Why is my TSH normal but my free hormone levels low?

[ABarzen]

Hello!  I was diagnosed with hypothyroidism a year and a half ago.  I was started on Synthroid 25 mcg and felt great!  For about 2 months.  Then went back to being symptomatic.  The weird thing is, my TSH on this dose dropped but so did my FT3 and FT4 levels.  And now, after several dose increases and the addition of Liothyronine, my TSH is normal (1.13) but my FT3 and FT4 levels are rock bottom.  And I feel awful.  What can I do?

Labs as of yesterday:
TSH:  1.13 (RR 0.3-4.2)
FT4:  0.8 (RR 0.8-1.6)
FT3:  2.7 (RR 2.0-4.4)
TT3:  86 (RR 80-200)
TPO Antibodies:  3.9 (RR 0-3.9)
Ferritin:  35.8 (13-150)
RBC:  3.92 (3.9-5.2)
Hgb:  11.5 (11.5-15.7)
Hematocrit:  34.1 (34-45)
Zinc (as of September 2017):  74 (RR 60-120)
Saliva Cortisol (as of April 2017):  Very high (off the chart) morning, mid-day, and afternoon levels, high-normal evening level
Vitamin D (September 2017):  58.9 (RR 30-80)
B12:  (March 2017):  484 (RR 211-946)
Progesterone (June 2017):  6.78 (0.95-21)
SHBG (June 2017):  124 (18-144)
DHEA (June 2017):  282 (35-430)
Testosterone (June 2017):  0.55 (0.1-0.75)
Estrone Sulfate (June 2017):  2.59 (0.75-4.28)
Estrone (June 2017):  55 (28-163)
Estradiol (June 2017):  93 (27-246)
Estriol (June 2017):  <80 (<=80)
2-Hydroxyestrone (June 2017):  133 (112-656)
16a-Hydroxyestrone (June 2017):  1,277 (213-680)
2:16a-hydroxyestrone ratio (June 2017):  0.1 (0.4-1.4)

Notes:
- On dose of 50 mcg Synthroid 4x week, 75 mcg Synthroid 3x week, 15 mcg Liothyronine (generic Cytomel) daily
- Have been supplementing with Iron (various forms) for over 6 months and ferritin level has not changed at all
- Have been supplementing with Zinc for over 6 months, level has not changed at all
- Feeling very symptomatic (fatigue, can't concentrate, wired but tired, obsessive thinking, dizzy especially upon standing, sleep a lot, low sexual functioning, depression, low body temperature, low motivation, have trouble taking a deep breath, muscles burn and breathless after walking up only one flight of stairs, acid reflux, sugar craving, emotionally numb)
- Chronic low-grade nasal congestion, occasional sinus headaches, and chronic post-nasal drip that clears once in a blue moon but can't for the life of me figure out why or how to make it stay that way...have tested negative for environmental allergies, was not able to convince 2 allergists to test food allergies
- RT3 tested yesterday but have not received results yet
- Tested Compound Heterozygous for MTHFR, on Adenosyl and Hydroxycobalamin and Methylfolate (couldn't tolerate methylcobalamin)

[Red_Star]

Well good news for eating chocolate eh? lol I have read that mercury lowers zinc levels so I had a look and found an article from Mthfr Living - Things That Plague Us: Heavy Metals...

"Unfortunately some people have a genetic predisposition to toxicity from heavy metals. As with other toxins, people with unaddressed MTHFR mutations have trouble clearing metals from their systems."

Something to consider anyway as it's very weird to not boost zinc levels taking zinc...unless that supplement is going in one end and out the other lol.

[ABarzen]

I will ask my doctor about this, too. I was supplementing with Zinc 50 mg Zinc Gluconate daily.

[ABarzen]

We are hopefully going to talk about malabsorption issues as well. She is going to check for intestinal bleeding for sure.

[gimel]

Are you going to also ask about an increase in your thyroid med dosage and iron injections?

[ABarzen]

I am nervous asking her about the thyroid increase because she has stated before that she is concerned about the heart and bone risks of having a suppressed TSH.  But I will print out the information you gave me and give it to her.  Maybe she will be willing to try it :)  I confess, I haven't read the document through yet.  The problem with thyroid issues is it's hard to concentrate long enough to learn the information needed to reduce thyroid issues!  I will also ask about the iron injections. I have been more focused on figuring out the cause of the low iron so I can prevent it in the future but I think you are right, getting injections right now may be helpful as a stop gap.  I am currently feeling quite poorly but I am still able to function, luckily! An extra boost to feel well would be nice :)

[Red_Star]

I did find a study on zinc...

