20867016 tn?1551836666

TT on March 13th. I have some question on latest labs.

Labs before surgery on 3/7/19:
TSH-.01 Low
T4-1.35ng/Dl (211-911 pg/mL) Normal but this was in and out of normal, into high then back to normal from January-March
T3-120ng/dL (211-911 pg/mL) Normal

The surgeon delayed taking Synthroid until a week after surgery due to possible excess thyroid hormones in body, but started it on 19 based on the levels below:
Labs 3/19/19: 6 days after surgery
TSH-.0.04(.36-3.74) uU/mL Low
T4- 1.04 ng/dL (.076-1.46 pg/mt) Normal
T3-54 ng/dL (86-192 pg/mL)Low
Synthroid started 3/19/19
Labs 3/26/19:
T4- 1.35(.76-1.46)
T3-74(86-192) LOW

LABS 4/9/19 prior to first visit with endo since surgery:
TSH- 0.27(.40-4.50) LOW
T4- 1.8 (.08-1.8) ALMOST HIGH
T3-2.4(2.3-4.2) LOW NORMAL

At first he was going to lower me from 112 Synthroid to 100, then changed his mind and said stay on 112 but only take ½ on Sundays. I am concerned that the TSH has gone down and the T4 is almost in high range again and I don’t want the A-fib to start again. He also told me no more need for the Propanylol(Inderal) since no more rapid heartbeat or A-fib and that I could also stop taking Eliquis for A-Fib. Also to stop taking Vitamin b12 because mine was 2000(200-1100) and to take 1000 units of Calcium each day due to Ostesporosis.

Any thoughts or input would be appreciated. Wondering why my TSH is going down again and T4 creeping into the high ran
7 Responses
Sort by: Helpful Oldest Newest
20867016 tn?1551836666
Correction to labs:

Labs before surgery on 3/7/19:
TSH-.01 (0.76-1.46 ng/dL)Low
T4-1.35ng/Dl (.76-1.46 ng/dl) Normal but this was in and out of normal, into high then back to normal from January-March
T3-120ng/dL (0.76-1.46 ng/dL) Normal
Helpful - 0
Avatar universal
first, here is a quick lesson in thyroid labs.
The lab can measure Total T4 (TT4) and Free T4 (FT4) and Total T3 (TT3) and FreeT3 (FT3).
T4 with range (.76-1.46) is FT4
T3 with range (86-192) is TT3
T3 with range (2.3-4.2) is FT3.

Doses of 100 to 125 Synthroid (T4) are very common, so your 112 is very middle of the road and it won't make you hyper. And I don't think there is any reason to take a little less on Sunday.

When you start taking T4 it takes time to build up to full strength in your body. You can calculate the build-up based on the half life of T4. So at 7 days you are up to 50%, at 21 days 87.5%, 30 day 95%.

So on March 26, which is only 7 days after you started T4 you are only at 50% build-up and both FT4 and TT3 have moved up a bit from where they were on March 19.

On April 4th, (21 days from start) the synthroid build-up should be at 87.5%, and that is shown by your free T4 being quite a bit higher and I don't think it will go much higher. Your free T3 has at least moved up to the bottom of the range at 2.4, but is still slightly low and I believe it will move up if you give it another week or two. (It is unlikely to go up if you cut back to 100 synthroid).

Looking at your questions:
1. "why is my TSH is going down again?" The numbers that you posted show TSH is slowly going up. I think on 112 synthroid your TSH will slowly go up to around 2 and you don't need to worry about it.

2. "T4 is almost in high range again and I don’t want the A-fib to start again?" I think your FT4 isn't going to go much higher. But FT4 is not the one to worry about - it is very high FT3 that will give you AFIB - and your FT3 will not go very high on 112 synthroid. (FYI very low FT3 can also give you AFIB).

Sunny - it seems like your thyroid has been putting you thru the wringer for quite a while, so it might take two or three months to get back to normal again. I  think you can be pretty confident that 112 synthroid is a pretty good starting dose and I would give it more time to see how you feel.

If you have been reading other peoples posts here, you may have seen that some still have hypothyroid symptoms if they take Synthroid alone and they go to combinations of T4 and T3. I think because you are just starting out it would be best to give synthroid a try first (unless you have a doctor who really knows what he is doing with combinations).

Incidentally, if you are taking Vitamin D and calcium, you should also be taking Vitamin K2, especially if you have osteoporosis.  Search for this book: "Vitamin K2 And The Calcium Paradox". The author also has a web site with lots of good information. Note: it is not Vitamin K, it is not Vitamin K1, it is VITAMIN K2 that is important.
Helpful - 0
Thank you very much for the detailed, easy to understand response.  I am not taking the calcium anymore. Only 1000 Vitamin D.

