Please help with test results

[Gzsimo]

Here are my latest test results. I have been feeling achy and tired lately. I am not sure if this is related to my thyroid hormones or possibly female hormones.  

Ferritin  29  4.6-204

Vit D. 39. 30-100

Tsh .38. .35- 4.94

Rt3 10. 8-25

Ft3 2.0. 1.7-3.7

Ft4. 1. 0   .7-1.5

B12. 818.  211-911.

Also, in March I had blood work and my tsh was 1.1. Ref  .35-4.94
Freet4 was 1.1. Ref range .7-1.5
Freet3 was 2.4. Ref range 1.7-3.7

I take synthroid and cytomel.  I had labs drawn in the morning.  My latest labs I did not take that Cytomel till after my blood was drawn. It was around noon that I took the Cytomel and I noticed my energy was better in the afternoon. I used to take this Cytomel right after my Synthroid in the morning around 5 AM. I think spacing this Synthroid and Cytomel apart has made a difference? In the way I feel.  I don't know! I do not know how my thyroid test results can change so much in one month. I am beginning to think that the female hormones play a big role in this.   Any suggestions please!

[gimel]

The way I see it right now is that all your test results show adequate levels of everything except Free T3, which is at rock bottom of the range.  Since Free T3 has been shown to correlate best with hypo symptoms, while Free T4 and TSH did not correlate at all, you need to coerce your doctor into gradually increasing your T3 med until your symptoms are gone.  That is most likely to be when your Free T3 is increased to the upper part of its range.  I see no reason to reduce your T4 med, based on your last test results.  

If you are unsuccessful with your doctor then you need to find a new doctor that will treat clinically, by testing and adjusting Free T3 and Free T4 as necessary to relieve symptoms, without being constrained by TSH levels.  If needed we may be able to suggest a doctor in your area.

[Gzsimo]

125mcg of synthroid 6 days and 2 pills of 125 on day 7. 5mg of cytomel. She wants me to do 125. A day now. Will suddenly decreasing dose cause problems?  Thanks.

[gimel]

Your Endo declared you as hyper based only on TSH.  He is wrong.  TSH is frequently suppressed when taking thyroid medication.  That does not mean that you are hyper, unless you do have hyper symptoms due to excessive levels of Free T3 and Free T4 which is not the case for you.  In reality your Free T3 is way too low in the range (I am assuming that the range is 2.3 - 4.2), which is frequently associated with having hypo symptoms.  Your Vitamin D and ferritin should be adequate.  

So, what med are you currently taking and what is the daily dosage?

[Gzsimo]

I need some help interpreting my labs. My TSH was .09, my free T-3 was 2.3, my free T4 was 1.2, ferritin was 60 and vitamin D was 56.  My endo says I am hyper. Any suggestions?  I have been having random aches. I know this can be a symptom of hyper and hypo.

[Gzsimo]

Thanks Goolarra!

[goolarra]

That's a legitimate option for increasing.  T4 builds in your system slowly, so unless you are overly sensitive to meds, taking extra once a week just contributes a little more to the "pool".  If you're worried about adding so much in a single additional dose, you could take an extra half twice a week, or an extra quarter every other day.  Don't trust it to memory...grab a calendar and write what you take down every day!

[Gzsimo]

Forgot to say.  She also said I could take 2 synthroid 125 once a week while the other days I stick with 125.  Any options on this?  Thanks.

[goolarra]

Well, I definitely agree that your FT4 could use some improvement, and increasing to 137 will help that.  Many of us found that FT4 had to be very close to 50% of range before conversion really kicked back in.  

As far as dropping the Cytomel is concerned, I'm less confident.  If I remember correctly, you've been taking it just once a day, in the morning with your T4???  Taking T3 just once a day can make you more tired.  T3 peaks in your blood about 3 hours after taking it, and then it's quickly neutralized, leaving you in a "valley" of low T3, which can give you a real energy lag.  That's why it's recommended that even small doses be split so that your FT3 level remains more consistent throughout the day.

Furthermore, I'm a big fan of changing only one thing at a time so you can really see what the change did.  

[Gzsimo]

Just talked with doctor again.   She said to stop cytomel and go to 137 on synthroid in order to increase t4.  To be honest with you, I have been on this cytomel dose for 5 years and have not seen any difference. In fact I sometimes think the cytomel makes me more tired. So I may try this. Would love your opinion.

[Gzsimo]

Thanks so much for your advice.  I think that's the route I will take. I will keep you posted.

[goolarra]

The problem is that T3 meds (Cytomel) will often suppress TSH.  So, once on meds, TSH usually becomes even more useless.  Also, you are taking 125 mcg of T4 and 5 mcg of T3, which is pretty much a full replacement dose, which indicates your thyroid is producing little, if any, hormone.  

If you convert well, the increase in T4 meds will help you to feel better.  Your FT4 is too low.  You really want FT4 at about midrange.  If you've never had a problem with increasing, you might go for the extra 1/4 tablet per day your doctor suggested.  I only suggested going more slowly because you aren't too far from midrange, and you did feel hyper on 125 mcg Tirosint (which isn't more pure, but more easily absorbed).

I think you should see how you feel on the increase, get tested again after about 4 weeks and go from there.  If you still have symptoms, you may have to beat your doctor up for an increase in T3 or find a new doctor.  