"Zinc was measured in hair, urine, erythrocyte and serum before and after each period. At the end of four weeks hair, urine and erythrocyte zinc levels rose significantly (p less than 0.005, p less than 0.001, and p less than 0.001) during zinc picolinate administration. There was no significant change in any of these parameters from zinc gluconate, zinc citrate or placebo administration.  There was a small, insignificant rise in serum zinc during zinc picolinate, zinc citrate and placebo supplementation. The results of this study suggest that zinc absorption in humans can be improved by complexing zinc with picolinic acid."*

*Agents Actions. 1987 Jun;21(1-2):223-8.

Comparative absorption of zinc picolinate, zinc citrate and zinc gluconate in humans.

[ABarzen]

Thank you!  I am going to the vitamin store today so will pick up some better stuff :)

[ABarzen]

(meaning Zinc picolinate)

[gimel]

Please have a look at Rec. 13 on page 13 of the link I previously gave you.  There you can note that, "Only when TSH is suppressed enough to no longer stimulate natural thyroid hormone production, will serum thyroid levels reflect further increases in thyroid medication. "  Studies have also shown that most people taking thyroid medication adequate to relieve symptoms have suppressed TSH levels.  That does not mean hyperthyroidism, unless there are accompanying hyper symptoms due to excessive levels of FT4 and FT3.

With all your symptoms it seems clear that you need to raise your FT4 to around mid-range, and your FT3 into the upper part of its range, or as needed to relieve symptoms.  If you doctor think you are too focused on thyroid, remind her of your many symptoms and also give her a copy of the link.   That should dispel her concern.

Also note in Rec. 11 on page 12 the discussion about RT3 and the variables that affect conversion of T4 to excess RT3, including low iron.  

[Red_Star]

I take sublingual B12 spray daily for autoimmune pernicious anaemia (sublingual bypasses the gut and goes directly into the blood stream). I find it very strange you can't get your iron or zinc levels up taking betaine HCL with pepsin so I suspect your MTHFR issues might be causing problems. I had a look online and found this very interesting article...although avoiding chocolate...so cruel lol.

Excerpt from the article: MTHFR genetic mutation – what it is and how it can affect you...

"High Copper/Low zinc

This can be a common finding when you have an MTHFR defect (or other methylation snps)–a high level of copper, which will conversely mean your zinc levels will fall. And since the ratio of these two metals is highly important, correcting the problem is crucial, since high copper can be related to hyperactivity, depression, fearful ruminating thoughts, headaches, acne, frequent colds due to lowered immunity, sensitive skin and/or bruising, worsening hypothyroid, adrenal stress and more.

High copper can also make it difficult to raise iron levels, or keep those levels where they should be.

Vitamin C is known to help lower high levels of copper via detoxing, but patients report they need to go low and slow to tolerate the detoxing. Zinc is also used the same way–to encourage the lowering of copper, but the same caution with detoxing applies. Lawrence Wilson, MD recommends a nutritional approach to correcting the imbalance: remove IUD’s, avoid high copper foods like chocolate, seeds and avocados, avoid stress and more. Work with your doctor."

[ABarzen]

Hmmm this could be something.  Thank you!  I will look up how to detox copper :)

[ABarzen]

Although I'm a little confused as to how this will be possible because both of my lab results are low in range.  Zinc was 74 (RR 60-120) and Copper was 92 (RR 80155).  If to achieve an 8:1 Zinc:Copper ratio by lowering copper, my copper levels would have to drop way below the reference range. So the only way to achieve that would be raising zinc, which so far has been difficult.

[gimel]

I don't think you need to focus on lowering  copper level.  Your level is well within range.   Have a look at this link.

https://www.ahealthymeal.com/7523/calculate-ratios-of-zinc-copper-ceruloplasmin/

In the link you will note that they calculate the ratio for copper to zinc.  Your ratio is 92 divided by 74 which is 1.2, where they say in the link .8 - 1.0 is ideal.  So since your zinc result is on the low end of the range all you would have to do is raise your zinc up to about the 95-100 level. I recall you had no luck with that so far, but it seems to be the right idea.  How much were you supplementing with?  

