We've been looking at studies linking increased chance of mortality with slighltly elevated TSH. We've done a meta-analysis of 13 studies and find:
1) It is more likely that elevated TSH is the result of changed set point of thyroid hormones arising from subtle alterations in their interaction, caused by age, medication, mental health etc. It is not that TSH elevation is prompting and is responsible for unwanted changes in health, but that changes in health (non thyroidal) are controlling the TSH and resetting it to mirror the situation.
2) Subclinical hypothyroidism can therefore both point to either the start of hypothyroidism or to what we call allostatic load (eg depression, post traumatic stress disorder, obesity) which strongly relates to changed TSH.
3) Because of these features, it is likely that the skewed TSH reference range normaly found, with a large tail of values from about 2.5-4.5 is because apparently healthy subjects may have underlying TSH changes upwards because of such nonthyroidal influences.
4) This further complicates TSH's role in diagnosis.
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diogenes
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I must admit I hope your findings don't become yet another stick for doctors to beat sufferers with. If Subclinical Hypothyroidism is declared to be a problem caused by depression or some other mental health condition then people will end up being denied thyroid hormones for even longer than they already are.
My TSH is usually between 5 and 6 if/when I ever stop taking thyroid hormones.
Some years ago my Free T4 was 8% of the way through the range with a TSH of 5.7.
Another time my TSH was 5.49, my Free T4 was 14% of the way through the range and my Free T3 was 11% of the way though the range.
There are very, very few doctors who would treat me with these numbers even though I felt as if I was developing dementia and could barely make it upstairs.
I agree with you and it is due to the guidelines in UK stating we've not to be diagnosed until our TSH reaches 10. This is ridiculous and doesn't even refer to symptoms the person is suffering.
The problem is that we can't get away from the fact that mildly raised TSH has many sources, not all thyroidal. If doctors use their noddles to examine and listen to the patient first before coming to conclusions. outcomes would be much better. But we simply can't any longer get into the situation of clear indications from borderline results. That's the way of reality I'm afraid, and what the professionals make of it I haven't any control over.
With the results I gave in my earlier post, given that I had many, many symptoms of hypothyroidism at the time, would you think I was suffering from non-thyroidal illness or subclinical hypothyroidism?
What happens to Free T4 and Free T3 when the patient is suffering from subclinical hypothyroidism?
And what happens to Free T4 and Free T3 when the patient has some form of non-thyroidal illness?
I'm at a loss to work out how anyone could ever know which they were suffering from when they were first found to have a slightly raised TSH. If there is no clear cut difference between the two conditions, doctors will just diagnose depression and anxiety for all sufferers and will prescribe anti-depressants.
I think I'm looking for a bone here, that I can toss at a doctor to convince them I need treatment for my thyroid problems. (I currently self-medicate.)
You would know from your FT4/FT3 ratio what was happening. A high ratio indicates nonthyroidal illness if FT4 normal. A low ratio is more indicative of possible hypothyroidism. It's a great shame doctors don't test for FT3 and FT4 to get this information. It isn't foolproof but is suggestive.
I’m assuming if you have the FT3 / FT4 base results, somewhere on the internet will be the maths to work out the ratio (a bit like 250g sugar, 500g butter is a ratio of 1:2). Ive gotten my Reverse T3 ratio before as part of bloods (privately) but not the FT3 / FT4.
At the bottom of this article is a way to manually calculate it, and the article talks about baseline and upper levels of the ratio and the possible reasons for what a low or high ratio means. I hope that helps!
If you have some symptoms of illness, then a ratio getting towards 4 and above, with a borderline or low FT3 indicates away from hypothyroidism, whereas a ratio below 3, with low-normal FT4 and normal FT3, + symptoms would suggest looking at hypothyroidism possibilities more. It's not foolproof, but the ratios can indicate something.
Oh! to return to the days when patients were diagnosed and treated due to the skill of the GPs. i.e. symptoms alone considered and patients given a trial of NDT. (instead of the nonsense used to remove NDT which helped many patients for years).
