Latest thyroid results

[Jay23]

Haven't had my thyroid tested for over 2 years and had blood test this week. GP called today with results saying they were normal. TSH is 2.38 and T4 is 11.1, I'm on 100mcg levothyroxine. I tried to say this was a bit low but she insisted it is normal. Any thoughts?

[greygoose]

As so very, very often happens - too often! - the patient is right and the doctor is wrong. A TSH of over 2 in no way 'normal', and is too high for someone on thyroid hormone replacement. We'd need to see the range for the FT4 too tell how low it is, but it looks very low. You need an increase in dose.

[Jay23 in reply to greygoose]

Thanks greygoose , I thought I was right and tried to argue. Will try again today when GP calls back about something else.

[greygoose in reply to Jay23]

It's quite possible that you won't ever get anywhere with this doctor. They just don't have the education in thyroid to understand what it's all about. But, tell him/her to check the NICE guidelines.

Tests for follow-up and monitoring of primary hypothyroidism

1.4.1Aim to maintain TSH levels within the reference range when treating primary hypothyroidism with levothyroxine. If symptoms persist, consider adjusting the dose of levothyroxine further to achieve optimal wellbeing, but avoid using doses that cause TSH suppression or thyrotoxicosis.

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

[Annoynomice in reply to greygoose]

greygoose . If its in reference range doesn't that mean the range that they give when you have a blood test e.g 0.20 - 4.20? In this case, then 2 would be in range. Nb, I'm not disagreeing, I just want to use these NICE guidelines with my doctor and don't understand what they are saying.

[greygoose in reply to Annoynomice]

Yes, it is in-range, but you have to understand what ranges are - what they mean and what they don't mean - first. So, have a look at this article:

The normal range: it is not normal and it is not a range

pmj.bmj.com/content/94/1117...

And, another thing that you should know is that a euthyroid - i.e. in someone who has no thyroid problems - TSH is around 1, never over 2, and you are technically hypo when the TSH reaches 3.

So, what all that adds up to is that whilst your TSH is undoubtedly within the range, that does not necessarily mean that you are fit and healthy and all is well with your thyroid. So, doctors should not just be looking at the TSH test and telling you 'it's in-range so everything is OK', because it obviously isn't. And, their job is to make everything ok - in as far as they possibly can - and not just be dismissing you're lack of good health because of a dubious blood test.

[Annoynomice in reply to greygoose]

Thank you. It appears that the top of the reference range is being used as a decision point (as per 2nd link), I.e if over range, then increase dose but if within range don't. Whereas with thyroid problems, the range is just that, a range of results from that lab.

On Nice, from what I can see if you are out of range, then the guidance is easy to follow. If you are within reference range, then the NICE guidance is a bit vague as it says consider medicating more but be careful of Ill effects from over medication but also test T4.

So, there isn't magic number to quote from the NICE guidelines but describing how you feel, the guidelines can be used to show that there is no reason if you still feel ill, are in reference range, that an increase in dose can be trialled.

I don't know how you get all if this knowledge Grey Goose, but thank you.

[tattybogle in reply to Annoynomice]

You're correct, the NICE guidelines themselves do not specifically say to "get TSH in lower end of range"

There are other references in articles written for GP's that do suggest this lower end (below 2/2,5 ish ), which are much more use if wanting to get GP to increase a Levo dose when TSH is 'in range'

particularly this one :

gp-update.co.uk/files/docs/...

"The goal of treatment is to make the patient feel better and this tends to correspond with a TSH in the lower half of the reference range (0.4–2.5 mU/l).

If a patient feels perfectly well with TSH between 2.5 and 5 mU/l there is no need to adjust the dosage" .

and this one:

gponline.com/endocrinology-...

"Replacement therapy with levothyroxine should be initiated in all patients to achieve a TSH level of 0.5-2.0pmol/L." (Written for GP's by) "Dr Iqbal is a specialist registrar in endocrinology and Dr Krishnan is a specialist registrar in cardiology, Liverpool".

See my reply to this post (4th reply down) for some others : healthunlocked.com/thyroidu...

[Annoynomice in reply to tattybogle]

Thank you so much. This is really useful.😊

[Buddy195 Administrator]

Ask your GP for a print out of your results and post these (with the ranges in brackets). As different laboratories use different ranges, we do need these to offer better advice.

As greygoose advised, those on thyroid medication do need TSH under 2 (many need if significantly under 1). How long have you been raking 100mcg of Levo?

[Jay23 in reply to Buddy195]

Been on 100mcg since 2016 and persuaded them to increase to 125mcg in 2017. Think it was 2019 that it was decreased to 100mcg as TSH was suppressed (TSH < 0.02, T4 19). Rechecked 3 months after that and TSH was 0.03 and T4 18. This is the first I have had checked since then. GP did agree to check bloods, haemoglobin, iron etc so have to make appointment for that. GP is calling back today on something else so will try again.

[EMBoy]

My GP says that they always aim to have TSH levels just above the lower limit of normal, so 0.03 would be just about right. A level of 2 may suggest you need a higher dose of Levo.

[tattybogle in reply to EMBoy]

TSH 0.03 is quite a lot below the lower limit of most reference ranges '(normal')

Most TSh ranges go from about 0.4 ish to 4 ish.

So most GP's will consider 0.03 to be 'too low' .. however there is evidence proving that TSH of 0.04 and above when on levo, has no greater risk for heart/ bone problems than TSH 'in range' does ... but this same evidence showed some risks do increase quite sharply when TSH goes below 0.04 on Levo.

academic.oup.com/jcem/artic... (Research evidence )

healthunlocked.com/thyroidu... (post with several links discussing low TSH/risk versus quality of life )