Today I saw the Endocrinologist

[Sammyg61986]

Hey all! Today I went to see the Endocrinologist and before I even saw him they drew 4 vials of blood work. This office has their own lab right there and some things I will know the results of today. I am being tested for ANA, Prolactin IGF1, TPO, TFT’s & RF. My previous blood tests were TgAb 214 (reference rang 0-115), Sed Rate for inflammation 22 (reference range 0-20), He also wants me to do a test for Cushing disease next Tuesday to rule everything out. My question is, do these tests seem right? He didn’t put me on any medication although I have a notebook page worth of symptoms? I’m so anxious to find out what is going on, I feel like I am dying. My hair is falling out a lot now, and my eyebrows are jacked up too. This is just awful. He said my Previous TFT’s test everything was within range but barely. This sound familiar to anyone?

[gimel]

In assessing a person for possible hypothyroidism, the most important consideration is symptoms, which then need to be confirmed by biochemical tests.  So please tell us about what symptoms you have, and also please post your previous TFT results and reference ranges shown the lab report.   Were previous tests done by the same Endo?

[Sammyg61986]

I had posted about a month ago. I asked my PCP to order blood work for me because even though my TSH was in “normal reference range” I still felt like there was something very wrong.

These are labs from 4/17/18
TgAb was 214 (reference range 0-115)
Sed rate for inflammation 22 (reference range 0-20).
TSH- 2.01 ( RR 0.40-4.50)
Free T4- 1.21 (RR 0.93-1.70)
Free T3- 2.99 (RR 2.00-4.90)
Total T3- 1.13 (RR 0.80-1.80)
T Uptake- 33.6 (RR 25.0-38.0)

I went to my Endocrinologist On Thursday I was nested for ANA and it just says negative. Also, on Tuesday I’m getting the blood test for Cushings disease. He is very thorough and wants to rule it out.
My symptoms include:
Severe chronic fatigue, brain fog, memory loss, feel like I can pass out sometimes, heart rate will be at 64 and shoot up to 120, 6 hours a day my heart rate is over 90, low blood pressure 95/55, unable to lose weight with strict dieting, muscle fatigue/weakness, hard to swallow, recently started my hair is thinning and becoming dried out (eyebrows too), hard to swallow when eating, excessive facial hair on chin, migraines, severe joint pain/stiffness/cracking, increased anxiety, dry rough skin/brittle nails, swelling in ankles/feet/arms/wrists/ occasionally puffy face, sleep does not help with fatigue, I feel the worst when I wake up. I should also add that I had an ultrasound of my thyroid done, and it came back normal, no visible nodules or inflammation. Thank you!

[Red_Star]

I've had all those tests done actually. I had tests for Cushing's but my symptoms were due to a combination of severe insulin resistance and hypothyroidism. The hump in the back of my neck is so big! :( stupid delicious sugar lol. *cries*

[gimel]

SammyG.  First thing to understand is that hypothyroidism, is not just related to serum thyroid hormone levels.  Hypothyroidism is insufficient T3 effect in tissue throughout the body due to inadequate supply of , or response to, thyroid hormone.  Your Free T4 and Free T3 test results are only at 35% of their range, which is inadequate for many people.  Just being in the range does not mean all is okay.  Most of us find that we needed Free T4 at mid-range, and Free T3 in the upper third of its range, in order to relieve symptoms.   TSH is useful as an indicator of thyroid status only when at extreme levels.  Symptoms are more important than test results, and you have many symptoms that are often related to being hypothyroid.  

In addition to being borderline on FT4 and FT3, there may be other variables that are affecting the response to the available serum thyroid hormone.  Low ir high cortisol has a negative effect.   In addition, Vitamin D, B12 and ferritin are frequently deficient for hypothyroid patients.  D should be at least 50 ng./mL, B12 n the upper end of its range, and ferritin should be at least 100.  So you also need to test for those and supplement s needed to optimize.    Deficiencies in these areas can also cause excess conversion of T4 to Reverse T3, which adversely affects how Free T3 is metabolized at the cellular level.  

