This may sound initially a bit off topic, but its relevant to my current situation. Just wondered if anyone here (particularly age 55+) uses HRT in any form as well as thyroid medication.
I recently had an appointment with an endocrinologist in London. Cried when I came out as it was such a relief to have someone listen properly and take in what you've said when you've been asking GPs the same questions over and over (can I be referred? can I be referred please? I still have hypo symptoms... etc etc.
After going through my history and current situation he came up with two suggested treatment options. One would be to try NDT (he prescribes Erfa) and as he felt some of what I'm experiencing is menopausal (though I'm 61 and its 9 years since I had a period) he suggested trying Evorel Conti HRT patches.
Have to admit I was quite taken aback at this suggestion as I felt I'd sailed through menopause with relatively few problems, compared to the distress many women suffer, so felt I'd gone past the time when HRT might be an option and wanted to get through without it at the time, which I did.
I had blood tests taken and he'd said lets see what results are like, but gave me a prescription for the patches and suggested I could do either or both. I mentioned the cancer risks associated with taking oestrogen. He said on a short term trial basis it would be safe enough to see what sort of impact it might have.
He was a little reticent about trying Erfa first as I have in the past suffered bouts of SVT (Supra Ventricular Tacchycardia) where heart rate has risen out of the blue to 140 - 160 bpm. Hasn't happened for a few years but have had a couple of bouts recently. I think he felt the addition of T3 within the NDT might worsen this problem perhaps.
I do have to read patient information labels and in the patch info leaflet it mentions various side effects. Of course not everyone gets them, but a rise in blood pressure is a possibility and I'm already taking BP med for high spikes, plus it outlines the percentage cancer risk.
I did mention to him that I had recently bought a quantity of T3 tablets with a view to trying them as I felt perhaps I'm not converting T4 : T3 well. Blood test results came back: -
Blood test results from that day were:-
TSH 3.59 (0.27 - 4.20)
Free T4 21.3 (12 - 22)
Free T3 3.4 (3.1 - 6.8)
It was also suggested that I could take a small dose of the supplement DHEA as my level was a little on the low side.
I'm not a medical person so I can only comment according to what it seems like from your test results. Your FT3 seems really low and TSH is quite high even if it's within range. I know that I'd feel unwell with TSH anything higher than about 0.5. You know your body best and it sounds like you sailed through menopause so it seems like worth getting your thyroid medication on track. Perhaps as we get older we also need some vitamin and mineral support to help us convert T4 to T3. I've found it's helped to get my B vitamins a lot better and take magnesium etc Did your endocrinologist test your vitamin levels? If not, it could be a good thing to do.
I had supraventricular tachycardia too but it could be due to variations in thyroid medication and possibly vitamin deficiencies. It's settle down since making those changes. I'm a little younger than you but not too much.
Hi Nanaedake, thanks so much for your thoughtful reply. Its odd that when I was in with the Professor, he seemed to be giving me the option of either or both treatment and said you don't have to decide now. He said lets see what the blood test comes out like and perhaps if you're T3 is 'on the floor' you could try natural thryoid first. So I was a bit confused when he replied (kindly and personally) to my first email with small list of questions, to seemingly push me towards the patches first.
I suppose I have to make a decision and be assertive (I usually am but thyroid things bring me to a crumbling mess) and just say to him I'd rather not use the patches and would prefer to try NDT first.
Interesting that you've had SVT. When I first had it many years ago, it was debatable between an ambulance team whether it was AF (Atrial Fibrillation) or SVT because they said they did need an ECG to prove which it was. The episode had stopped by the time they got to me, reverted to sinus rhythm. But later I had it again and was told it was AF. But in 2014, I mentioned it to a GP and she threw a fit and said I must see a cardiologist, in danger of clots flying, stroke etc. So saw cardio, had monitor fitted for a week. Went back for review having pushed the button on the monitor twice for 2 short episodes.
He said what you've been having is SVT (which isn't quite as dangerous as AF, though still needs monitoring) he said I could take beta blockers or see how I go and if it became troublesome, then return to the GP for medication. Weird I didn't have it after that from Dec 14 through to August this year when it came out of the blue. As I understand it AF is far more irregular (fast heart / bit slower / fast again / etc) so there is risk of blood pooling in the arteries and clotting. Whereas SVT is raised heart rate but its continuous and regular. Still some risk but not as bad as AF.