[Gzsimo]

Thanks.  I agree with you. I may go every other day. Also, I have posted before.  About a year and a half ago I felt extremely tired.  Now looking back I think I was over exercising and not getting enough rest. I was also following an extreme paleo diet. I need the carbs. Anyway, I had my endo change me over to tirosint same dose as the synthroid 125 and had cytomel at 5 mg.   I was on this dose for 6 months.  Well, 3 months after starting the tirosint I had extreme joint pains.  I had hair breakage too. I also chipped a tooth. Well I felt over medicated. I was hungry all the time and gained a few pounds.  I told my doctor I was over medicated. Tirosint is very pure and you need to start at a lower dose I came to find out. My doctor insisted it wasn't the tirosint. At 6 months I decided to switch back to synthroid at same dose I kept cytomel the same.  I felt a lot better at first and certainly better now than on tirosint.  I still had joint pain often though and fatigue.  No hair loss either.  Now though , I feel hypo. I am  constipated and lethargic. I still have joint pains. Can't figure it out I went to gp and ran tests for lyme, lupus, ra Hashimotos and all was normal. If you google low tsh low ft3 and low ft4 it points to pituatary problems. I miss my old self. I feel if I had a good doctor this would be resolved. Sorry this is so long.  Desperate for advice!

[goolarra]

That's a little bit of a heavy increase.  You'll be taking an extra approximately 31 mcg of T4 with the extra 1/4 pill.  The general rule is to increase 12.5-25 only in one step.  Your FT4 is only a little low, so 31 could be too much.  It depends how sensitive you tend to be to increases, but you might consider only taking the extra 1/4 every other day for a couple of weeks.  If that goes okay, you can go to every day???

It takes any dose change 4-6 weeks to reach it's full potential in your blood.  Typically, it takes a couple of weeks to start feeling it, but once again, that depends on how sensitive you are.  Some people report feeling it sooner, some later.

Tell me a little more about why you're thinking you have a pituitary issue...

[Gzsimo]

My endo increased my synthroid. I am currently taking 125 and she told me to add 1/4 of my current dose. In other words since I have the 125 pills to cut them up and take 1/4 pill in addition. What do you think?  How soon do you think I will feel this?  Cytomel stays the same. Also, wondering if I have a pituatary problem.  Any advice?

[Gzsimo]

Lol. Just got off the phone with the doctor. No. Go figure?  I think I am going to really focus on bringing my ferratin levels up. I think this impacts my Thyroid levels.   I think there are so many factors that impact our thyroid test results.   I need a good iron supplement though. I may also consider ablation for heavy periods?  Thanks.

[goolarra]

That's an interesting article, isn't it?

I think you could use an increase in both T4 and T3.  FT4 is only at 38% of range, so you have plenty of room in there to improve.  FT3 is only 15%, so lots of room there, too.

I wouldn't increase both at the same time.  Do you think your doctor would up your T4 meds?  

[Gzsimo]

No. Cytomel once a day 5 mg at noon.  My ft3 and ft4 has been the same for about 5 years. Tsh value has been lower the past year or so.  I came across an interesting website that discusses iron and vitamin d levels http://nahypothyroidism.org/deiodinases/#individual%20variations.  

[goolarra]

So, you're taking 10 mcg T3 altogether?

I wouldn't do this without discussing it with my doctor, but people often take 50,000 IU per week of D until levels begin to rise, and then they cut back and finally settle on a maintenance dose.

Has your FT3 gone up since starting Cytomel?

I'm no iron expert., but I'll take a look if you want to post the results and ranges.

[Gzsimo]

I am taking 125 synthroid and 5 mg cytomel. At 5 am ish and 12 noon respectively. I take the iron biglycinate with 500 mg vit c at 4 pm   I also will take 2000 iu of vit d at this time.   I struggle to get my ferritin up. I also had an iron panel done. I can post the results if you like.  I don't know if I should see a hematologist. Thanks for your advice.

[goolarra]

I just checked myself on the ferritin reference ranges.  Reference ranges are different for men and women, but they don't change for pre- and post-menopausal women.  However, vitamin D should be 50-70 for proper metabolism of thyroid hormones and ferritin should b 90-110.

Typically, iron and D would both be approached by your PCP, if he understands that both of these have to be higher for hypothyroid patients.  

How much levo and Cytomel are you taking?

[Gzsimo]

I am getting frustrated with my doctor. My doctor will not increase the Cytomel.   What should I address first?  Should I see a specialist for the iron levels?  If so what kind of doctor?  I will start vit d again.   The endo doesn't even look at ferritin!  My ob gyn says my iron is fine!  

[goolarra]

I agree that your ferritin is WAY too low for the proper metabolism of thyroid hormones.  Usually, ferritin range is further broken down (male/female, pre-/post-menopausal).  I believe the lower end of the range for pre-menopausal women usually starts somewhere around 70 (check me on this).

Vitamin D also has to be much further up in the range, or you won't be able to get T3 into your cells.

Your FT4 is a little low; it's 38% of range (guideline: 50%).  FT3 is very low at 15% of range.  It's lower than it was in March...is that when the Cytomel (how much?) was added.  FT3:RT3 ratio is 20, which is good.

The whole endocrine system is interrelated, so you're absolutely right that one can affect the other.

Most people split the dose of Cytomel and take half in the morning with their levo and half later in the day (timing depends on your schedule and when you feel your energy lag).

[Gzsimo]

Any other suggestions

[Red_Star]

I fast overnight personally have have my tests done in the morning. T4 medication also affects labwork but not as much as T3 does. Try taking iron supplements (I recommend chelated) to boost ferritin levels. That is one wide reference range and the person who is 4.6 is not going to feel like the person who is at 204 I'd wager. :)