Far more important I think is to optimize your thyroid levels.  I would want to start by raising your T3 dosage to get your FT3 level into the upper third of the range, or higher if needed to relieve hypo symptoms, without creating hyper symptoms.  You need the higher FT3 to offset your low FT4.  

Along with that I think you need to get your doctor to give iron injections, if supplementing with iron has not helped.  How much iron were you supplementing daily?  By optimizing your ferritin, that should help prevent converting so much T4 to RT3, and then you could increase your T4 med.  

[Red_Star]

Thank god someone can do maths on this forum. lol.  

[ABarzen]

Thank you Gimel! I will ask about injections. At various times I have taken 90? Mg chelated iron plus vitamin c, liquid iron 2 capfuls daily, ferrous Gluconate 325 mg with vitamin c...my doctor is going to check for intestinal bleeding at the next visit. I suspect there is malabsorption going on, possibly due to food sensitivities or allergies. Of course, figuring out the offending food is a whole other matter. Since being borderline anemic seems to be more pressing, I am focusing on that for the time being and putting the thyroid stuff on the back-burner, especially since my doctor thinks I am obsessing over it. I am a little unsure whether to raise T3 or not because I was actually on a higher dose (20 mcg) in the spring and the same deal happened - I felt an improvement for a couple months and then became symptomatic again. And my FT3 rose slightly but then dropped down again.

[flyingfool]

My wife had severe acid reflux, UNTIL, she was increased dosage of thyroid medications.  At which point the acid refulx ended and she no longer needed to take the strong reflux medications!

So it is POSSIBLE that if you get a more proper dosage of Thyroid medication, your acid reflux will go away.

Acid reflux is often caused by too LITTLE acid in the stomach.  Which as "red" above indicated that too low of acid in stomach can cause lack of Iron absorption. So it seems like you have at least TWO indications that solving your acid reflux problem with more stomach acid could help potentially your iron levels with increased absorption.

I think your FT4 levels are WAY low.  And I would recommend if you are able to get an adjustment to your meds, I would indicate increasing your T4 medication.

Also you did not say whether or not you are splitting your T3 medication into two doses.  if you are not, you may want to try taking half the T3 dose in the morning, and the other half about 1PM to 3PM in the afternoon.

T3 is used in HOURS. So by splitting the T3 dose in half, the first dose starts to wear off about the time your 2nd half starts to ramp up. So it helps keep your FT3 level a bit more constant than being blasted all at once in the morning, and then it all wearing off at once and you feel like you run out of energy by the end of the day.

how are you supplementing with B-12?  The best maybe sublingually.  If you are doing that, you may have pernicious anemia. Which means you have an inability to absorb B12 and you will have to get regular B12 injections.

Rule of thumb for people to feel well is to have BOTH of the following:

1) Free T4 to be 50% of the range if not a bit higher

AND

2) Free T3 to be 50% to 67% of the range. With most people needing it closer to the 67% rather than 50%.

Your last test results put your FT4 at ZERO percent of the range. A FAR cry from the rule of thumb of 50%.  Your FT3 is at 29.2% of the range.  Again a FAR cry from a minimum of 50%.

An increase of T4 medication IF you convert, should cause an increase in your Free T3 level.  Since you are so deficient in FT4, I would not expect much of an increase in the FT4 level even with an increase in your T4 dosage as most of the increase will be used to convert to T3.

[ABarzen]

Thank you!  That is really helpful info about your wife's acid reflux.  I hope it works for me, too!  I do take Betaine with HCL and it seemed to help at first but then stopped working.  I do split my T3 dose, usually 10 mcg in the morning and 5 mcg around 3 or 4 (I work until 9:30 PM and don't get home until 10:45 so it helps taking it slightly later to make through my shift).  I take a B12 supplement with Adenosyl and Hydroxycobalamin recommended by a previous doctor (although not sublingual - I tried sublingual methylcobalamin and could not tolerate it).  Again, that seemed to help a little at first but then stopped working.  I have not gotten my levels checked yet but will do so next time I see my doctor (hopefully in a week or so).