Yes, i have been put through the wringer, especially since January of this year when the A-Fib and 170-180 bpm started. I was on a first name basis with some in the ER and hospital. :( That is the reason I decided to have it removed, could not handle the A-fib and side effects of the Inderol beta blocker which made me ache all over and have zero desire for food or to even smell it cooking. Now that the T4 is back up in the high area again, some of the old familiar symptoms have occurred. No A-fib so far but a feew bout of rapid heart beat the past week and irritable bowel and stomach issues are back again. It was so nice having it all quiet for 3 weeks. The body aches have been a constant problem since I began the beta blockers in January but intensified after surgery, got a little better and now are back again. Some days are better than others. Honestly if I had know how bad this would be I might not have had it removed and just dealt with the beta blocker and Eliquis for A-fib. I wonder if I will ever feel good again. I feel like my whole body is just freaking out. I cherish the minutes,, hours I feel decent. Sleeping well is the only good thing i  can say. And the rapid heart beat that was constant is gone for now. So far no weight gain, lost a pound actually since the surgery.
My T3 never was out of normal range, only the THS and the A-fig began only when the T4 began to get near the  high end of normal and jumped back and forth from normal to high. I have had PVCs and rapid heart beat for 3-4 years, ever since the TSH got so low. Until this year both T3 and T4 were within normal range. High normal on the T4, but in normal range. Since 2012 the T4 had been creeping upward.
Avatar universal
HI Sunny,
Body aches could be from being absolutely hypothyroid since the surgery. Even on April 9, your FT3 was at the very bottom of the reference range. On 112 synthroid your FT3 should go higher than that.

Does your doctor know you are still feeling pretty crappy? Maybe he is still chalking it up to lingering effects of the Plummers and surgery. But he should at least make sure your FT3 gets up to a decent level ASAP. When did your doctor say you can get lab tests next? Maybe try for 3 weeks after the April 9 tests, which would be April 30.

Even if you do not take calcium, you should still take Vitamin K2 because everyone is deficient in Vitamin K2. Vitamin D promotes calcium absorption from your intestines. Vitamin K2 gets the calcium to the right place in your body - your bones rather than your arteries. Read the book...
Helpful - 0
My next labs are May 1, so in about a week.
I saw my endo June 4th. We discussed my labs and he was happy with the numbers and said T3 was going up and he gave me a copy of the labs. Today I got an email from Advent Health saying I could view my records on HelloWell. I signed up and viewed them and realized that yesterday he did not have my most recent labs and was discussing, comparing May 6th compared to April’s. My T3 has not gone up as we discussed but has in fact dropped below normal which explains why I am feeling much worse again. If I continue on 100, with 1/2 on Sunday I find it highly unlikely my T3 is going to get back in normal range on anywhere near that and the way I feel with the T3 that low is not acceptable to me. As it has been dropping I am having less and less energy and feeling more and more tired and worn out. Also neuropathy is getting worse like it was before when the T3 was so low right after surgery and feeling colder and getting cold feet all the time again. I still have some of the 112 left that I can begin to take or perhaps take 112 some days a week them 100 others. I felt better on the 112 until the T4 popped into the high range and I began to get stomach problems (IBS) again.. Apparently 100 is not enough and 112 may be too high. My body has been telling me things were getting worse now that I know what hypo feels like since I went very hypo after the surgery for 2 weeks. This is why I like to get my labs myself before I see the doctor. If I had them I would have known right away he was not looking at the most recent because I keep a chart of them. Below are the labs I have had including the most recent done on May 31.

LABS 05/31/2019-TSH: 2.53[.40-4.59], T4 Free 1.2 [ .08-1.8] T3 Free 2.1 [2.3-4.2] LOW
WHILE On Synthroid BRAND 100mcg 1po daily for 6 days and 1/2 on sunday. LOST 1.5 lb.

LABS 05/06/2019- TSH: 0.76  T4 Free: 1.7 . T3 Free: 2.6.
CHANGED FROM 112mcg Synthroid BRAND to 100mcg 1po daily for 6 days and 1/2 on sunday. Lost 1,5 lb

LABS 04/9/2019: TSH: 0.27..T4 Free: 1.8..T3 Free: 2.4.
WHILE On Synthroid BRAND 112mcg 1po daily. Lost 1 lb


Avatar universal
The problem is that your doctor did not like your .27 TSh and 1.8 FT4 on 4/9 so he reduced your dosage.  Reduced it again in May with your FT4 at high end of range.The problem is that even at the higher levels of FT4 you were not converting it adequately to FT3.   Doctors like to think that the body converts T4 to T3 as needed.  Scientific studies have confirmed that is not the case.  There are many variables that affect conversion.   Hypothyroidism can be described as " the clinical state resulting from suboptimal T3 effect in some or all tissues of the body.     This can be caused by inadequate thyroid hormone or inadequate response to the hormone.   You cannot have optimal T3 effect when your FT3 is so low in the range, like yours.  

Some of the variables that affect the response to thyroid hormone and also symptoms are cortisol, Vitamin D, B12 and ferritin.  If not tested for those you should do so and then  supplement as needed to get Vitamin D to 50 ng/mL min.  B12 in the upper part of its range, and ferritin at least 100.  Cortisol should be neither too low or too high.  

