Thyroid function test results

[Bibbleb]

So I’ve recently had my levels checked. The results on patient access say serum tsh 3.56mu/L. The range for my serum tsh is 0.35-5.5. My serum free t4 level is 16.3 pmol/L - abnormal. The ranges for serum free t4 is 7.86- 14.41. When I queried it the receptionist (not clinically trained) said doctor wanted to leave me on current medication (75mg levothyroxine.) I’ve had the condition four years now (developed during pregnancy of my last child.) Don’t feel great, just whacked, lacking motivation and head cloudy... I also asked for my iron to be checked. I was told that there were no indicators in this blood test that I needed iron levels checking. Any advice / opinions are invited please. Thanks for reading.

[SlowDragon Administrator]

Welcome to the forum

Just testing TSH and Ft4 is completely inadequate....but often all that thousands of U.K. patients get

Was this test done as early as possible in morning before eating or drinking anything other than water and last dose levothyroxine 24 hours before test

Do you always get same brand of levothyroxine

Which brand?

For full Thyroid evaluation you need TSH, FT4 and FT3 plus both TPO and TG thyroid antibodies tested. Also EXTREMELY important to test vitamin D, folate, ferritin and B12

Low vitamin levels are extremely common, especially if you have autoimmune thyroid disease (Hashimoto's) diagnosed by raised Thyroid antibodies

Ask GP to test vitamin levels

Recommended on here that all thyroid blood tests should ideally be done as early as possible in morning and before eating or drinking anything other than water .

Last dose of Levothyroxine 24 hours prior to blood test. (taking delayed dose immediately after blood draw).

This gives highest TSH, lowest FT4 and most consistent results. (Patient to patient tip)

Is this how you do your tests?

Private tests are available as NHS currently rarely tests Ft3 or thyroid antibodies or all relevant vitamins

List of private testing options

thyroiduk.org/getting-a-dia...

Medichecks Thyroid plus antibodies and vitamins

medichecks.com/products/adv...

Thriva Thyroid plus antibodies and vitamins By DIY fingerpick test

thriva.co/tests/thyroid-test

Thriva also offer just vitamin testing

Blue Horizon Thyroid Premium Gold includes antibodies, cortisol and vitamins by DIY fingerprick test

bluehorizonbloodtests.co.uk...

If you can get GP to test vitamins and antibodies then cheapest option for just TSH, FT4 and FT3

£29 (via NHS private service ) and 10% off down to £26.10 if go on thyroid uk for code

thyroiduk.org/getting-a-dia...

monitormyhealth.org.uk/

Also vitamin D available as separate test via MMH

Or alternative Vitamin D NHS postal kit

vitamindtest.org.uk

On levothyroxine we should have TSH under 2

Many people when adequately treated on levothyroxine will have TSH well under one. Most important results are always FT3 followed by Ft4

All four vitamins need to be optimal

[Bibbleb in reply to SlowDragon]

Thank you for the reply. The brand is Teva. I think I’ve always been on this brand, yes. I’ve not felt myself since pregnancy and first diagnosis.

I had a full blood test. Results are as follows -

Total white cell count

Result 8.0 10*9/L

Normal range 4.0 - 11.0

Platelet count Result 278 10*9/L

Normal range 120 - 400

Haemoglobin estimation

Result 133 g/L

Normal range 115 - 160

Red blood cell (RBC) count Result

4.42 10*12/L

Normal range 3.5 - 5.5

Haematocrit Result 0.39

Normal range 0.34 - 0.46

Mean corpuscular volume (MCV)

Result 89 fL

Normal range 82.0 - 100.0

Mean corpusc. haemoglobin(MCH)

Result. 30.1 g/dL

Normal range. 26.0 - 32.6

Mean corpusc. Hb. conc. (MCHC)

Result 338 g/L

Normal range 320 - 360

Neutrophil count Result

5.70 10*9/L

Normal range 2.0 - 6.0

Lymphocyte count Result

1.6 10*9/L

Normal range 1.0 - 3.5

Monocyte count Result

0.5 10*9/L

Normal range 0.18 - 0.86

Eosinophil count Result

0.2 10*9/L

Normal range 0.0 - 0.6

These results are what the receptionist said the doctor took to not indicate I required further tests.

My blood test was done in the morning about 11. I did not fast. I’d had a cup of tea snd a banana.

