Should I be concerned about recent labs, Low T3 with symptoms?

[connie527]

Hello,
I was diagnosed with subclinical hypothyroidism and multinodular goiter about 3 years ago. Started on 12.5mcg Levothyroxine. My dose was increased to 25mcg last fall because of continued hypothyroid symptoms.
Most recent labs:
2/20/19 T3 TOTAL 61ng/dl  (range 76-181)
             TSH 0.93miu/L (range 0.40-4.50)
             T3 UPTAKE  35%  (range 22-35%)
             T4 THYROXINE TOTAL 6.9mcg/dl  (range 5.1-11.9)
              FREE T4 INDEX (T7)    2.4  (range 1.4-3.8)

Symptoms: muscle and joint pain, muscle stiffness and cramping in legs, back inflammatory pain, fogginess,hair loss, fatigue, constant feeling of sore throat/fullness in neck,heart pounding feeling, had been weight gain but I've lost 40 lb doing weight watchers over last year.

I have a follow up endocrine appt and ultrasound next week but am just wondering if anyone has any comments on my labs. I don't have great confidence in my endo I guess and want to know what to ask.

Thanks.

[gimel]

Nothing further should be required.  Your Total T4 is still only at 26% of a range that is way too broad and skewed to the low end and your Total T3 is well below range.  You are only taking 25 mcg of T4 and haven't had an increase since last fall, which is ridiculous, give your symptoms and low thyroid levels .    Be sure to give the doctor a copy of the one page Overview I mentioned previously and tell him that you need regular increases in your med dosage about every month until you get your Free T4 to about mid-range, and your Free T3 to at least mid-range, as needed to relieve symptoms.   Getting your Free T3 to an adequate level will most likely require adding a T3 med to your dosage.  Be sure to always defer your morning dosage of thyroid med until after the blood draw, in order to avoid false high results.  Also insist on being tested for Free T4 and Free T3, not the others previously tested, every time you go for new tests.  Ans insist to the doctor that you want to be treated clinically,  by adjusting your Free T4 and Free T3 levels as needed to relieve symptoms, not treated based on TSH levels.  

[connie527]

Thank you!

[gimel]

I agree with telus 213 that your relatively low TSH with low Total T3 may indicate a hypothtalamus/pituitary issue:  insufficient TSH to stimulate the thyroid gland.  That  is called central hypothyroidism, which doctors like to think is a rarity; however, it is quite common, just rarely diagnosed due to their  incorrect, but almost total reliance on TSH for diagnosis and treatment.

[connie527]

Thank you both! Is there any other test I should ask for at my follow up that would confirm central hypothyroidism?

[telus2]

I'll just add a couple of comments to what Gimel has said. The answer to your question is yes, you should be concerned about these labs. T3 is the active and most important thyroid hormone and your Total T3 being below range clearly indicates that you are hypothyroid. And that is confirmed with all of the symptoms that you listed.

The red flag here is that your TSH is low, when ordinarily it should be high if you are hypothyroid. The low TSH may be an indication that your pituitary gland is not functioning properly to produce TSH, which stimulates your thyroid to produce thyroid hormones T4 and T3.

It would be a gross error if your endo merely looks at your TSH and declares that you are fine because it is low in range.

[gimel]

I just sent you a PM with info.  To access, click on your name and then from your personal page, click on messages.

[gimel]

If you will tell us your location perhaps we can suggest a doctor that has been recommended by other thyroid patients.

[connie527]

That’d be great. I live in Massachusetts, about 30 minutes south of Boston.

[Ainfante1114]

I live in Chicago, Illinois. I had a total thyroidectomy due to papillary cancer but no RAI on December 7, 2018.  None of my doctors including endo believe I’m the  free T 3 testing.  I have so much anxiety off .112 synthroid. I weigh 166. I lost 14 pounds  in 4 weeks. Please if you know of a good endo in Chicago who has time to talk to their patients  and open to all meds plus accurate blood tests, please let me know

[gimel]

I just sent you a PM with info.  To access, click on your name and then from your personal page, click on messages.