So you need for your doctor to do the additional testing.  If cortisol is adequate, then you need to start on thyroid med as needed to relieve symptoms, without being influenced by resultant TSH levels.   Symptom relief should be all important, not just test results, and especially not TSH results when taking thyroid med.   If your doctor resists doing all this then you will need to find a good thyroid doctor that will do so.

If you want to confirm what I have suggested, then click on my name and scroll down to my journal and read the one page overview of a paper on Diagnosis and Treatment of Hypothyroidism: A Patient's Perspective, which also has a link there.    

[Sammyg61986]

Thank you Gimel! What would be the difference between hypothyroidism and Hashimoto’s? I’m pretty sure I have the Hashi’s I have up and down everything, and all the symptoms of it (except for my period being off). My endo said that he thinks it’s the Hashi’s thyroiditis, just wanted to make sure there was nothing else.

[gimel]

Hashi's is a main cause for hypothyroidism.  Hashimoto's Thyroiditis results when the autoimmune system erroneously identifies the thyroid gland as foreign to the body and produces antibodies to attack and eventually destroy the gland.   As this is occurring the output of natural thyroid hormone diminishes and in response the pituitary produces more TSH in a vain effort to stimulate the thyroid gland to produce more hormone.    So Hashi's eventually results in inadequate thyroid hormone output.

So when the Endo says he thinks it is the Hashi's Thyroiditis, he is correct in that Hashi's is the start of the problem; however,  your hypothyroid symptoms are the direct result of inadequate supply of thyroid hormone and/or inadequate response to thyroid hormone at the cellular level.   Corrective action to relieve symptoms means prescribing thyroid med adequate to raise your Free T4 level to at least mid-range,and your Free T3 level to about the upper third of its range, or as needed to relieve symptoms.    along with that you need for your cortisol, Vitamin D, B12 and ferritin to be optimal.        

[Sammyg61986]

I do the cushings test on Tuesday. Vitamin D I have had a deficiency in for years, I take gummies because my system does not absorb the gels. B-12 was low and on a couple occasions high because I was on a multivitamin with that in it. I recently started a new multivitamin with all of those in it. Not sure what my ferritin is but I’ll have all new labs this coming week that o will post the results for... I so appreciate your help, I’m in the medical field and I want to absorb any good info I get. I need to feel better, just can’t function correctly, so I get frustrated with myself and turn into a little bit of a crab lol

[gimel]

If you need to get injections to get your D up to at least 50 ng/mL, then you make sure to  do that.  B12 needs to be in the upper end of its range.   Ferritin needs to be tested and then supplemented with a good iron supplement like VitronC to raise it to at least 100.   So make sure you ask about and agree with the tests that will be done for you.  

If you are in the medical field I again suggest reading my journal and the one page overview of the full paper on Diagnosis and Treatment of Hypothyroidism: A Patient's Perspective.  The more you know, the better you can be as your own advocate for getting the testing and treatment you need.  

[Sammyg61986]

Today I received the lab results via patient portal that were taken this past Thursday. I’m petrified I could be diabetic. I should also add that I have 3 masses on my liver that they are watching. I really hope Thyroid is responsible for the abnormalities. Here is the lab work and thank you so much for your help!!!!

A1C 5.4 (4.2-6.0)

Basic Metabolic Panel
Calcium 9.3 (8.4-10.5)
**Creatinine 0.75 (0.80-1.50)** abnormal
**Glucose 130 (70-105)** abnormal
BUN 8.0 (7.0-20.0)
Sodium 135 (135-145)
Potassium 3.9 (3.6-5.0)
Chloride 102 (101-111)
CO2 25 (21-31)

**Vitamin D 28.66 (30-100)** abnormal
Prolactin 8.39 (2.80-29.20)
Cortisol 14.61 (3.09-22.40)
Insulin like growth factor 219 (87-286)
ANA- negative

TPO <28 (10-60)
TSH 2.929 (.370-4.000)
Free T4 1.14 (0.89-1.76)
Free T3 2.80 (2.30-4.20)

[gimel]