I do have health coverage but as this is a long standing condition I doubt it’ll be covered. I’ve just seen there was a deadline for one of the private companies offer - I’ve missed that! 🤦🏼‍♀️

[SlowDragon Administrator in reply to Bibbleb]

Had you taken your levothyroxine that morning?

Recommend you get FULL thyroid and vitamin testing done .....yes annoying Medichecks offer just closed

You need B12, folate, ferritin and vitamin D plus BOTH TPO and TG thyroid antibodies, TSH, Ft4 and Ft3

What vitamin supplements are you currently taking .....if any?

Teva brand upsets many many people

Teva is only brand that makes 75mcg tablet

Recommend you get tested ASAP

Likely to need increase in dose to 100mcg unless very petite

guidelines on dose levothyroxine by weight

Even if we don’t start on full replacement dose, most people need to increase levothyroxine dose slowly upwards in 25mcg steps (retesting 6-8 weeks after each increase) until on, or near full replacement dose

NICE guidelines on full replacement dose

nice.org.uk/guidance/ng145/...

1.3.6

Consider starting levothyroxine at a dosage of 1.6 micrograms per kilogram of body weight per day (rounded to the nearest 25 micrograms) for adults under 65 with primary hypothyroidism and no history of cardiovascular disease.

Also here

cks.nice.org.uk/topics/hypo...

gp-update.co.uk/Latest-Upda...

Traditionally we have tended to start patients on a low dose of levothyroxine and titrate it up over a period of months.

RCT evidence suggests that for the majority of patients this is not necessary and may waste resources.

For patients aged >60y or with ischaemic heart disease, start levothyroxine at 25–50μg daily and titrate up every 3 to 6 weeks as tolerated.

For ALL other patients start at full replacement dose. For most this will equate to 1.6 μg/kg/day (approximately 100μg for a 60kg woman and 125μg for a 75kg man).

If you are starting treatment for subclinical hypothyroidism, this article advises starting at a dose close to the full treatment dose on the basis that it is difficult to assess symptom response unless a therapeutic dose has been trialled.

A small Dutch double-blind cross-over study (ArchIntMed 2010;170:1996) demonstrated that night time rather than morning dosing improved TSH suppression and free T4 measurements, but made no difference to subjective wellbeing. It is reasonable to take levothyroxine at night rather than in the morning, especially for individuals who do not eat late at night.

BMJ also clear on dose required

bmj.com/content/368/bmj.m41

bestpractice.bmj.com/topics...

[SeasideSusie Remembering]

Bibbleb

It's unusual to have an FT4 level over range with TSH quite high in range.

The aim of a treated hypo patient on Levo only, generally, is for TSH to be 1 or lower with FT4 and FT3 in the upper part of their ranges if that is where you feel well.

When did you take your last dose of Levo before this test? Last dose should be 24 hours before the blood draw.

Do you take a biotin supplement or B Complex? If so did you leave it off for 7 days before the test?

[Bibbleb in reply to SeasideSusie]

Thanks for the reply. I took my levothyroxine that morning around 7.30. Blood test was around 10.30-11. Please see my reply to slow dragon. I take no additional vitamins. I’m completely in the dark as to the fact I should be! All I’ve ever been told is to take this medication.

[SeasideSusie Remembering in reply to Bibbleb]

Bibbleb

I took my levothyroxine that morning around 7.30. Blood test was around 10.30-11.

So you have a false high FT4 result. Levo peaks in the blood 2-4 hours after ingestion so by taking your Levo 3-4 hours before your test then it's measuring your T4 at it's peak which is not a reflection of your normal circulating hormone. If you had left 24 hours between last dose and blood draw then your FT4 would have been lower, I would say definitely in range but I can't say how much lower.

I’d had a cup of tea snd a banana.

The banana may not have made too much of a difference but the cup of tea might have. Coffee can affect TSH so it's logical to assume that any caffeine containing drink will do, and tea contains caffeine.

It's good that your GP doesn't want to reduce your dose but it would be best if you could explain that you had taken your Levo before the test which, you understand, means that your test resulted in a false high FT4 and you'd like to repeat the test and take your Levo afterwards which the NHS actually recommends ( SlowDragon has that link I believe). This may then show a lower FT4 and with your high in range TSH you may be able to get an increase in your dose of Levo.

