Log in
Thyroid UK
93,416 members107,475 posts

both hyper and hypo symptoms on T4+T3 combo? Could that be?!?

Long story short.

1. Graves - thyroidectomy - T4 only only worked for a while than crashed into mental and physical meltdown with hypo symptoms

2. Switched to T4/T3 combo, went quite well for more than a year and now feels a crash is around the corner.

Funny thing is now the symptoms are from both worlds:

Hypo - Dry skin, Weight gain

, Elevated blood cholesterol level

, Joints Pain, Thinning hair, Depression

, Impaired memory

Hyper - Increased appetite, Nervousness, anxiety and irritability, Increased sensitivity to heat, Changes in bowel patterns, especially more frequent bowel movements, Fatigue, Skin thinning, Fine, brittle hair

Now, before asking how this can be possible...test results are quite OK, the TSH between 0.5 and 1.3 T3, FT3, FT4 are good in their ranges and have stayed there for a long time.

On the other hand, D3 is duly supplemented, B12 - though at median range - has been mildly supplemented (up to the point when it got me a acne eruption)

Therefore...questions that make me loose sleep:

a) What could cause me a cyclical 18 months mental and physical crash? I fail to see a reasonable cause or causality but I need your opinion too

b) It is possible, due to the dual hormone replacement therapy (T4&T3) to be hyper to a component and hypo to the other, while test results more or less stable and reasonable? I use Novothyral combo, 125 T4 and 30 T3 (1 100/20 pill and a quarter I fail to cut precisely almost every time)

Thank you, I hope to receive some light from you, as this constant fight gets me tired sometimes.

40 Replies


How long since your last thyroid function test? Can you post the most recent results and ranges and any for ferritin, vitamin D, B12 and folate?


Hi Clutter,

last tests I have described here, this are since Dec 2016


Last vitamins test, since august 2016, here:


Supplemented D3 constantly since february 2006 with 2000 IU/day and B12 on and off until triggered acne (I think that was Sep 2016)



You should leave 60 minutes between Levothyroxine and T3 meds and coffee. Coffe can reduce absorption by up to 40%. For maximum absorption Levothyroxine should be taken with water 1 hour before, or 2 hours after, food and drink, 2 hours away from other medication and supplements, and 4 hours away from calcium, iron, vitamin D supplements, magnesium and oestrogen.

If you observe the above your absorption should improve which may stabilise TSH, FT4 and FT3.

B12 acne is usually a sign that B12 supplementation is working and is, I believe, a temporary side effect. Folate was low in range. There is no Vitamin D result that I can see. If you were vitD deficient 2,000iu would be an insufficient dose. I would recommend retesting B12, folate and vitD.

Ferritin was good last August which pretty much rules out low iron which can often cause hyper and hypo feelings.

1 like

1. I need to retest, both hormones and vitamins.

2. I am aware of the absorption issue but tbh I barely made it to 30 minutes. :) Will improve on that.

For the time being, I was considering increase a bit the T4 and decreasing a bit the T3, but considering Grey goose advice from below it may be the case that would not be the smart move.

Therefore I will do nothing going until new test are available.

One more question please: I sometimes have a "iminent faint" sensation, tingling and numbness in the hand fingers, only for a fee seconds. Any thoughts on that? What could indicate?

Thanks again for your patience



Some people set the alarm an hour before they need to get up so they can take their thyroid meds and then have coffee/breakfast when they get up.

Add calcium to your tests. Tingling and numbness can be due to either low B12 or low calcium.

1 like

I had no idea absorption could be reduced by up to 40% if you have coffee right after taking thyroid meds...that's an awful lot. Thanks for this very important information.


I can double confirm that, learnt on my own skin. When I've first started the replacement therapy I was barely averaging 15 minutes and it was noticed quite rapidly.


Another thanks Clutter, I didn't know about low iron causing hyper and hypo feelings, presumably low ferritin can do the same?

And Caesard please ignore my previous comment - I had low ferritin as well when over-medicated and since reading Clutter's comment think I wrongly attributed the symptoms to the over-med.

1 like


Low ferritin can indicate low iron so, probably, yes.



Does this apply to transdermal estrogen as well? I hope not, as I usually apply Estrogel and take NDT within ten minutes of each other...



As far as I'm aware it applies to oral oestrogen.


What a relief...thanks:-) All I know is that the Hertoghe doctors in Belgium only prescribe dermal estrogen, as oral estrogen (according to their school of thought) has a tendency to accumulate in the liver...


thyr01d thanks, note taken

Clutter , I used for the past 1 year to take vit D, as well as other supplements (Bs, bone/joint support, magneB6 etc) in about 30 mins after thyroid hormones. What would be the effect? Poor absorption for T4/T3, for the vitamins or for both? Thank you!



Poor absorption of the T4 and T3.


Makes sense in the greater scheme of things...Small absorption window plus association of other meds/supplements might have been what was leading to a crash effect.