Yes, I have heard those optimal ranges before but for some mysterious reason, I am having the hardest time actually getting my levels there.  I was actually on 75 mcg Levothyroxine daily and 20 mcg Liothyronine for a while and that combination sunk my TSH to <0.10 while keeping my FT4 at 0.8 and only increasing my FT3 slightly to 2.9.  My RT3 was also starting to rise so we tried lowering my dose and while my TSH jumped to where it is now, my FT3 and 4 stayed almost exactly the same.  I am now also borderline anemic (don't know why this is, either) and my RT3 has continued to rise, so I suspect there is something else going on that is making my body not respond to the medication and essentially shut down.  I just have no idea what it could be!  Food allergies or sensitivities is my best guess so  I am trying a gluten free diet (on day 4).  We'll see if that if that makes a difference...Am also thinking of getting tested for Lyme.  Doctor is ordering a stool sample to check for intestinal bleeding so that may provide some clues as well.  Looking for any ideas and avenues to explore so I can finally get a handle on this and start living life again!

[Red_Star]

I have iron deficiency anaemia from chronic stress lowering my stomach acid.  I took iron supplements for a month but couldn't really say it was working as well as expected considering the high dosage in each supplement.  I have started betaine HCL with pepsin supplements to boost stomach acid along with watching ASMR videos with headphones (tingles~! lol) to help with stress..it is very relaxing. I also took zinc tablets maybe 8 months ago and developed copper deficiency which caused symptoms from skin sores to pain when swallowing. smh. I won't be taking zinc tablets again!

"Poor absorption of iron. Iron is absorbed from food in the upper part of the gastrointestinal (GI) tract. Disorders affecting the GI tract, such as celiac disease, Crohn’s disease or gastritis, can reduce the absorption of dietary iron. Gastric bypass surgery can also lead to iron deficiency, as it causes food to bypass the upper part of the small intestine where most of the iron absorption takes place. The acidic environment in the stomach greatly facilitates iron absorption. This is why in conditions such as achloridia and hypochloridia - in which acid production is, respectively, absent or reduced - dietary iron absorption is severely compromised."  - Three White Coats - Iron Deficiency Anaemia.

[ABarzen]

I'm glad I'm not alone! I am also taking HCL with betaine and I think it helps a little bit. I am currently trying to go gluten free to see if that helps as well.

[gimel]

There is much to discuss.  Probably the first thing to note is that when taking relatively low doses of thyroid med,  there is usually very little/no change in serum FT4 and fT3 levels.  This is because the med causes TSH to drop, which then reduces stimulation of the thyroid gland.  Since serum levels are the sum of both natural thyroid hormone and thyroid med, only when TSH is suppressed enough to no longer stimulate natural thyroid hormone production, will serum thyroid levels reflect further increases in thyroid medication.  So taking thyroid med adequate to relieve hypo symptoms usually results in a suppressed TSH.  Unfortunately most doctors interpret a suppressed TSH as hyperthyroidism and want to reduce med dosage.   This is wrong.  You are hyperthyroid only if having hyper symptoms due to excessive levels of Free T4 and Free T3.  

It is no wonder you are having hypo symptoms.  Your FT4 is at rock bottom of the range and your FT3 is only at 29% of the range.  A good thyroid doctor will treat a hypo patient clinically by testing and adjusting FT4 and FT3 levels 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 levels.  An excellent thyroid doctor has stated that, "in tests done about 24 to 28 hrs after their last daily dose, most people on adequate NDT therapy have a suppressed TSH. They usually have FT4 levels that are 1 to 1.3ng/dL, and free T3 levels that are rather high in the range or even slightly above the range. The higher FT3 level compensates for the lower FT4 levels on NDT. These patients have no symptoms or signs of hyperthyroidism--if such occur the dose is reduced."  Two things to note here.   One is that the morning dose of thyroid med should always be deferred until after the blood draw, in order to avoid false high test results.  Second is the relative levels of FT4 and FT3 needed to relieve symptoms for many people.  So you need to get your doctor on board to treat clinically, as described and keep increasing your med dosage as needed to relieve symptoms.  

Hypothyroid patients are frequently deficient in Vitamin D, B12 and ferritin.  Your D is adequate.  Your B12 should be in the upper end of its range, and your ferritin is way too low.  It needs to be at least 100.  If you cannot raise your ferritin level with supplements, you should ask the doctor about iron injections.  How much iron did you supplement with daily?