Dr Toft, past president of the British Thyroid Association and leading endocrinologist, states in Pulse Magazine (the professional magazine for doctors):

"The appropriate dose of levothyroxine is that which restores euthyroidism and serum TSH to the lower part of the reference range - 0.2-0.5mU/l. In this case, free thyroxine is likely to be in the upper part of its reference range or even slightly elevated – 18-22pmol/l. Most patients will feel well in that circumstance. But some need a higher dose of levothyroxine to suppress serum TSH and then the serum-free T4 concentration will be elevated at around 24-28pmol/l. This 'exogenous subclinical hyperthyroidism' is not dangerous as long as serum T3 is unequivocally normal – that is, serum total around T3 1.7nmol/l (reference range 1.0-2.2nmol/l).*"

*He recently confirmed, during a public meeting, that this applies to Free T3 as well as Total T3.

You can obtain a copy of the article by emailing Dionne at

[e-mail]

print it and highlight question 6 to show your doctor if this will help.

I’m completely in the dark as to the fact I should be!

Optimal vitamin levels are necessary for thyroid hormone to work properly (unfortunately doctors seem to be unaware of this) so it's essential to test Vit D, B12, Folate and Ferritin and address any low levels or deficiencies. You can put your results on the forum for comment and further help.

Looking at your full blood count results which you say "These results are what the receptionist said the doctor took to not indicate I required further tests", they are all nicely within range and show no problem.

[humanbean]

I also asked for my iron to be checked. I was told that there were no indicators in this blood test that I needed iron levels checking.

If all you had tested was a thyroid function test which included TSH and Free T4 then neither result will tell you about your iron level or your ferritin (iron stores) level, so the person who told you that was lying or ignorant.

The results on patient access say serum tsh 3.56mu/L. The range for my serum tsh is 0.35-5.5.

Your TSH is much too high for most hypothyroid people to have a hope of feeling well. To get full info on your thyroid you really need Free T3 to be measured as well at the same time as TSH and Free T4. And getting thyroid antibodies measured (TPO and Tg Antibodies) would also be informative.

Your Free T4 is over the range but the reference range is very low. I'm not sure what the significance of this is without a Free T3 and antibody results.

You should find this link of interest - it shows TSH levels in healthy people with no known thyroid disease :

healthunlocked.com/thyroidu...

Do you know how good or bad your nutrient levels are? (Vitamin B12, folate, vitamin D, ferritin, iron.) They can have a pronounced effect on thyroid hormone levels.

You can get TSH, Free T4, Free T3 and antibodies done along with basic vitamins with the companies mentioned on the following links - and be aware that you can get discounts off some test prices :

thyroiduk.org/

thyroiduk.org/getting-a-dia...

Medichecks is currently having their January Sale. There is less than two hours left but Medichecks has 25% off all of their tests (sale ends at midnight). You have 3 or 4 months to make use of the tests before they expire.

medichecks.com/products/adv...

The above test includes folate and is the only one that can be done with a finger-prick test to do so - but it is common for the folate test to fail for reasons I've never understood.

[Bibbleb in reply to humanbean]

Thank you for the reply. Please see my reply to slow dragon. I had a full blood test - it didn’t include vitamins though. I take no supplements.

[SlowDragon Administrator]

TSH should be under 2 as maximum

gponline.com/endocrinology-...

Replacement therapy with levothyroxine should be initiated in all patients to achieve a TSH level of 0.5-2.0pmol/L.

[Bibbleb in reply to SlowDragon]

I don’t feel well. I’ve not been well for long time.

[JAmanda]

That t4 range is unusual - are you sure it's correct? You could get a second opinion by doing blood tests yourself privately - and including T3 for the full picture.

[Bibbleb in reply to JAmanda]

It is correct as per patient access. However I had eaten a banana prior and take my meds a few hours before. So I possibly did that wrong. I wasn’t told to fast. I’m so fed up! Thank you fir taking time to reply to me.

[SlowDragon Administrator in reply to Bibbleb]

“taken my meds a few hours before”

So this gave false high Ft4

Last dose levothyroxine must be 24 hours before test

Make an appointment with GP and request 25mcg dose increase in levothyroxine up to 100mcg

Make sure to get different brand of levothyroxine at next prescription

Accord/Almus/Northstar are all Accord brand and usually easily tolerated

Or Mercury Pharma is other widely available brand

Also ask GP to test vitamin D, folate, ferritin and B12

Many people find Levothyroxine brands are not interchangeable.

