Post parathyroidectomy T4/TSH....

[Deliward]

Hello everyone,

I'm wondering if you can help with some advice for my mum. She has a long history of thyroid problems and shoddy treatment from the NHS for them. She has, however, been taking liothyronine for the past 15 years which is what keeps her going. Last year she has a scan which showed a parathyroid tumour and also that her thyroid has basically shrivelled up and is very small now. She had a parathyroidectomy in January, after which her calcium levels returned straight back to normal but she still isn't feeling fully well - she's exhausted all the time. She has just had a set of tests done:

Serum parathyroid level: 30ng/L (15.0 - 65.0)

Serum TSH: 0.19 miu/L (0.3 - 5.5)

Serum T4: <1.0 pmol/L (12.0 - 22.0)

Serum triiodothyronine: 5.3 pmol/L (3.1 - 6.8)

Vitamin D: 18nmol/L (50.0 - 144.0)

The Endocrinologist has prescribed vitamin D supplementation but hasn't taken any notice of the low T4 or TSH, saying that she just needs to reduce her liothyronine from 45mcg to 30mcg per day. It seems to me that she desperately needs some T4 which is easy to get in the form of levothyroxine. Reducing the liothyronine makes her unwell and although we're hopeful the vit D will make a difference does anyone have any ideas why the Endo won't give her levothyroxine? Also, the combination or low T4 and TSH - could this be indicative of a pituitary issue? Or is it possible that many years of T3 supplementation alone have affected things and caused imbalance? I'm also curious to know why the thyroid itself has shrunk and why the Endo doesn't seem to be bothered by that at all!

Many questions, but any thoughts or ideas about this are gratefully appreciated.

Adele

[Clutter]

Deliward, TSH 0.19 is low but not suppressed. It's perfectly natural for TSH to be low when taking sufficient T3 and FT4 will be low when someone is taking T3 only. Neither indicates pituitary dysfunction.

Your mother's FT3 isn't even in the top third of range let alone near top of range so I'm baffled why her endo wants T3 reduced to 30mcg. If anything I would say there is scope to increase her dose to 50-55mcg T3 without FT3 going over range.

Levothyroxine converts to T3 but it isn't necessary to have Levothyroxine in addition to T3 if your mother is happy on T3 only.

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I am not a medical professional and this information is not intended to be a substitute for medical guidance from your own doctor. Please check with your personal physician before applying any of these suggestions.

[Deliward in reply to Clutter]

Thank you so much Clutter - seemed logical to me that if T4 was low it needed to be supplemented but I don't know much about the effects of T3. It is all she has but she isn't completely well on it and she was told the parathyroidectomy would improve everything which hasn't been the case. I'm hopeful the vitamin D supplements will pick her up.

If her thyroid has shrunk, can or should anything be done about it?

Thanks again, Adele.

[Clutter in reply to Deliward]

Deliward, thyroid usually atrophies when patients have autoimmune thyroiditis (Hashimoto's). As the thyroid shrinks it is less able to produce hormone and Levothyroxine or T3 dose has to be increased to meet the requirement.

The purpose of T4 is for conversion to T3. Taking T3 directly means that there is no need for Levothyroxine or T4 for conversion. Levothyroxine is the preferred thyroid treatment so I imagine your mother must have been prescribed it in the past and was switched to T3 because Levothyroxine didn't suit. Two observational safety reviews into long term Liothyronine (T3) use show no adverse effects.

endocrine-abstracts.org/ea/...

ncbi.nlm.nih.gov/pubmed/269...

Your mother's vitD is deficient and she should feel better when it is replete. Is her calcium also being monitored? I believe vitamin D and calcium need to be balanced in parathyroid patients. Make sure your mother takes T3 4 hours away from calcium and vitD which reduce uptake.

__________________________________________________________________

I am not a medical professional and this information is not intended to be a substitute for medical guidance from your own doctor. Please check with your personal physician before applying any of these suggestions.

[gabkad in reply to Clutter]

Clutter, Magnesium? Shouldn't her mother be supplementing that as well if she's taking calcium?

[Clutter in reply to gabkad]

No idea, Gabkad. Deliward hasn't said whether calcium is being taken.

[Deliward in reply to Clutter]

Thanks both of you - she isn't supplementing calcium. Her levels were tested in January immediately after surgery but I don't know if they have been since - but now I know to push for this to be checked. Very useful to know about the time gap between the vit d and T3.

Have a lovely evening!

[bantam12]

What are her calcium levels now ? calcium and PTH should be tested for several months post op as they can change.

She may also find recovery from the para surgery will take longer than anticipated, many people don't feel better for many many months and some have no improvement, if that happens then its possible another adenoma is lurking around.

[Deliward in reply to bantam12]

Thank you - I'll check the tests again and post tomorrow. She was told she would feel better straight away and she did for a while but has dipped again. Am I right in thinking that her calcium level would rise again if another adenoma was present?

[bantam12 in reply to Deliward]

Some people do feel better immediately but most don't, particularly those who also have thyroid problems.

Her calcium may have gone up or down, that PTH level looks OK but you need calcium as well for a better picture.

Calcium would usually rise if another adenoma is there but can also be stuck within the range.

We have several people on our forum who have had second and third surgeries, not common but it does happen.