It is very important for a hypothyroid patient to have optimal cortisol levels.  Low cortisol can cause problems with metabolism of thyroid hormone at the cellular level.   Since cortisol is an antagonist of thyroid hormone, high cortisol will offset some of the effect of thyroid hormone levels, adding to your problem.  So you need to discuss your high saliva cortisol results with your doctor and  see what he recommends.  I know that reducing stress would be important.

You can read about all this in the following link.  I highly recommend reading at least the first two pages, and more, if you want to get into the discussion and scientific evidence for all that is recommended.  

http://www.thyroiduk.org/tuk/TUK_PDFs/The%20Diagnosis%20and%20Treatment%20of%20Hypothyroidism%20%20August%202017%20%20Update.pdf

Your doctor's willingness to prescribe T3 med is a good sign.  Hopefully he will also be willing to treat clinically, as described, rather than based on TSH.  If not, then perhaps you can persuade him to change his approach by giving him a copy of the paper in the link.  

Please keep in touch and let us know what your doctor has to say bout the cortisol and clinical treatment.    

[ABarzen]

Thank you gimel!!!  I will see what she says :)

[gimel]

You are very welcome for the info in the paper.   Did the doctor accept that TSH being suppressed when taking thyroid med is a typical result?

Regarding your test results and med dosage, I think you could increase your dosage of NP Thyroid by 1/4 - 1/2 grain.    That should help both your FT4 and FT3 levels.  Clearly you are still having hypo symptoms so an increase is needed.  


Another concern is that you mentioned having high cortisol levels.  You did not provide actual results but said they were off the charts.  If that is still the case then you need to note that high cortisol will inhibit conversion of T4 to T3 and increase conversion to RT3.   So at next opportunity it would be good to test for RT3 along with FT4 and FT3 and others.  Note the following info about a way to reduce cortisol, that you could discuss with your doctor.   "A large, phase III placebo-controlled clinical trial was conducted in Sweden in 2009, studying participants aged 20-55 years with a diagnosis of stress-related fatigue.  Subjects taking the rhodiola extract had significantly lower cortisol responses to chronic stress than did the placebo recipients—and as a result they had lower scores on scales of burnout and improved performance on cognitive testing."   Of course finding ways to reduce stress is also good for your health.  

Also, your test results from last year showed B12 around mid-range.  B12 is better for you in the upper part of its range.  Also, your ferritin at that time was terribly low.  Have you been supplementing for that to get it over 100?

[ABarzen]

Yes, my doctor is allowing me to dose by symptoms instead of TSH. I can try to post a copy of my contract test on here. The thing about that is I don't know what caused it to be so high. I wasn't particularly stressed at the time except for being undermedicated.  I would be open to taking an adaptogen, I think. The dose I shared with you actually is increased by 1/4 grain and 13 mcg Tirosint from the dose I was on at the time of labs (just 3 grains NP Thyroid). Yes, I am really hoping it helps! I am taking Floradix liquid iron to get my iron/ferritin up. B12 supplements I don't like to take, however, because they give me racing thoughts and the jitters :(

[gimel]

Good to hear from you again.   What are your latest test results for  FT4, FT3, Vitamin D, B12 and ferritin?  What is your current dosage of T4 and T3 meds?  Did the doctor ever do anything in response to your high cortisol levels?

[ABarzen]

TSH <0.02, FT3 3.0 (RR 1.7-3.7), FT4 1.0 (0.7-1.5, Vitamin D 80 (30-80).  

B12 and ferritin haven't been checked in a while but I will get my ferritin checked next time I do labs (6 weeks-ish).  

Current dose is 3.25 grains NP Thyroid + 13 mcg Tirosint.  

I'm trying to get my FT4 to a little over the half-way mark.  My symptoms have improved a lot but I'm still having trouble with digestion, especially of fiber and fats.  I have frequent burping and hiccups after eating plus gaseous reflux that is inflaming my nasal passages and I think ear canals as well.  I can't breathe through my nose clearly and my ears ring.  Still have trouble paying attention, tired frequently, and get constipated frequently (especially when I eat fiber).  I'm really hoping that getting optimal levels will clear up these final symptoms.  Depression and digestion were the first symptoms I had 15 years ago so I'm guessing they will be the last to go.

