Hi everyone. Following on from my previous post about doctors reducing my levo due to low TSH. I have been since arguing with GP and they say low TSH cases osteoporosis and heart disease this is their rationale for the reduction.
Is this right ?
I have asked for a referral to the endo I usually see if there is a problem.
The short answer is "no". Low TSH with high FT4 and FT3 in hyperthyroidism is certainly dangerous, but not because of the TSH, but the elevated thyroid hormones. On T4 therapy, TSH can be safely below the reference range for healthy people, if the FT4 and FT3 are in their ranges Here is a reference that describes this, from a group of Japanese workers.
Thyroid 2017 Apr;27(4):484-490. doi: 10.1089/thy.2016.0426. Epub 2017 Feb 6.
Biochemical Markers Reflecting Thyroid Function in Athyreotic Patients on Levothyroxine Monotherapy
Mitsuru Ito 1 , Akira Miyauchi 1 , Mako Hisakado 1 , Waka Yoshioka 1 , Akane Ide 1 , Takumi Kudo 1 , Eijun Nishihara 1 , Minoru Kihara 1 , Yasuhiro Ito 1 , Kaoru Kobayashi 1 , Akihiro Miya 1 , Shuji Fukata 1 , Mitsushige Nishikawa 1 , Hirotoshi Nakamura 1 , Nobuyuki Amino 1
PMID: 28056660 PMCID: PMC5385443 DOI: 10.1089/thy.2016.0426
Free PMC article
Abstract
Background: Some investigators reported that among athyreotic patients on levothyroxine (LT4) monotherapy following total thyroidectomy, the patients with normal serum thyrotropin (TSH) levels had mildly low serum free triiodothyronine (fT3) levels, whereas the patients with mildly suppressed serum TSH levels had normal serum fT3 levels, and the patients with strongly suppressed serum TSH had elevated serum fT3 levels. The objective of the present study was to clarify which of these three patient groups is closer to their preoperative euthyroid condition.
Methods: A total of 133 consecutive euthyroid patients with papillary thyroid carcinoma who underwent a total thyroidectomy were prospectively studied. The patients' serum levels of lipoproteins, sex hormone-binding globulin, and bone metabolic markers measured preoperatively were compared with the levels measured at postoperative LT4 therapy 12 months after the thyroidectomy.
Results: The postoperative serum sex hormone-binding globulin (p < 0.001) and bone alkaline phosphatase (p < 0.01) levels were significantly increased in the patients with strongly suppressed TSH levels (≤0.03 μIU/mL). The postoperative serum low-density lipoprotein cholesterol levels were significantly increased (p < 0.05), and the serum tartrate-resistant acid phosphatase-5b levels were significantly decreased (p < 0.05) in the patients with normal TSH (0.3 < TSH ≤5 μIU/mL). In the patients with mildly suppressed TSH (0.03 < TSH ≤0.3 μIU/mL) and fT3 levels equivalent to their preoperative levels, all metabolic markers remained equivalent to their preoperative levels.
Conclusions: The serum biochemical markers of thyroid function in patients on LT4 following total thyroidectomy suggest that the patients with mildly suppressed TSH levels were closest to euthyroid, whereas those with normal TSH levels were mildly hypothyroid and those with strongly suppressed TSH levels were mildly hyperthyroid. These data may provide novel information on the management of patients following total thyroidectomy for thyroid cancer or benign thyroid disease
So is a tsh of 0.01 or 0.005 problematic? That’s where I am and struggling to get the dose increase I need. Endo is a reasonably well informed on (e.g. happy to consider T3).
That’s why I’m asking on here. My TSH is 0.01 and the gp wants to reduce my levo but my t4 is normal. The gp is saying it causes heart disease and osteoporosis. I have been non detectable for six years before this so am sure I would have heart disease if that’s the case. I just wanted to ask thoughts on here before i confront gp again
I am 0.02! I have Atrial Fibrilation but cardiologist says no problem at all!
Undetectable TSH. In some people on therapy this can mean over treatment, but with others not. Medicine simply has to get over the nonsense of categorisation. This is where you are designated OK if you are anywhere in the reference range and not OK if you are outside it. Everyone is an individual, with individual needs. It's quite wrong to judge a patient by within/outside range thinking. The reason why doctors don't like undetectable TSH is that in hyperthyroidism, such levels are found, but with high FT4/FT3 as well. They then carelessly project this thinking onto therapy with T4/3, not realising the basic difference in the two states. In the therapy group, undetectable TSH often accompanies perfectly good levels of FT4/3. And it is FT4/3 that defines health, not TSH.
academic.oup.com/jcem/artic...
Interestingly, patients with a serum TSH below the reference range, but not suppressed (0.04–0.4 mU/liter), had no increased risk of cardiovascular disease, dysrhythmias, or fractures. It is unfortunate that we did not have access to serum free T4 concentrations in these patients to ascertain whether they were above or within the laboratory reference range. However, our data indicate that it may be safe for patients to be on a dose of T4 that results in a low serum TSH concentration, as long as it is not suppressed at less than 0.03 mU/liter. Many patients report that they prefer such T4 doses (9, 10). Figure 2 indicates that the best outcomes appear to be associated with having a TSH within the lower end of the reference range.
heart.bmj.com/content/84/4/...
Over replacement with thyroxine?