NHS would then save millions of £££s for blood tests and for the 'extras' that are prescribed to try to control symptoms or being diagnosed with 'another' condition.
Also checking vitamins/minerals to make sure everything is optimal.
If doctors could diagnose patients as hypo/hyper before blood tests were introduced, why cannot they do so today? The NHS would then save even more.
Dr Peatfield and Dr Gordon Skinner knew their stuff and the symptoms (and also people like yourself and your colleagues .
The trouble with today's medicine is that it wants to be thought of as a science, ranking with the others like biochemistry, chemistry etc. Now a true science involves studying events and reactions that are repeatable - that is you find out by repeating the study, the identical outcome, so that that bit of the problem is now solved. If it comes out differently, then your concept is wrong. Now medicine cannot be a science. This is because people are hugely complicated entities, each with their own particular set of events making up the action of the body AT THAT PARTICULAR INSTANT WHEN MEASUREMENT IS MADE! So not only is the measurement but a snapshot of the person's activity at that time, but at another time it may be somewhat different (still within range if euthyroid, but slightly altered). For those on therapy, then control is less and consecutive readings are at the mercy of the event (time of taking pill). Add to this external pressures of nonthyroidal illness (eg having a cold) and growing age, then you can no longer accept medicine as a science but as an art, which in the olden times it was. This belief in science exactitude has misled medicine into categorisation - that is if you are within a range developed from a large population all is well, otherwise not. No attention is paid to WHERE in the range suits one best and even if being in the range is optimal for the patient. (eg TSH).
Thank you diogenes, once again, for a clear and understandable answer.
One day my GP phoned re my blood test - they knew I bought my own T3, he said
"Mrs ? Your blood test shows that your TSH is too low - FT4 too low - and FT3 too high. I said, yes doctor that is how I want it as I feel well. I take T3 alone.
GP states "but T3 converts to T4" ! I state, I'm sorry doctor but it is the other way around, T4 converts to T3. T4 is an inactive hormone.
This statement says it all yet we, the patients suffer through very poor training. This doctor must be well into his 50's.
Also I had to diagnose myself (very, very unwell) when GP phoned in 2007 to tell me I had no problems at all (I think he tested 27 items) as I had told him previously that I would have to pay for a 'whole body scan' as there was something seriously wrong. I cried.
I, at that time, had no knowledge of hypo. Fortunately someone had told me to get a test for hypo which I did but the doctor didn't appear to notice a TSH of 99.
p.s. some months before a private consultation told me I had a 'web in throat' which would cause me to choke and it would have to be removed.
Underwent a procedure but no-one came to see me after op - which is usual. At the next appointment I was the only one in the waiting room, he popped his head round the door and didn't appear to see me. Half hour later I queried at reception. I then went into his office and he told me I didn't have a 'web' what was on the barium swallow I said. There was no answer so, much later on when finally diagnosed, I assume the 'web' was actually a swollen thyroid gland.
Thank You Diogenes for your great post once again. In a true and wonderful world it would be nice if patients would be treated via symptoms and not TSH nor lab results only.
Dr's that truly have their patients well-being for most will respect and appreciate when patients present symptoms to their Dr's. And treated accordingly.
Symptoms are cellular results . Lab results are a snap shot of the moment the labs where drawn.
Off-topic, but I have a couple of questions which I wondered if you could answer for me, if you have the time.
I think I'm right in saying that the Total T3 test measures the total of bound and unbound T3 in a blood sample, and the Total T4 test measures the total of bound and unbound T4 in a blood sample.
Cortisol measured in blood is mostly bound but with a very small amount of unbound cortisol. I don't know of a test for measuring unbound/free cortisol in blood. Cortisol measured in saliva is measuring unbound cortisol.
T4 and T3 are bound to thyroxine-binding globulin (TBG), transthyretin, and serum albumin.
Cortisol is bound to transcortin and serum albumin.
I've read that high levels of oestrogen will increase TBG and transcortin, and high levels of cortisol will lower TBG.