Many patients do NOT get on well with Teva brand of Levothyroxine. Teva contains mannitol as a filler, which seems to be possible cause of problems. Teva is the only brand that makes 75mcg tablet. So if avoiding Teva for 75mcg dose ask for 25mcg to add to 50mcg or just extra 50mcg tablets to cut in half

Teva, Aristo and Glenmark are the only lactose free tablets

Most easily available (and often most easily tolerated) are Mercury Pharma or Accord

Note Accord is also boxed as Almus via Boots, and Northstar 50mcg and 100mcg via Lloyds ....but beware 25mcg Northstar is Teva

List of different brands available in U.K.

thyroiduk.org/medications-f...

Teva poll

healthunlocked.com/thyroidu...

Once you find a brand that suits you, best to make sure to only get that one at each prescription.

Watch out for brand change when dose is increased or at repeat prescription.

academic.oup.com/jcem/artic...

Physicians should: 1) alert patients that preparations may be switched at the pharmacy; 2) encourage patients to ask to remain on the same preparation at every pharmacy refill; and 3) make sure patients understand the need to have their TSH retested and the potential for dosing readjusted every time their LT4 preparation is switched (18).

Levothyroxine is an extremely fussy hormone and should always be taken on an empty stomach and then nothing apart from water for at least an hour after

Many people take Levothyroxine soon after waking, but it may be more convenient and perhaps more effective taken at bedtime

verywellhealth.com/best-tim...

No other medication or supplements at same as Levothyroxine, leave at least 2 hour gap.

Some like iron, calcium, magnesium, HRT, omeprazole or vitamin D should be four hours away

(Time gap doesn't apply to Vitamin D mouth spray)

If you normally take levothyroxine at bedtime/in night ...adjust timings as follows prior to blood test

If testing Monday morning, delay Saturday evening dose levothyroxine until Sunday morning. Delay Sunday evening dose levothyroxine until after blood test on Monday morning. Take Monday evening dose levothyroxine as per normal

[tattybogle in reply to JAmanda]

JAmanda, my NHS tests in NW England use that range too [7.9-14] i think it is done on an Abbott machine.. so it is proper. (however, i did ask diogenes his opinion of it , cos my fT4 nowadays is so high above it , and he said it's both too low and too narrow )

[Bibbleb in reply to tattybogle]

I am in the north west too!

[tattybogle in reply to Bibbleb]

Hi Bibbleb,

The difficulty is that your TSH (Thyroid Stimulating Hormone) indicates he need to increase dose ........but your fT4 indicates the need to leave it alone or possibly even reduce it.

Because your fT4 has shown as over range in this test , the GP will probably be unwilling to raise Levo dose at the moment, even though your TSH seems to be too high.

This is assuming GP actually notices fT4 result is over range! , if they just look at TSH they would be more willing to increase dose.

If they just pay attention to the over range fT4 result you could even find they ask you to reduce dose, but i notice they haven't lowered it ,so that's good.

As others have said , if you can persuade them to let you have a repeat test without taking that day's Levo so close before it, the fT4 will probably be lower and in range, and also if the test is earlier than 11 am the TSH might be be a bit higher , since TSH is highest in the middle of the night and falls to it's lowest at around 2pm.

The fT4 result shows the T4 from the last dose of Levo, plus what is left over from the few days before, and any of your own from your thyroid.

The TSH is more of a window back in time, and is the pituitary's response to T4 and T3 levels in the blood over the last couple of weeks or so.

So if you CAN get a retest , you want it at 8/9 am so TSH is highest, and last dose levo taken 24 hrs previous, so fT4 is lowest.

It might be tricky to get them to agree to a retest , because GP's do not think it matters what time the test is in relation to when you took the Levo, and if you told them you'd taken that day's dose before the test , they will probably say , "that's what you're supposed to do".

(Vet's know better than to do this , but sadly most GP's don't)

I think there is an NHS reference somewhere that recommends not to take the dose before the test, but i don't have it sorry , perhaps ask SlowDragon

sorry to hear you're still struggling to feel well, but pleased you've found your way here. There's more knowledge about how to get the best out of thyroid treatment here than you'll find at any Doctors.

x

Tat

Out of interest .... not important, just me being nerdy because i've been keeping an eye on peoples over range fT4 results that come up using this [7.9-14] lab range,

..... do you have access to any of your previous TSH/fT4 results , and any that were done using a previous lab range ?

mine, in Morecambe Bay area have been done using the [7.9-14] one since about 2016/17 i think, and before that they were done on a machine with an [8-18] range.