Your Free T4 level of 1.14 is only about 29% of its range, which is lower than optimal.  Your Free T3 of 2.80 is only about 26% of its range, and also not optimal.  You prior test showed the antibodies of Hashimoto's Thyroiditis, so these levels will only get worse over time.  With all the symptoms you have and the confirming test results you need to be started on thyroid medication and then increased gradually as needed to bring Free T4 up to mid-range, and Free T3 to the upper half of its range, or as needed to relieve symptoms.  I would not be to concerned about the creatinine and glucose tests at this point.  Certainly you can try to cut back on sugar intake for the glucose, but I think both may improve when you get your Free T4 and Free T# levels optimized.  

Your test also confirmed a very low Vitamin D so you need to do whatever is necessary to bring that up to at least 50 ng/mL.  You also need to know your B12 and even more importantly, your ferritin level and then supplement as needed to optimize those as well.

So those things are what you need to push your doctor for.  Do you think he will do what you need?

[Sammyg61986]

Hey Gimel!
Thank you so much for the reply! I also read your page, very interesting! I’m still trying to wrap my head around all of this. I had to do the Cushings test this am, and while I was there they told me the doctor wants to start me on 25mcg of synthroid (levothyroxine) as of this am. I also have Labs scheduled in 6 weeks to see where I’m at and adjust the dose. I am still waiting for blood work to come back for Rheumatoid arthritis and I think a couple other things. I have been on vitamins D gummies religiously plus a multivitamin to help bring the levels up. I hope this Hashi’s is the only thing I have to deal with. I am not sure of I have been tested for ferritin or B12, I will ask. I can’t believe how on top of things my dr is. He is rated #1 in Rhode Island, now I know why. His office staff even told me if I have any “stomach issues” ::wink:: that they will give me the brand name Synthroid.

[gimel]

Starting you on 25 mcg of T4 is typical, with followup testing in 6 weeks to determine dose adjustment.    A good thyroid doctor will treat a hypothyroid patient clinically by testing and adjusting Free T4 and  Free T3 (and sometimes Reverse T3) as needed to relieve symptoms, without being influenced by resultant TSH levels.  Symptom relief should be all important not just test results, and especially TSH results when taking thyroid med.     Be aware that many doctors will medicate a hypo patient only enough to reach a target TSH level.  That does not work for most people.  There was a very important scientific paper posted that concluded, "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."   Usually this cannot be achieved with T4 med only, so also be aware that you may need to add a source of T3 to your med.  

In addition, it would be good to test for cortisol to assure it is adequate.  Also, make sure you get tested and then supplement as needed to optimize: Vitamin D, B12 and ferritin.   All 4 of these are important, since they affect the response to thyroid hormone at the cellular level.  

[Sammyg61986]

I will make sure this blood work gets done.

I just did got back the cortisol test and it is abnormal. It is  0.74 with a reference range of 3.09-22.40.... does that indicate cushings? What would the treatment be. I’m so nervous about all of this.

[Sammyg61986]

If those tests weren’t preformed then I will make sure they are.

I also just got my cortisol test results back this evening and it is Abnormal at 0.74 with a (reference range of 3.09-22.40).
Does this indicate Addison’s dosease or because I have the Hashimoto’s would it be from my pituitary gland not functioning properly?

[Sammyg61986]

I should mention the cortisol lovel is from a dexamethasone suppression test

[gimel]

Not being familiar with the dexamethasone suppression test, I did some reading and found this link.  

https://www.uofmhealth.org/health-library/hw6479

From the link, is this description consistent with your test?

"The night before the blood test, you will take a dexamethasone pill. The next morning, the cortisol level in your blood will be measured. If your cortisol level stays high, Cushing's syndrome may be the cause."

So it seems that you don't have Cushings.  I don't know whether the low result is indicative of low cortisol or not.  Need to discuss with your doctor and ask if you need further cortisol testing.    If you do have low cortisol, I don't know that it would be Addison's Disease.  It could also be related to low pituitary output of ACTH.