My questions are :
What makes bound T4 and bound T3 and bound cortisol separate from their binding proteins? Can the "unbinding process" - whatever it is called - ever go wrong? Is there a way of helping the unbinding process along so that people have more free thyroid hormones and free cortisol?
Why can some people have a very high level of cortisol in blood, and very, very low levels of cortisol in saliva? And what can those people do about it, if anything?
There are forum members who have had cortisol measured in both blood and saliva who have had symptoms very similar to those present in people with very low cortisol, and yet their blood cortisol is actually high and their saliva cortisol is very low.
Since doctors only look at cortisol in blood they dismiss patients with normal cortisol levels in blood who have very low levels in saliva. This is completely the opposite of testing thyroid hormones (in most of the world), where it is usually understood that Free T4 and Free T3 are superior tests to Total T4 and Total T3.
Cortisol, T4, T3, oestradiol, progesterone, testosterone are all examples of situations where the free unbound part is accompanied by the appropriate parts bound to proteins. This is a little bit of chemistry we need to know before going further. There are two sorts of bonds in carbon chemistry (substances with carbon in their structure). One sort of bond is eg in methane (CH4). The hydrogen atoms bind strongly AND IRREVERSIBLY to the carbon atom and can only be removed by strong chemical means. CH4 standing alone in normal conditions is exactly that - there is little interchange of H atoms between different molecules. In the case of carrier proteins like TBG or albumin, for T4 and T3, the thyroid hormones bind REVERSIBLY to the proteins These are ionic bonds. So TBG with its bound T4 standing in a liquid sample will have the vast majority of the T4 bound on the the TBG and a small quantity free. The molecules in the free part and the bound part equilibrate with each other - that is free molecules are becoming bound at the same time as some bound ones are becoming free. The ratio of the bound and free molecules doesn't alter, but the identities of the molecules in each phase does. Now when TBG and its bound T4 + a little free T4 passes by a tissue that needs T4, the free T4 is taken up by the tissue. Same for T3. This forces the TBG to release an equivalent amount of bound T4 to free T4, for the next tissue to use. This system is true for all carrier proteins. Cortisol has its own specific protein carrier. However, unlike T4 and T3 whose free fraction is only 0.02 and 0.2% of the total bound + free, with cortisol the free fraction is about 7% of the total. This makes it extremely difficult to measure the free directly, because any test you devise takes so much cortisol that it upsets the bound fraction, so you don't get a good accurate answer. I did think of a way some years ago, but it was never followed up, as free molecules other than T4 and T3 weren't considered sexy enough to spend money on. Salivary cortisol is supposed to measure the free part, because that is all that is in the salivary glands. However passage of cortisol into salivary glands is also subject to interferences. Like all other situations, you can find people with high levels of cortisol binding globulin, therefore relatively lower free cortisol, and the other way around, where there is less protein and more free cortisol. There are actually patients known who have no cortisol binding protein at all so these only weakly have bound cortisol bound to the general factotum carrier albumin, with free cortisol far more than 7% of the total. So like for T4 and T3, cortisol binding and free levels can vary considerably depending on how much binding carrier protein the patients have in the blood, but unlike T4 and T3, cortisol binding is much weaker. This makes measuring cortisol in blood as the total..
This is what worries me I am afraid. I find all this really hard as I just can't remember information after reading it. I have been self-treating with help from this group. These were my results in March 20 before starting self-treatment in April and my TSH was up and down for at least 17 years to my knowledge, the lowest being 1.9 -
Monitormyhealth.org.uk 16th March 2020
TSH5.4 mU/L[range 0.27-4.2 mU/L] 130.53% through range
FT412.9 pmolL[range 12-22 pmol/L] 9% through range
FT34 pmol/L[range 3.1-6.8 pmol/L] 24.32% through range
I am just waiting to do a further test but this week I dropped the vial in the sink full of water where I had been soaking my hands (which would have been 10 weeks since last test), so now waiting for another test to arrive !
I have been having slight pain in my heart area every day for quite a few weeks, I hope this is nothing bad. Now this post makes me think, yes I have had some stress over time, and did I need to treat myself?
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