I did join the 'Recovering with T3' group for a while on FB and spoke to Paul Robinson couple of times (he's very helpful as are all the admins) and he felt that those episodes could be a result of low T3 - which I've now found I do have.
I can only tell you my experience and you can decide if it has any relevance to you. I am 69. Went through menopause early at 45. Have been taking HRT ever since so for 24 years. Around the same time was diagnosed hypo (had Hashi's but they didn't test for that then) . Was placed on Synthroid (T4) around same time. Felt unwell off and on (mostly on!) for over 20 years. More recently found doc who tested and diagnosed Hashi's. Slowly clawing my way back to feeling normal. At least what's the new normal for me. Still on HRT. I've had no problems with it. Have no history of cancer in my family, never smoked and not overweight. My BP tends to be low. Now on T3 in addition to T4 and it has made a big difference. Lots of family history of heart disease but no adverse symptoms in myself. You will have to judge. And if you trust this new endo follow his advice. Just be sure your doc is monitoring your heart. Also as suggested above nutritional testing is very helpful. I did this privately and found I was deficient in many places. Adding those nutrients has also really helped. Also watching your diet. No gluten, soy, dairy, sugar, alcohol or caffeine. I wish you the best on your journey to better health.
Hi teenarocks, I'm so chuffed with all the replies. I'm a bit of a worrier where medicaton is concerned. Partly because some years ago (long before meno) I had a mirena coil fitted. The fitting was fine and the physical aspect of it was fine, but the hormone it has in it affected me dreadfully. Within 2 weeks or so I had a dreadful downturn in mood and was in tears regularly, I haven't experienced that at any other time other than when my son was born and I had post natal depression, so it was the coil most definitely. I managed to get an emergency hospital appointment to have it taken out and the doctor who whipped it out said she wouldn't have given me a mirena coil with my previous background.
With regard to food, I have Coeliac Disease, so I have been on a strict gluten free diet for over 40 years. I can't tolerate caffeine at all, it raises my heart rate quite quickly. I stopped alcohol about 9 years ago altogether. I haven't eat anything soy since I researched thyroid more and found it interferes with thyroid function and uptake of medication. I try to eat little sugar and also I avoid any artificial sweeteners like the plague. I'm still eating dairy as I already cut out so much, but considering a spell without it to see how I do.
this is why people use bio identical hormone creams, rather than the patches or pills. They do not have the side effects and dangers of pharmaceutical type hormone drugs.
i have hashimotos and am on the autoimmune paleo diet..no eggs, seeds, nuts, grains or dairy...it keeps my inflammation and headaches to a minimum.
Hi SlowDragon, many thanks for your reply and for taking the time to look through previous posts. Yes I have Coeliac Disease, been diagnosed since I was small, though 60 years ago there were no definitive tests to prove it, so usually they went by symptoms and trial with gluten free diet. Also they believed you 'grew out of it' at that time which of course they now know is not the case. But because of this when I was about 7, I had regained weight and grown to where I should be and was put back on normal food. But in later years (turbulent teenage years which may have been attributed to eating gluten perhaps) I started having symptoms which tied in with Coeliac and was eventually 're' diagnosed when I was 25. I'm 61 now so been gluten free a long time.
Thanks for the advice about vits / minerals etc, I have had those all checked (apart from magnesium) and all are OK. A test with a private doctor Sept 15 showed Vit D a little lower than he felt it should be, so I took a supplement for sometime. But have had another test since then which has been OK.
Ferritin was checked at A & E a week ago as my husband took me there Bank Holiday Monday as I was feeling very ill with breathless feelings and a pain in my hip and back which was quite severe. They diagnosed a pulled gluteal muscle which eventually healed, but said with Hypothyroidism such things do take longer to heal. Of all the research I've done, I hadn't read that before. The doctor at A & E said other blood checks were very good (clot possibility / ferritin) and felt symptoms were probably due to 'worsening hypothyroidism'
I am hypothyroid and was on thyroxine since years. Now I take Erfa that I ordered myself but that's another story why I had to...
Last year I tried HRT and yes the sweating disappeared and the sleep got much better. BUT, it impacted on my thyroid treatment and I gained 4 kilos... skipped the patches and noticed that I did not need them. My problems were most likely thyroxine side effects. That's how the other story started, no understanding at all from my doc.