[Sammyg61986]

Yea I took 1mg of dexamethasone at 11pm and got blood work drawn at 8am. That’s exactly the test. It did drop real low sonitnisnt cushings, but I was wondering if it went to low, my normal cortisol without the test was 14.61 (reference range 3.09-22.40)

[Sammyg61986]

Would Hypopituitarism coincide with Hashimoto’s? Would that make sense?

[gimel]

Not that I know of.  

Your morning serum cortisol level of 14.61 is about 58% of its range and of course that is total cortisol.  Due to the level of cbg (cortisol binding globulin). that may not accurately reflect free cortisol.  So let's go back and review every symptom you have.  

[Sammyg61986]

Do you want me to list them here? I also have panic attacks, and IBS that goes with them. I’ll have a panic attack, and need the restroom ASAP.

[gimel]

You previously listed the following symptoms: Severe chronic fatigue, brain fog, memory loss, feel like I can pass out sometimes, heart rate will be at 64 and shoot up to 120, 6 hours a day my heart rate is over 90, low blood pressure 95/55, unable to lose weight with strict dieting, muscle fatigue/weakness, hard to swallow, recently started my hair is thinning and becoming dried out (eyebrows too), hard to swallow when eating, excessive facial hair on chin, migraines, severe joint pain/stiffness/cracking, increased anxiety, dry rough skin/brittle nails, swelling in ankles/feet/arms/wrists/ occasionally puffy face, sleep does not help with fatigue,   To those you have added panic attacks and IBS.  

So you have many symptoms that are frequently related to being hypothyroid.  For that you need thyroid med adequate to raise your Free T4 to at least mid-range and Free T3 to the upper third of its range.  Starting with the low dose of 25 mcg, and re-testing every 6 weeks is going to take a while to get you there.  Also, you may find that your body does not adequately convert T4 to T3, so you may have to add a source of T3 to your med.  I can't be sure about cortisol adequacy,  since your total cortisol result was at 58% of the range; however that may improve with you taking thyroid med, since the adrenals will not be stressed as much.  We would know a lot more if you could get tested for free cortisol with a diurnal saliva cortisol panel.  Would you want to do that by paying for a test kit from an online source?  Cost is about $145 including shipping.  

Do you think this doctor is going to be willing to treat you clinically, as required to relieve all those hypo symptoms.  To achieve that will require what I posted previously from a recent, excellent scientific paper.  "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."   If you want I will send you a link to the paper which has a graphic showing the relationship between Free T3 level and the incidence of symptoms.

In addition you have to get your Vitamin D up to at least 50 ng/mL, B12 into the upper end of the range, and ferritin at least 100.   Do you see any problem with getting those tested as required and then supplementing as needed to optimize?


I think you need to proceed with the 25 mcg of Thyroid med

[Sammyg61986]

That shouldn’t be a problem to get those tests done. My dr called me today and told me we are just going to treat the thyroid for now, and get all new labs in 6!weeks, however if I don’t have any relief in 2-3 weeks they will do labs sooner and increase dose as necessary. My dress is more than willing to cooperate with whatever it is I need to do, thank god.

[gimel]

Glad to hear that they will review in 2-3 weeks and increase dose.    Remember the target for you is to get full symptom relief  by getting your Free T4 to mid range, and your Free T3 into the upper third of its range.   And of course optimize Vitamin D, B12 and ferritin.    Please let us know how it goes for you.

[Sammyg61986]

Thank you so much for your help! I will keep you all updated, as events occur. Kind of feel a little hyper today.

[Sammyg61986]

Update: My dr started me on Cytomel 5mcg on Tuesday. I had blood work done yesterday and these were my new numbers:
TSH: .840 (ref range .370-4.00)
Free T4: 1.45 (ref range .89-1.76)
Free T3: 3.31 (ref range 2.30-4.20)

My symptoms are slightly better, but there isn’t a big difference there. Although, my anxiety has definitely decreased. I know I’m acting inpatient, but I cannot for the life of me, lose weight. Are my numbers where they should be? What is optimal? I have lowered my carbs down significantly to only 2 servings of carbs per day, so I’m preparing to go full Keto this coming week. My weight is making me super depressed, I’m afraid to weigh myself. I want to go to the gym, but most days I physically can’t get my body to cooperate. However, I want to push of it means it will help, but I’ve seen mixed  opinions on working out. If I did anything, it would be weights with some cardio. My heart rate is still pretty high, so I don’t want to do anything to strain my heart.