I need to be careful with this! Thanks a lot Clutter!


I can't answer no 1), but I'll have a shot at no 2).

' It is possible, due to the dual hormone replacement therapy (T4&T3) to be hyper to a component and hypo to the other'

Not quite sure you understand how this works. T4 is a storage hormone. It doesn't do an awful lot, just hangs around until it's needed to be converted into T3, the active hormone. So, T4, in and of itself, cannot make you have hyper symptoms (you can't be hyper, because your hypo, the thyroid can't jump around like that). It's too much T3 that causes hyper symptoms. But, you don't always have to have too much...

The amount of T3 you have in your blood, is not evenly distributed throughout the body. It is possible for some cells to get too much, causing hyper symptoms, and other cells not enough, causing hypo symptoms. Some cells might not be getting any at all...

When T3 is in short supply, the body - in order to stay alive - shuts down certain less important cells - switches off the T3 receptors, so that the available T3 goes to the most important parts of the body, like the brain, the heart, the kidneys. When supplies of T3 improve - because you're taking thyroid hormone replacement of some kind - the body gradually switches those receptors back on - but not all at once, you understand! There won't be enough T3 straight away for it to do that. And, while the receptors are switched off, and those cells aren't getting any T3, they cause hypo symptoms.

So, yes. It's perfectly possible to have hypo and hyper symptoms at the same time. :)


Of course! Thanks!

This is what happens....I am perfectly aware of the mechanism of T4 conversion to T3. But I'm once again unable to put things together in a coeherent manner.

How can I address this situation of having it from both worlds? More T4, less T3? viceversa?


Depends on your labs. Just saying 'good in range' doesn't tell us anything.

And, if your labs are good, it's just a question of time, that things even themselves out.


You're right, I agree...

I need new test results. Will come back when available.

1 like

Very interesting and informative posts, Greygoose:-)


Thank you. :)


Hi greygoose. I am on T3 and T4 and having a tricky time so this is fascinating for me.

Can you tell me where you got this from so I can read up more and sound more coherent than I usually do when talking to my endocrinologist. Many thanks!!


I rarely get things from just one source that I can link you too. Things crop up, in different forms, in many different articles and documents. I just paraphrase them in answer to questions. I can't tell you where I read anything because I've read so much. But try reading up on Dr Lowe. But, then again, it might have been in a lecture, I don't know.

And, of course, in answering that question, I did forget the obvious! A lot of symptoms cross over from hypo and hyper - they can be symptoms of both!


Thanks GreyGoose, great explanation.


You're welcome. :)


Guys, there is one last thing I would like to ask you.

We have agreed that nothing can be accomplished now in absence of recent test result, in order to see why I feel a decline in the last few weeks.

But, for the last 4 days I've been away, with the meds forgotten and without any possibility to purchase some.

From last similar experience I was expecting a quite rapid decline in energy levels.

What actually happened? Day two felt some energy decrease, more sleepy than usually and cognitive shutdown (but I was already not on my brightest levels...)

But throughout days 2 and 3 I've had the most peaceful period in a very long time and felt I could really relax and get some deep sleep and get rid of exhaustion.

Day 4 this zen state changes, I get some emotional strange effects, the roller-coaster type with change of mood and also physically the situation is worsened below feel good level.

What on earth could explain this ? Might be interested was a little over medicated? Again, understood, mere theory without test results.


Your experience was quite common. Most people find that if they stop their thyroid hormone replacement, they feel much, much better for a few days. And, they very often start to wonder if they ever needed it in the first place! But, the feeling doesn't last. At some point you're going to start feeling worse, symptoms are going to creep back in, and before long, you'll be back to square one.

There is no explanation of this phenomena. Although lots of people report it, i don't think there's ever been any research into it. You could say that, if you're on levo or NDT, it's because the T4 is still in your system for a few days - but that wouldn't explain why you felt better! Besides, it happened to me on T3 only. Who knows.

However, it doesn't work for everyone. Some people can feel the worse if they're a few hours late taking their levo! All we can say is, that we are all different, and nobody has ever been able to explain those differences.


@greygoose, for sure I need the hormone replacement, my thyroid is out :) I'm on a T4/T3 combo, I was expecting the faster burning T3 to mark its depleting more significantly, for sure i wasn't expecting....serenity :)


I'm on T3 only, and I went off it for 6 months, and I felt fine and happy. At the end of six months, I noticed I was putting on weight, so asked my doctor for a test. TSH was 35.

I'm not recommending anyone try doing this! Just to illustrate that it's something that happens, that's all. :)


But your thyroid retains some function, right?


At the end of six months, my FT4 was below range, and FT3 unreadable.

1 like

And sole symptom the weight gain?!? Wow!


Well, my skin was turning to scales, a bit. But, apart from that, no.