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Hi Asound. Many thanks for your reply. I've also been on Thyroxine for many years, currently on 75mcg. A couple of years ago I tried an increase to 100mcg but can't remember why at that time, didn't tolerate it and dropped back to 75mcg. Earlier this year one of the GPs suggested trying 100mcg again because I complained (again!) of continual tiredness and inability to lose weight. So did it again, but around 3 weeks started getting strange symptoms, tightness across my chest, slight breathlessness and other which I felt could be anxiety. Saw one GP who checked pulse and sounded chest said all was fine. Went back 2 days later saw another GP who threw a panic and sent me to walk in chest clinic for tests. I asked him could it be the increase in Levo. He said no. Went to the hospital had all the tests, all OK, doctor at hospital said symptoms definitely increase in Levo. Suggested trying 100mcg / 75mcg alternate days, but didn't bother, I just hate taking it really and dropped to 75mcg and told the GP staying at that dose.
The odd thing about the patches (sorry I diversed above a bit lol) is that I haven't had the sweats or other symptoms which many women get and its 8 / 9 years since I had a period. So I'd dismissed the idea of it being menopause, considered myself totally and finally post menopausal. But it seems perhaps the energy level side of things could come from lack of oestrogen.
Hello. It's certainly great the the endo has given you a prescription for ndt. And a choice to take either or both. Choice is a precious thing.... I think it would be mighty hard to know what was doing what if you took both so my suggestion -which I am sure you've already considered - is to start with one. NDT would be my choice. As others have indicated your T3 levels are very low. Additionally here is a link to more info regarding the patches. There is interesting info regarding the careful monitoring of thyroid hormone levels and the interesting fact that women over 65 ( you aren't, I know) may not benefit as much. Or at all. They don't know as there is too little data. medicines.org.uk/emc/medici...
Catrich, many thanks for your reply. I'm so pleased to get all these replies as I've been in such a dilemma. The patches are sitting on the kitchen worktops and my husband is saying when are you going to start them. Paid all that money to see a private doctor but not taking his advice. But I can't help feeling dubious about them for many reasons. Also he didn't actually give me the prescription for the NDT, he said he would 'hold that' for me, though originally he seemed to be leaving the decision up to me after the appointment, although gave me the presc. for the patches as you can get them at any pharmacy. But in emails later he seemed to sort of saying try patches first, tell me how you feel in 8 weeks time.
Thank you also for the link. I think I read a similar page of information somewhere and also the leaflet in the box is very comprehensive with similar information. I did ask him about the cancer risk and because the appointment was coming to a close, didn't have chance to tell him my eldest of 2 sisters had breast cancer around 4 years ago. All successfully treated, but I feel its relevant.
My mum is hypo and uses the HRT patches. She is doing well with them. She is 64 and still using them.
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Hi Katie, many thanks for your reply. Nice to get a positive experience from someone. Do you know if your mum is taking the same ones? Evorel Conti?
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I am not sure sorry but will ask when I speak to her tomorrow. I know she had problems with her HRT previously as she is super sensitive and some were making her sick.
I have been taking Angelique HRT for 2 years, with nothing but positive side effects, & WP Thyroid for 1 year.
I asked for that brand as my friend's gynaecologist sister recommneded it to her, It's supposed to be the safest available, although it still contains progestin.
As far as meds go, it's been absolutely great. I had hot flushes day & night for 6 years, & would have killed someone or myself, as I felt so deranged.
I already have a higher risk of breast cancer, & accept the pay-off of a shorter but considerably less unpleasant life to feeling that crazy all the time, rather than 10 days a month!
This brand is one of the newer ones on the market. I'm reliably informed that it's the older HRTs are the ones causing the cancer issues. Time will tell. Like all meds, some individually, or in combination, suit some people better than others.
I did find NDT & HRT more effective taken well apart, as with several other foods & supplements.
I agree with you. I still have all my parts and my doctor won't allow me to take HRT. I'm now 68 and tried to get on it a couple of years ago due to hot flashes and night sweats so bad I could barely stand it. She suggested going on Zoloft, which will stop them dead in their track, but I wanted HRT instead. NO WAY, she says. I guess if you start it when you're younger, the doctors don't take you off of it, though, but maybe that's just the women who don't have all their parts.