[gimel]

So just to be sure of the basic facts, what is your current doses of T4 and T3 meds?   You said your doctor started you on thyroid med Tuesday and you had blood work done yesterday.   So both on the same day?  Did you take your thyroid meds before the blood draw for those tests?  Were you re-tested for Vitamin D?  Have you tested for B12 and ferritin?  

[Sammyg61986]

Hey Gimel! Thank you!
I have been on 25mcg of Levothyroxine for 6 weeks as of yesterday. I started 5mcg of Cytomel twice a day on Monday night. I had my regular (every 6 weeks) blood work done yesterday. The results are what I posted today. I have not been recently tested for B12 or Ferritin, or Vit D. I also take a multivitamin everyday that contains vitamin D (125% Daily Value). I Did take both the Levo and T3 before my blood work yesterday!

[gimel]

So with you taking 25 mcg of T4 for 6 weeks and then adding 5 mcg of T3 twice a day starting Monday night you then had blood drawn sometime Tuesday.   From  prior test results to current,  TSH went from 2.93 to .84; FT4 went from 1.14 to 1.45; FT3 went from 3.80 to 3.31.  That just doesn't compute that a small dose of T4 med and almost no T3 med would have make that much difference, so I believe that the results for FT4 and FT3 are falsely high due to taking the med before the blood draw.     Even the ATA/AACE Guidelines for Hypothyroidism recognize this potential problem and suggest delaying morning dose until after blood draw.  

Also I seriously doubt that the multivitamin will provide adequate Vitamin D.  I suggest that you obtain some D3 and take enough to raise your D level to at least 50.  That will probably require about  2000 IU daily.   You also need to test for B12 and especially ferritin and then supplement as needed to optimize.  

If possible I suggest that you also re-test for Free T4 and Free T3, and even Revere T3 and that you delay your thyroid med dose until after the blood draw.   Is this possible?

[gimel]

Sorry, FT3 went from 2.8 to 3.31.

[Sammyg61986]

Also, the endocrinologist is going to be calling me. His medical secretary called me and told me that my levels are “normal” so I don’t need to increase my 25mcg Levothyroxine. I’m so confused. I will ask him if they can retest before I take my medication and I will talk to him about that when he calls me. Would it hurt to supplement with iron, B12 and vit D in the event he won’t do that blood work? I know ideally it would be best to know if I have a deficiency... I know I am Vit D deficiency. I will add in a vitamin D supplement. Another thing about the vitamin D supplement: I usually get the gummies because my body does not absorb the capsule. I am not sure if that has any significance or not. The blood work that was drawn yesterday did not include reverse T3.

[gimel]

When talking to the doctor, keep in mind that when starting on thyroid med as you did, it causes the TSH to drop, like yours, and that reduces the stimulation of the thyroid gland to produce natural thyroid hormone.   Since serum thyroid levels are the sum of both natural and thyroid med your levels remain essentially unchanged until the dosage becomes high enough to effectively suppress TSH.  After that, increases in dosage will start to raise the Free T4 and Free T3 levels.   That is why I suspect that your last test results  were not representative of your actual levels and need to be re-tested.  If your doctor has an issue  with re-testing, mention the ATA/AACE Guidelines that recommend delaying the morning dose of thyroid med until after the blood draw for tests.  

If you want to confirm what I have said, please click on my name and then scroll down to my Journal and read at least the one page overview of a full paper on Diagnosis and Treatment of Hypothyroidism: a Patient's Perspective.  You can also use all that info if the doctor resists treating you clinically, to relieve hypo sympotms.

[Sammyg61986]

Thank you! I will mention this to him. I’m praying that he will let me re-test and he can see the comparison. Am I correct by saying my TSH should be suppressed below normal ref range?