Hi Caesard, when I was over-medicated I had both hyper and hypo symptoms - don't know if that's any help.


To offer an update, after the 4 days interruption of T4/T3 combo I have resumed the treatment but i feel increasingly more on the hyper side, but also with hypo symptom.

I am now religiously keeping an hour between administration of hormone and breakfast/coffee.

I have stopped supplements in preparation for a larger batch of tests, including vitamins/minerals.

Due to the hyper symptom and improved absorption, I have reduced the dosage from 125 T4 and 25 T3 to 125 T4 and 20 T3 but, as it still feels over medicated, I have drawn blood for a quick guidance set of results (TSH TT3 FT3 FT4), taking care of leaving 12 hours between last meds administration and the moment of drawing blood.

Results shall be available on Monday but meanwhile I get cold/warm rash, the "running hot" feeling and some anxiousness (not anxiety!) and some variable body temperature, between 35.7 and 37 Celsius. What really drives me crazy is that i feel without energy during afternoon and, of course, lobotomized and engulfed in brain fog.

I'm slowly regaining my will to fight but it's really difficult to constantly being under assault and in need to adjust and test and think and consider and wonder and hope and test and...I'm pretty sure you know what I mean :)

Thank you a lot, you are a lovely, supporting bunch, I wonder where I would be without you...




So, test results are here and are self explanatory; worth mentioning again that those results are registered after 4 days without any hormone administration + one week of resuming the treatment and from blood drawn 12h after last administration.

FT3 = 3.64 pmol/L[3.1 - 6.8]

FT4 = 9.83 pmol/L[12 - 22]

T3 = 1.12 nmol/L[1.3 - 3.1]

TSH = 2.29 µUI/mL[0.270 - 4.20]

Initial dosage (stable for more than one year though in the last months predicting a crash) was 125 T4 and 25 T3 in single dosage but with insufficient window of absorption of 30 minutes.

This test result are on 125 T4 and 20 T3 and 1h absorption time.

AS it looks like it needs to be acted upon I shall supplement with 12.5 T3 in a separate dosage, still thinking about administration time, be it either 17 o'clock or before bedtime.

After 6 weeks of having that....tests, with full complement of vitamins and minerals this time.

How does this sound?


Sounds good. At least, now, you know there's no way you're hyper! :)

1 like

Thanks! Beats me how on earth could I feel hyper with those results....


Well, I did explain that, above.


So, after increasing from single dose 125 T4 and 20 T3 to 125 T4 and 32.5 T3 in two doses, the results are the following (blood drawn at 24h after last t4 and 12h after last T3)


VITAMIN D3 = 26.5 ng/mL[30-50]

CALCIUM = 4.09 mg/dL[3.6 - 5.2]

CA serum = 9.52 mg/dL[8.4 - 10.2]

Ferritin = 479 ng/mL[30 - 400]

Fe (SIDEREMIE) = 87.4 µg/dL[59 - 193]

ACID FOLIC) = 6.76 ng/mL[2.7 - 16.1]

VITAMIN B12 = 466 pg/mL[197 - 771]

ACTH = 74.73 pg/mL[7.2 - 63.3]

CORTISOL = 491 nmol/L a.m. : 138 – 690

FT3 = 5.44 pmol/L[3.1 - 6.8]

FT4 = 13.4 pmol/L[12 - 22]

TT3 = 1.7 nmol/L[1.3 - 3.1]

TSH = 0.248 µUI/mL[0.270 - 4.20]

TESTOSTERON = 10.9 nmol/L age 20 - 49: [8.64 – 29]

DHEA – S = 164 μg/dL [88.9 – 427]

•Changes on the symptoms side:

Hypo - Dry skin and blood cholesterol level have come down, some joints pain (especially in the morning) and impaired memory still remain

Hyper - Increased appetite, Nervousness, anxiety and irritability seem much better under control since the last entry. I have noted though increased sensitivity to heat and more frequent bowel movements,

From both worlds fatigue and lack of energy is still plaguing me...

•I am concerned about the increased Ferritin, it’s the first time it gets above max; similar with ACTH, elevated while serum cortisol within normal range. (no other meds besides fever reducing meds )

To put some context, blood has been drawn 4 or 5 days away from the debut of what I think it was a severe stomach infection that started with very rapidly increasing temperature (from normal to 39 Celsius in 2 hours) and bad stomach.

Anyway, will repeat Ferritine and ACTH in a month’s time and will take also saliva cortisol test too.

Testosterone is quite low too and I feel accordingly :(

Will keep an eye on it....might correlate with a stressful time I am facing on a personal and professional level but I am open to suggestion and advice.

In respect to the HRT meds, I am honestly unable to pass judgement, I still get joint pain and fatigue/low energy plus less than normal cognitive function (but better than one month ago) Considering the T3 involved the test are somewhat irrelevant but I would have expected at least the FT4 to be higher in range.

Your thoughts?


You may also like...