Hi sweetsusie. I love that 'still have all my parts' It made me giggle. Yes I still have all my parts. I was offered some sort of repair job on my womb some years ago as its prolapsed but I looked up what the surgeon had described and didn't like the idea of it (A 'Manchester' repair - cut off the cervix, then run a stitch around the top of the cervix to hold it up where it should be. No further risk of cervical cancer, bonus, but no cervix, someone told me don't ever have your cervix removed if you don't need to. But quite high risks of severe bleeding during the surgery. I'm terrified of anaesthetic too, no matter how much people tell me how safe it is.
So I sought a second opinion from a surgeon / dr I'd seen on embarrassing bodies. He offered another operation with a long name where they use polyethylene tape to hitch up the top of your cervical canal, but I read things about the tape which weren't good. He suggested a pessary to hold womb in place. I said yes, had it fitted there and then and have stuck with that for the last 4 years or so. Pessary changed at Dr surgery every 6 months. So I'm keeping my bits thanks lol
But as mentioned I didn't have all those awful sweats, I feel so sorry for women who do and I didn't think I was suffering menopause symptoms now, felt it was all thyroid, but Professor seems to say otherwise. I feel awful even questioning his word / diagnosis, but I'm just the type of person that likes to think carefully before making decisions.
Hi Angel. Many thanks for your reply. There is a mix of two hormones in the patches he has prescribed and I'm aware of the horse thing, but haven't checked into the background of these patches. Part of me wants to throw them in the bin (or give them to someone who really wants to use them!) but part of me thinks I should give them a go - maybe they might make me feel great and I'd have wasted all this time worrying about it. Difficult decision
Hi Leverette. Many thanks for your positive reply. Interesting to hear from someone who is using both treatments. I think the Evorel has some progestin in it too as I think you need both if you still have a uterus (which I do - poor little wrinkled thing I think lol) as it stops the uterus lining from thickening I think.
I too am not a medic – but have done a lot of research re health over the past 8 years (at least half hour p/day, and now get paid to research and write about health) due to having a lupus-like condition, as well as underactive thyroid.
Before you take HRT, pls pls pls read Dr Jonathan V Wright's excellent book (terrible title):
'Stay Young & Sexy with Bio-Identical Hormone Replacement: The Science Explained'
– I guarantee you won't want to touch HRT afterwards! (Do you – or does your body – really want to be ingesting stuff distilled from pregnant mare's urine? Yep, true. If you doubt the veracity, think about the HRT name PreMarin...)
I'm now a patient of Doc Wright (flew over from the UK to Seattle in July to see him, at vast expense, but worth every penny) and he talks utter sense, and 1000s of patients and people worldwide benefit from his care & wisdom. I'm taking bio-identical progesterone with a small amount of estriol (oestriol in the UK), available in the UK as 'Twenty to One' cream, and am doing really well. The following is NOT an ad as I have no benefit from you seeing it... for convenience/time-saving on my part (!), pls see my FB page 'thriving on corticosteroids' and scroll down to the MENOPAUSE bit.
In the States, you can get bio-identical hormone creams from compounding pharmacies.
NB1: as he says, use transdermal cream (on body skin or vaginally) as tablets go straight to the liver (the 'first pass' effect) which does its best to get rid of the hormone/s! – and can create potentially very undesirable 'metabolites'.
NB2: do NOT take DHEA as tablets, for the 'first pass' reason given above. Copy nature as closely as poss and put it on your skin*! – as I do. (*from where it goes straight into your blood stream, as it does naturally from your adrenals) Last October, my level was pretty much zilch, now rising slowly but steadily – skin, bones etc recovering from the steroids – and I'm getting my libido back!!
You can get DHEA cream, in in-expensive 2oz bottles, online in the USA & UK. Apply at bedtime, and rotate the sites if putting on your body skin, or can use vaginally every day (cos mucus membranes don't get saturated). Use for 25 days then 5 days off, then repeat. If using DHEA long term, you ought to get yourself tested for metabolites.
I wasn't given the option of vaginal when creams didn't work (although I had oestradiol pessaries for a couple of weeks for vaginal atrophy). I have intrabuccal lozenges (like sublingual), though, rather than tablets and the ratio is more like 50 to 1.
I get Dr Wright's newsletters. He talks a lot of sense.