No doctor has done anything for high cortisol.

[ABarzen]

By the way, thank you for the paper that you sent me.  Those studies were really helpful in helping sure up my case for suppressing my TSH with my doctor.

[gimel]

I hate to rain on your parade, but from some minimal feedback I don't expect that the doctors at the Mayo Clinic will have any different diagnosis of your thyroid status.  If they follow the usual standard of care, you will hear that your thyroid test results are within the "normal range" and your symptoms cannot be thyroid related.  That is very wrong.  As mentioned previously a hypothyroid patient taking thyroid med adequate to relieve symptoms like you have usually will have a suppressed TSH.  That does not mean hyperthyroidism, unless you have attendant hyper symptoms due to excessive levels of FT4 and FT3, which is not your case.  If you read about suppressed TSH in Rec. 13 on page 13 of the link I gave you it provides some references to scientific studies that confirm this.  

You need a good thyroid doctor that will treat clinically (for symptoms), by testing and adjusting FT4 and FT3 as necessary to relieve hypo symptoms, without being influenced by resultant TSH levels.  Symptom relief should be all important, not just test results.  Many of us have found that we needed FT4 at least at mid-range, and FT3 in the upper third of its range.  Since our bodies operate with a continuous low flow of thyroid hormone, going to a single dose once daily changes the equilibrium among TSH, FT4 and FT3, so TSH should not be used to determine thyroid med dosage.  

I have some info on doctors in your area that have been rated as good thyroid doctors by thyroid patients.  I will be sending you a PM with info.  To access, just click on your name and then from your personal page, click on messages.  

[ABarzen]

Thank you Gimel!  I am nervous about the Mayo appointment, too, for that very reason.  I was wondering about that and posted in some other forums for reviews of Mayo thyroid care.  They were mostly negative, just as you predicted.  I received another tip about a competent endocrinology nurse practitioner and have made an appointment with her.  If she does not work out, I will move on to the list you provided.  I am a little nervous about treating clinically but your reasoning about the body being used to a continuous output of thyroid hormone instead of short bursts makes a lot of sense and seems to be exactly what my pituitary gland is responding to.  My hormone levels are even lower than they were without medication but my pituitary gland seems to think everything is hunky-dory.  I will take a look at those studies :)

[ABarzen]

You were correct.  Mayo is the worst for thyroid :(  Luckily, I found a doctor who is ok with suppressing my TSH and letting me raise my dose until my FT3 and FT4 levels are optimal.  Not quite there yet even after almost a year but I think I'm on the right track :)

[ABarzen]

Well, my doctor's appointment did not go well.  When I asked about the incongruencies in my lab results, she literally said "I don't know.  Let's stop all supplements and medication since they don't seem to be working."  So I need to find someone who can help me figure this out.  I am going to the Mayo Clinic in Rochester, MN next week and continue to search for better doctors here in Minneapolis.  If anyone knows of good people to see, please let me know!

[gimel]

I think the most important thing for you to do in prep for the appointment is to do some reading in the link I gave you so that you can discuss suppressed TSH as not being a concern.  That way you may be able to get the doctor to increase your dosage.  Your FT4 was at rock bottom and your FT3 was also inadequate.  Add to that your high cortisol, which is an antagonist of thyroid, and it is no wonder you have hypo symptoms.  Your doctor needs to address the high cortisol as well.

The results are usually much better when we learn enough about our illnesses to become our own best advocate for getting the diagnosis and treatment needed.

[ABarzen]

I agree! I actually already read the link you sent me and I will check out the specific studies that pertain to my situation so I can go in armed with supporting evidence :)

[ABarzen]

Well, my test result for internal bleeding came back negative.  So I am officially clueless as to why my iron is low.  I see my doctor on Monday so will ask her about iron injections, dose increase, possible looking into pituitary issues, and heavy metals.  I have started supplementing with Zinc Picollinate so hopefully that will make a difference :)  Thank you all for your help!  I'll keep you posted as to the results of Monday's appointment.

[Red_Star]

As I mentioned, I'm not a fan of zinc supplements after my copper deficiency dramas! I was taking chelated zinc - not sure what type - but it was far too effective! lol

[ABarzen]

Follow-up test result:  RT3 is currently 15 (RR 9-27)

[ABarzen]

*additional symptom:  constant hair loss