There is some concern that administering thyroxine in a dose which suppresses serum TSH may provoke significant cardiovascular problems, including abnormal ventricular diastolic relaxation, a reduced exercise capacity, an increase in mean basal heart rate, and atrial premature contractions.12 Apart from an increase in left ventricular mass index within the normal range, these observations have not been verified.13 Moreover, there is no evidence, despite the findings of the Framingham study, that a suppressed serum TSH concentration in a patient taking thyroxine in whom serum T3 is unequivocally normal is a risk factor for atrial fibrillation.
Low TSH no heart issues
academic.oup.com/jcem/artic...
In summary, patients on long-term T4 with either an increased serum TSH (>4 mU/liter) or a suppressed TSH (<0.03 mU/liter) have an increased risk of cardiovascular disease, dysrhythmias, and fractures when compared with patients with a TSH within the laboratory reference range. Patients with a low, but not suppressed, TSH (0.04–0.4 mU/liter) had no increased risk of these outcomes in this study.
So if my TSH is 0.01 I am at a mild risk of heart disease. Is that what you are saying even though t4 was 15
No ...if Ft3 is not over range you’re not over medicated
Are all four vitamins OPTIMAL
Do you get bloods tested as early as possible in morning before eating or drinking anything other than water and last dose levothyroxine 24 hours before test
what vitamin supplements are you currently taking
Vitamin D at least around 80nmol and around 100nmol maybe better
Serum B12 at least over 500
Active B12 at least over 70
Folate at least halfway through range
Ferritin at least halfway through range
Are you on strictly gluten free diet, or tried it?
After being hyperthyroid and RAI it’s very common for TSH to remain suppressed.
Thankyou for your reply. I am definitely asking for private referral Am fed up of gp’s. All my vits are optimal and I take everything you have recommended in previous posts
Previous post from 4 months ago
Did you coeliac blood test done...are you now on strictly gluten free diet?
I am trying. I do struggle with it but am doing ok.
Have you noticed any improvements being gluten free
It does need to be absolutely strictly gluten free to be effective
As explained here
chriskresser.com/the-gluten...
Thankyou. I have noticed a difference in my food digestion I’m not strictly gluten free but I am trying. I drink lactose free milk which has also made a massive difference.
He is wrong. These are just assumptions and not true.
TSH means Thyroid Stimulating Hormone and from the Pituitary Gland and it rises if we've a problem with our thyroid hormones (i.e. too much or too little).
It is not a thyroid hormone.
We, in the UK, want doctors like the following i.e. who knows exactly how thyroid hormones work in the body.
Dear Thyroid Patients: If you have thyroid gland failure--primary hypothyroidism--your doctor is giving you a dose of
levothyroxine that normalizes your thyroid stimulating hormone (TSH) level. Abundant research shows that this practice usually does not restore euthyroidism--sufficient T3 effect in all tissues of the body. It fails particularly badly in persons who have had their thyroid gland removed. Unfortunately, the medical profession has clung to the misleading TSH test since the some physicians decided to do so in the 1970s. Doctors are taught that hypothyroidism is a high TSH--when it is, in fact, the state of inadequate T3-effect in some or all tissues. They are taught wrong. TSH not a thyroid hormone and is not an appropriate guide for either the diagnosis or treatment of hypothyroidism. The hypothalamic-pituitary secretion of TSH did not evolve to tell physicians what dose of inactive levothyroxine a person should swallow every day. A low or suppressed TSH on replacement therapy is not the same thing as a low TSH in primary hyperthyroidism. IF you continue to suffer from the symptoms of hypothyroidism, you have the right to demand that your physician give you more effective T4/T3 (inactive/active) thyroid replacement therapy. Your physician can either add sufficient T3 (10 to 20mcgs) to your T4 dose, or lower your T4 dose while adding the T3. The most convenient form of T4/T3 therapy, with a 4:1 ratio, is natural desiccated thyroid (NDT-- Armour, NP Thyroid, Nature-Throid). If you have persistent symptoms, ask your physician change you to NDT and adjust the dose to keep the TSH at the bottom of its range. The physician cannot object. This may be sufficient treatment, but IF you continue to have persisting hypothyroid symptoms, and no hyperthyroid symptoms, ask your physician to increase the dose to see if your symptoms will improve, even if the TSH becomes low or suppressed. You can prove to your physician that you're not hyperthyroid by the facts that you have no symptoms of hyperthyroidism and your free T4 and free T3 levels are normal in the morning, prior to your daily dose. They may even be below the middle of their ranges. Your free T3 will be high for several hours after your morning T4/T3 dose, but this is normal with this therapy and produces no problems.
You should insist that testing be done prior to your daily dose, as recommended by professional guidelines. If you have
central hypothyroidism, the TSH will necessarily be low or completely suppressed on T4/T3 therapy. In all cases, your
physician must treat you according to your signs and symptoms first, and the free T4 and free T3 levels second.
We shouldn't be 'advising' the professionals that they are wrong but if we want to be well, we have to.
thankyou so much. That does help. I feel really well but the doc does not like my low TSH. A few years ago my TSH was non detectable for six years and I felt well then but they doc realised and dramatically reduced me from 250mcg to 100mcg. It’s been an uphill struggle since then but now I feel well on the 125mcg and they want to reduce me to 100mcg.
I wish I had known about this site a lot of years ago It is amazing.
When having your blood test do you allow a gap of 24 hours between your last dose and the test and take it afterwards? Do you also follow this method?
Always make the very earliest appointment (even if you have to make it weeks ahead). It is a fasting test and don't take levo before it but after. If you take a night dose, miss it and take after test and night dose as usual.This helps give us the highest TSH as they rarely test others.
If not the results will be skewed.
Low TSH
Low TSH
Low TSH & Low T4
Low TSH
Low TSH 