I'm glad the oestradiol wasn't long term…as JVW explains, along with oestrone, it's one of the 2 oestrogen's you DON'T want in your system post-menopausally, not least cos it increases breast cancer risk, UNLIKE the 3rd one – oestriol – which decreases it by occupying the relevant receptors – also protects vs all sorts of other nasties!
Re vaginal atrophy, have you tried omega 7? (Pharma Nord is the importer of the Norwegian (?) one used in clinical trials.) Might be worth a try for at least a few months, esp as does loads of other good stuff, too. (As with all omega fatty acids, JVW reco's taking 'mixed tocopherol' vit E to prevent oxidation/free radical formation; I use Vitasunn's (online), and as I take omega 3 as well, I take 800 iu vit E, i.e. 2 capsules, per day.)
Gosh, so many really interesting replies. Thanks for all the above. I guess I'm already doubtful of using the patches anyway, hence my post. Though if he'd offered me tablets I would have definitely said no, but thought I would at least think about the patches as the hormone doesn't go through the liver.
Some time ago I was offered at the GP hormonal pessaries to assist with vaginal atrophy (hate that term!) because having my pessary (for prolapse uterus) changed was quite painful. When I walked into the doctor that day ( a female) the first thing I said was, is there anything I could have which is not hormonal to help with the issue. But walked out with a prescription for hormonal pessaries. I got them, put them in the drawer where they stayed for some months and eventually took them back to the chemist for disposal.
I've heard of bio identical hormones before but having been entrenched in thryoid research and thyroid issues and not thought I had menopausal symptoms so haven't explored that side of things at all.
I have heard of Omega 7 and think I did try it once but possibly not for long enough so didn't think it had any effect, but maybe should have continued longer with it.
I still have oestradiol and oestriol in my biohrt, but the amount is minute. I've tried pretty much everything, but only biohrt worked. I eat sea buckthorn berries off the bushes that the council plant (they are a favourite shrub for landscaping round here - that's omega 7). DCIS hasn't got worse (might have gone), but I need to get a pelvic scan to see what's happening inside.
Hi Georgina, I am 55 and haven't had a period since last March. I am also borderline Hypothyroid. I have just had an appointment with a member of the Endocrinologist team (not the Dr who I was hoping to see and had waited 9 months for - Grrrhh) and she has suggested a return appointment with a view to starting a low dose of HRT. I am hopeful this may help my non existent libido!
Hi Baggiebod, thanks for your interesting reply. My periods ended when I was 52 some 8 / 9 years ago and diagnosis of hypothyroidism came a few years later. The Professor I saw in London did ask if I had a reference point when I felt well / OK. I said yes, most definitely when I was 49. I called it 'the storm before the calm' (yes I got that the right way round) as I really felt my hormones were 'raging', I'd lost weight then through a class, felt wonderful, although saying it myself, I looked wonderful too, glowing skin, my hair reasonable (has never been thick) and brim full of libido (husband couldn't keep up lol) My libido has diminished somewhat but I think some of that is because I'm put off trying because of my prolapsed womb with pessary (doughnut I call it) holding it up. Also I now have a little bit of incontinence, so would hate to leak during the process!
The patches are supposedly a very low dose anyway and he asked that I use half a patch and then you change it twice a week, so effectively one patch a week.
Obviously I'm the wrong sex to have direct experience with this. However I have read that estrogen dominance (lots of estrogen without progesterone) can drive thyroid levels down. If I were in your position, I would not introduce estrogen into your situation along with a thyroid change at the same time. Why change two variables at once? That is not a good experimental protocol! It seems clear from the test results above that you have enough T4 but not nearly enough T3; your FT3 should be at least 50% up in the range (i.e. 4.95), and preferably higher. If you are not already on a T4 preparation, then adding NDT could drive your T4 too high. It seems to me that the simplest thing you could do, is simply add in T3 to push that FT3 up (and pull that TSH down). If experimentation with T3 works, then (assuming you are already taking a T4 supplement) you could discontinue T4+T3 and start taking NDT in place of T4+T3, if you prefer NDT.
I would not agree to taking any estrogen preparation until you iron out the thyroid issue. There are some cases in which correction of thyroid will improve production of sex hormones (that was the case with me). If you do decide to use estrogen after thyroid is ironed out, make sure you are using a bioidentical type (not the stuff from horse urine) that is balanced with progesterone in the proper ratio. In other words, investigate what is in those Evorel Conti patches.