The most important thing is for you to get your doctor on board with adding some T3 to your med.  Keeping your T4 at 100 should be okay for you if you get some T3 med to get your FT3 into the upper half of its range, and then adjusted as needed to releive hypo symptoms..  The objective for treating hypothyroidism should be to raise FT4 and FT3 levels as needed to relieve hypothyroid symptoms, without going too far and creating hyperthyroid symptoms.   That "sweet spot" is called euthyroidism.  That has to be your objective.  

If you want some info to persuade your doctor, click on my name and then scroll down to my Journal and read at least the one page Overview of a paper on Diagnosis and Treatment of Hypothyroidism: A Patient's Perspective.    Everything there is supported by extensive scientific evidence.

Also for your doctor, this is a link to a study that quantified for the first time the effect of T3 on the incidence of hypo symptoms.  From the study they concluded that,  "Hypothyroid symptom relief was associated with both a T4 dose giving TSH-suppression below the lower reference limit and FT3 elevated further into the upper half of its reference range."

Helpful - 0
He did not see the new labs so our discussion was based on the old May 6 labs. He said he is not going to give me Cytomel due to my age and my past issues with A-fib, He also said it can take a while for my body to begin too convert the T4 to T3, It was going up on the 112 and I was feeling a lot better than I do now that is is low again. He said low TSH is what will cause A-fib along with T4 out of range. His credentials are pretty impressive and I have a feeling if I show him the articles he is not going to like it. But I will try to do so. I may have to find another and work with both of them, see what the other one says. I am going back on the 112 even if he says not to. I still have a refill on that and got it refilled. I see my cardiologist next week. I never had A-fib again when on Synthroid 112 but when it went to 1.8 I began to get IBS again. The recent A-fib was from the stomach virus and low potassium and dehydration. As soon as they gave be fluids and potassium it stopped and no signs of it the rest of the time in the hospital on cardiac monitor. My Vit D is low, and he put me on 1000 Vit D a month ago but still low so he upped it to 2000 a day.
Avatar universal
There are studies showing that T4 only does not adequately raise the FT3 level unless FT4 is at high end of its range, or above.   And of course that is not what you want either.    That is why FT4 only needs to be around mid-range, and FT3 in the upper half of its range and adjusted as needed to relieve symptoms.  

Also, a suppressed TSH does not mean thyrotoxicosis from taking excessive thyroid med.  The body is used to a continuous low flow of thyroid hormone from the gland.  When a significant dose of thyroid med is taken all at once, it spikes the FT4 level and  results in suppression of TSH for almost the whole day.   So a suppressed TSH does not mean you have become hyper, unless you also have hyper symptoms, due to excessive levels of FT4 and FT3, which you did not have.  

There is also a study showing that if the T4 dose is split into half and taken at different times of the day, it raised TSH by 1.0.  If the same dose was split into thirds and spread out over the whole day, TSH went up another 1.0.  So the suppression is not due to an excessive dosage, but due to taking it all at once.  

You are going to have to give your doctor this type of info, and try to persuade him to add some T3 to your med, and adjust as needed to relieve symptoms, or else you will have to find a good thyroid doctor that will do so.  And that is not easy to do either.  

Have you been tested for B12 and ferritin?
Helpful - 0
Yes, I took B12 but it was pretty high and out of range so was told to stop taking it. Ferritin I do not see unless it is called something else on the metabolic panel and CBC.
Avatar universal
Ferritin is one of the tests included in a full iron panel.  It is a precursor to serum iron levels and is very important for good conversion of T4 to T3.   It should be 100 min.
Helpful - 0
Ok, I will ask my PC Dr. to order that and reverse T3. I see her next week. I will also print your journal article and give that to her as well as my endo. I know my endo is not going to like it me giving him info  because he feels his experience and resume speaks for itself, lol
Avatar universal
If you are able to get a Reverse T3 test, it should be done with a Free T3 from the same blood draw, to determine the ratio of FT3 to RT3.   If not previously tested for ferritin it would be a good idea to do so.

When I first started working, an old-timer with great experience and knowledge told me that "A college education never hurt anyone that was willing to go on learning something afterward".    The same applies to doctors as well.   Learning  should never stop, yet the author of  an article in the New England of Medicine stated  "there is great concern that doctors continue to rely on what they learned 20 years before and are uninformed about scientific findings".   A young doctor would be expected to have more knowledge of recent science: however, they would lack valuable experience.   So the best of all worlds would be an older, experienced doctor that is open to new information and tries to keep up with recent scientific findings and incorporate that into his practice.  The worst of all worlds is a doctor that doesn't want to know what he doesn't know.  LOL    
Helpful - 0
Have an Answer?

You are reading content posted in the Thyroid Disorders Community

Top Thyroid Answerers
649848 tn?1534633700
Avatar universal
1756321 tn?1547095325
Queensland, Australia
Learn About Top Answerers
Didn't find the answer you were looking for?
Ask a question
Popular Resources
We tapped the CDC for information on what you need to know about radiation exposure
Endocrinologist Mark Lupo, MD, answers 10 questions about thyroid disorders and how to treat them
Herpes sores blister, then burst, scab and heal.
Herpes spreads by oral, vaginal and anal sex.
STIs are the most common cause of genital sores.
Condoms are the most effective way to prevent HIV and STDs.