaculate TSH Belief" and only want to diagnose and medicate based on TSH alone.  Also, they tend to be more rigid about treatment protocol, even if it doesn't get you symptom relief.  I also suggest that in view of your TSH level occurring with a low FT4, that you may have pituitary issues to be evaluated in the future.  

For now, keep in mind that a good thyroid doctor will treat a patient clinically, by testing and adjusting FT3 and FT4 as necessary to relieve symptoms, without being constrained by resultant TSH levels.  To help your doctor feel more comfortable in treating you clinically in this manner, this is a copy of a letter written by a good thyroid doctor for patients that are consulting with the author, from a distance.  The letter is sent to the Primary doctor, to help in properly treating the patient.




For Physicians of
Patients Taking
Thyroid Hormones

I have prescribed thyroid hormones for your patient because his/her symptoms, physical signs, and/or blood tests suggested that he/she had inadequate levels for optimal quality of life and long- term health. If there were clear improvements, I maintained the thyroid supplementation. Mild-to- moderate thyroid insufficiency is common and an unrecognized cause of depression, fatigue, weight gain, high cholesterol, cold intolerance, atherosclerosis, and fibromyalgia. Thyroid supplementation to produce higher FT3 and FT4 levels within the reference ranges can improve mood, energy, and alertness; help with weight control, and lower cholesterol levels.

Your patient’s TSH may be low or undetectable, even though their free T3 and free T4 are within the reference ranges. Why? We are taught that the TSH always perfectly reflects a person’s thyroid hormone status, supplemented or unsupplemented. In fact, we have abundant evidence and every reason to believe that the hypothalamic-pituitary axis is NOT always perfect. In clinical studies, the TSH was found not useful for determining T4 dose requirement.i The diagnosis of thyroid insufficiency, and the determination of replacement dosing, must be based upon the patient’s symptoms first, and on the free T4 and free T3 levels second. The TSH test helps only to determine the cause. Even here, “normal” may not be good enough. The labs’ reference ranges for free T4 and free T3 are not optimal ranges; but only 95%-inclusive statistical population ranges. The lower limits are below those seen in studies of healthy adults. They define only 2.5% of the population as “low”, but hypothyroidism is more prevalent than that.  

T4-only therapy (Synthroid, Levoxyl), to merely “normalize” the TSH is typically inadequate as the H-P axis is often under-active to begin with, is more sensitive to T4, and is over-suppressed by the once-daily oral thyroid hormone peaks. TSH-normalizing T4 therapy often leaves both FT4 and FT3 levels relatively low, and the patient symptomatic. Recognizing this, NACB guidelines call for dosing T4 to keep the TSH near the bottom of its RR (<1) and the FT4 in the upper third of its RR; but even this may not be sufficient. The ultimate criterion for dose adjustment must always be the clinical response. I have prescribed natural dessicated thyroid for your patient (Armour or Nature-Throid). These contain T4 and T3 (40mcg and 9mcg respectively per 60mg). They are more effective than T4 therapy for most patients. Since they provide more T3 than the thyroid gland produces, the well-replaced patient’s free T4 will be around the middle of its range or lower, and the FT3 will be high-“normal” or slightly high before the AM dose.

Excessive thyroid dosing causes many negative symptoms, and overdosed patients do not feel well. I suggest lowering the dose in any patient who has developed insomnia, shakiness, irritability, palpitations, overheating, excessive sweating, etc. The most serious problem that can occur is atrial fibrillation. It can occur in susceptible patients with any increase in their thyroid levels, and is more likely with higher doses. It should not recur if the dose is kept lower than their threshold. Thyroid hormone does not cause bone loss, it simply increases metabolic rate and therefore the rate of the current bone formation or loss. Most older people are losing bone due to their combined sex steroid, DHEA, Vitamin D, and growth hormone deficiencies. The solution is not life-long hypothyroidism or bisphosphonates; one should correct the hormone deficiencies.