A small dose of DHEA is certainly a good idea, safer than using estrogen-only. Natural DHEA drops pretty precipitously by 60. The body can use supplemental DHEA to produce sex hormones. I've added a male-appropriate dose (25mg) to my thyroid, and it does help. I'm not taking any other hormone supplements like testosterone.
P.S.: I sort of assumed you are on a T4 supplement since your FT4 is so high. Have you considered that SVT might be related to the fact that your GP (apparently) kept loading you up with more T4? There is a subset of patients (I am one of them) who do not do well when their FT4 is pushed to range top. Since I know my body doesn't convert T4 well and high T4 makes me feel anxious and out-of-sorts, I run my FT4 low in range. In any case, if you decide to try T3, you will probably want to reduce your T4 first. With your low FT3, the addition of T3 isn't going to create a problem, but the addition of T3 with so much T4 present might. I often suggest that patients compare their T4 dosage to Abbott's T4-only full-replacement recommendation of 1.7 mcg/kg body weight.
Thanks very much for your thoughtful reply (both of them) I really appreciate all the answers I'm getting for my post.
As you can probably tell from original post and other replies (if you've had time to read them) I'm already very wary of using the patches because of a previous experience with a mirena coil which sent me 'dulally' . I've read copious amounts of information about the patches which I'd half promised myself I wouldn't do on the train home from London after seeing the Professor. But I'm just that type of person that has to know what I'm taking.
This is the internet version of the ingredients in the patches :-
'Evorel conti patches are a hormone replacement therapy (HRT) preparation. Each patch contains two active ingredients, estradiol (previously spelt oestradiol in the UK) and norethisterone. These are forms of the main female sex hormones, oestrogen and progesterone. Estradiol is a naturally occuring form of oestrogen and norethisterone is a synthetic form of progesterone.'
EVORELCONTI
3.2 mg of estradiol hemihydrate
11.2 mg of norethisterone acetate
To answer your other question about current medication. Yes I'm currently taking Levothyroxine 75mcg and have been on this dose for some years, apart from two occasions when the dose was raised to 100mcg. One occasion was about 3 years ago, which I'd forgotten about until I looked at my own record of test results and dosages in order to send it to the Professor prior to the appointment. Evidently I didn't tolerate it then. The second time was earlier this year when my GP suggeted it having told him on many appointments that 'I'm still tired most of the time' Within about 3 weeks, I experienced tightness across my chest and feelings rather like anxiousness. I thought this was because my husband was away a few days and I don't sleep well when he's away. But went to get checked out. Got pulse and chest sounded. Told OK. Nothing wrong. Returned a couple of days later saw different GP who seemed rather over cautious, sent me for walk in chest clinic tests 'to rule out embolisms'. He said this while I was within earshot of him talking to the clinic which wasn't good to hear.
But went back to work, told my boss what happened, he said just go and get checked (did ask if I was OK to get there by myself) . Had blood test, ECG, blood oxygen level test. Saw Dr who was very patient and took copious notes, but said all tests OK, no evidence of clots and concluded this was definitely a result of the increase in Thyroxine. Suggested alternating 75 / 100 daily and wrote to the GP to this effect.
I had already tried this when I was first given the 100mcg so refused to increase and told the GP I would stick at 75mcg. So I'm not sure why my T4 was so high on the test done in London a week ago. Test was in the evening, took Levo in the morning. I just feel I'm probably not converting T4 / T3 well and perhaps this shows in my low T3 result on same test.
Hmmm what to do for the best, I wonder. I feel I need to discuss this with my lovely husband this weekend and whilst he has been encouraging me to take the Professor's advice 'he's seen all this before' etc, it is my body and I must make my own choice. I already have some T3 here which I bought a couple of months ago in preparation for trying it either alongside T4 or eventually instead of perhaps.
"instead of" isn't a bad policy. I was on T3-only for over a year and that worked quite nicely. The only downside is that you have to dose across the day (I dosed 5 times) if you want to avoid blood level spikes. Again, I would encourage you to try to get yourself out of the hypothyroid state, to see how you feel, before attempting patch therapy. Remember, just because the endo is a Professor doesn't mean he does everything 100% correct!
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