[gimel]

I have no idea why your Endo is testing for Total T3, T3 Uptake, Total T4, and Free T4 Index.  Total T4 and Total T3 represent the total amount of those hormones in serum.  Most all of that is bound to protein and thus rendered inactive.  Only a small portion of each  is free of protein.  Those are Free T4 and Free T3, which are  really important to know.    So you should always make sure to ask that they test for Free T4 and Free T3, not the Totals.    In addition, T3 Uptake, and Free T4 Index are outdated and not very useful.    

Next thing to note is that hypothyroidism is best defined as "the clinical state of suboptimal T3 effect is some or all tissue in the body".      There is no reliable measure of  TISSUE T3 EFFECT.  TSH has only a weak correlation with Free T4 or Free T#, and a negligible correlation with TISSUE T3 EFFECT.  Likewise FT4 and FT3 have only a weak correlation.    So in the absence of any reliable direct measure, indirect measures must be used.   The best of those are signs and symptoms, supported by tests for Free T4 and Free T3.    You have a number of signs/symptoms that are frequently associated with hypothyroidism.  In addition if your Total T4 and Total T3 are at all a reliable indictor of your Free T4 and Free T3 levels, those will be too low in the range , which would essentially explain those hypo signs/symptoms.  

A good thyroid doctor will treat a hypothyroid patient clinically by testing and adjusting Free T4 and Free t3 as needed to relieve hypo symptoms, without being influenced by resultant TSH levels.  Since you have not had a dose increase since last fall, along with the outdated tests, I have no confidence that you current doctor will do that.  I suggest that you confirm what I have said by clicking on my name and then scrolling down to my Journal and read at least the one page Overview of a paper on Diagnosing and Treatment of Hypothyroidism: a Patient's Perspective.   If you want you can also use the info to try and get your doctor to treat you clinically, as described, in order to relieve symptoms.    If unsuccessful you will need to find a good thyroid doctor.  

[connie527]

Thank you for your response.I did read the paper. I think I will start investigating a thyroid specialist to get things sorted out. I know I mentioned my confidence level in my endo was already low. Your response confirmed that. Thank you!

[connie527]

Hello again,
I had my repeat ultrasound and had a question. It basically says there are still multiple sub centimeter nodules bilaterally and they are stable. And says the dominant nodule on the right middle pole is without changes. My question is what does dominant mean? My prior ones didn’t use this term so I was just curious. Thank you again!

[Sarahjogs]

Hi connie527,

In this case, I believe when they use the term "dominant" they are referring to the most prominent or largest nodule in that location.   Using the word dominant might just be their way of indicating they are talking about the same prominent nodule they noted before, and different ultrasound techs or radiologists might use slightly different terminology to refer to the same thing.

[connie527]

That makes sense, thanks.

[connie527]

And this was my last ultrasound from 8/18 (having another next week).

Comparison: 3/7/2018

Technique: Duplex sonography was performed. Doppler US performed for evaluation of thyroid
vasculature and nodule characterization.

Findings:

Thyroid isthmus: 0.3 cm
Right lobe: 5.5 x 1.4 x 1.7 cm
Left lobe: 5.5 x 1.4 x 1.5 cm

Parenchyma: homogenous

Nodules:

0.9 x 0.6 x 0.4 cm hypoechoic upper pole right thyroid nodule is demonstrated,
demonstrating ill-defined margins and no calcification, TI-RADS 4

0.9 x 0.7 x 0.6 cm spongiform-appearing mid pole hypoechoic right thyroid nodule                          
demonstrating lobulated margins and no calcifications, TI-RADS
2.

Multiple other small subcentimeter spongiform and hypoechoic thyroid nodules are
demonstrated.

 
Impression:

Subcentimeter thyroid nodules are demonstrated, as detailed above. No specific imaging
follow-up is recommended.