hypothyroid following partial thyroidectomy. Question about HRT and optimum T4 levels.

[sewquilt3]

Dear forum,

I am 58. 3 months ago while having parathyroid adenoma removed, I also had partial thyroidectomy. This was because thyroid nodule was discovered during scans looking for the adenoma. The nodule was examined and contained micropapliiary carcinoma. No further treatment needed for that thankfully, as it was entirely removed. I am now hypothyroid.

I had hyperparathyroidism which caused osteoporosis, so am taking HRT oestrogen patch and utrogestan to strengthen my bones. Post op. calcium and parathyroid hormone levels are now fine ,but I have been advised to have a high calcium diet.

I am now taking levothyroxine 50mcg/day. I found something that said don't take oestrogen too close to Levo dose but as I have a patch rather than a tablet, is that different? How does oestrogen affect thyroxine? Will i need more of one or the other?

I have only been on levo for 2 months so just learning about how it affects me.

most recent blood test T4 15.4 (11-26) pre op 14.4

tsh 1.18 (0.27-4.20) pre op 0.93

t3 3.7 (3.9-6.8) pre op 3.5

What level of t4 should I be aiming at? Again I saw something about a percentage of the range but then couldn't find that page again. I have seen I need to contact the GP about B12, folate and ferritin testing.

This past year has been a roller coaster of having to educate myself about different conditions!! First the osteoporosis then hyperparathyroidism and now hypothyroidism!

Thanks

[SlowDragon Administrator]

FT4: 15.4 pmol/l (Range 11 - 26)

Ft4 only 29.33% through range

FT3: 3.7 pmol/l (Range 3.9 - 6.8)

Ft3 BELOW range at - 6.90%

Helpful calculator for working out percentage through range thyroid.dopiaza.org/

Request 25mcg dose increase in levothyroxine

Which brand of levothyroxine are you currently taking

Retest again in another 6-8 weeks

Always test thyroid levels early morning and last dose levothyroxine 24 hours before test

Meanwhile m getting vitamins tested and start improving to optimal

[sewquilt3 in reply to SlowDragon]

Thanks

so I'm aiming for over 50% levels of both T4 and T3?

First 2 months on Wockhardt 25s x 2 (small pharmacy only had 25s in stock that day) now been given accord 50s. Not had any contact with GP about this yet as still under ENT surgeon.

[SlowDragon Administrator in reply to sewquilt3]

GP likely to only look at TSH

You may need to be forceful to get 25mcg dose increase in levothyroxine

ESSENTIAL to get vitamin D, folate, ferritin and B12 levels tested

pathlabs.rlbuht.nhs.uk/tft_...

Guiding Treatment with Thyroxine: 

In the majority of patients 50-100 μg thyroxine can be used as the starting dose. Alterations in dose are achieved by using 25-50 μg increments and adequacy of the new dose can be confirmed by repeat measurement of TSH after 2-3 months. 

The majority of patients will be clinically euthyroid with a ‘normal’ TSH and having thyroxine replacement in the range 75-150 μg/day (1.6ug/Kg on average).

The recommended approach is to titrate thyroxine therapy against the TSH concentration whilst assessing clinical well-being. The target is a serum TSH within the reference range. 

……The primary target of thyroxine replacement therapy is to make the patient feel well and to achieve a serum TSH that is within the reference range. The corresponding FT4 will be within or slightly above its reference range.

The minimum period to achieve stable concentrations after a change in dose of thyroxine is two months and thyroid function tests should not normally be requested before this period has elapsed.

[sewquilt3 in reply to SlowDragon]

thanks

[pennyannie]

Hello Sewquilt and welcome to the forum;

A fully functioning working thyroid would be supporting you on a daily basis with trace elements of T1. T2 and calcitonin plus a measure of T3 at around 10 mcg plus a measure of T4 at around 100 mcg.

T4 is a prohormone and needs to be converted by your body into T3 the active hormone that runs the body and said to be around 4 times more powerful than T4 with the average person needing to convert and utilise around 50 T3 daily - just to function.

Your own ability to convert the T4 - Levothyroxine into T3 can be compromised by non optimal levels of ferritin, folate, B12 and vitamin D, inflammation, any physiological stress - ( emotional or physical ) depression , dieting and ageing - so whilst we can't turn back the clock, yet, we need to keep on top of that we do have some control over.

When hypothyroid we generally feel at our best when our T4 is up in the top quadrant of the range at around 80% as this should, in theory convert to good level of T3 at least over 50% through the range.

I've not seen these ranges before and your levels pre op were a low T4 and an under range T3 so possibly not good results to suggest as bench mark readings to try and work back to.

Symptoms of hypothyroidism can be insidious and diverse as the thyroid is the body's engine and responsible for full body synchroisation including your physical, mental, emotional, psychological and spiritual well being, your inner central heating system and your metabolism.

If you dip into Thyroid UK thyroiduk.org you can start your next learning curve on all things thyroid and within the pages there is a list of both hyper and hypo symptoms experienced as you may need this to understand better what you may feel in the way of symptoms as opposed to how your doctor may interpret your blood test results.

P.S. Sorry no knowledge nor experience of HRT.

[sewquilt3 in reply to pennyannie]

thanks, you're right before the operation the levels weren't that high.

[jrbarnes]

Hi there, I had a partial when I was 27(now 42) for a hurthle cell adenoma on my thyroid and two years later was placed on a full replacement dose of 88mcg Levothyroxine. 6 months ago I put on weight(now 59kg) and have gone up to 112mcg and now take 10mcg Liothyronine in addition. The dosage guidelines is 1.6 mcg per KG of body weight but the absorption percentage of Levothyroxine in pill for is only 80% so you're not actually getting 50mcg. I feel most functional when my FT4 and FT3 levels are closer to the top range.

[sewquilt3 in reply to jrbarnes]

thanks, weight gain has been one of the most frustrating things. At 1.6 mcg per kilo , I definitely need a higher dose!! I hope the GP is sympathetic to adjusting it.

[jrbarnes]

I would remind your GP that on the dosing guidelines which can be found on the prescription itself states 1.6 mcg per kg of body weight but also remind them that it also states that the bioavailabilty of Levothyroxine in pill form is only 80% so what he is prescribing to you is actually much lower than than what it is. 1.6 mcg is only a guideline so some may need more or less. I'm at 59 kg and if I were to need 1.6 mcg per kg of body weight that would be 94mcg of Levothyroxine but I take 112mcg per day because the absorption is only 80%. I've tried Levothyroxine in liquid and capsule form and that stuff is near 100% absorbed. I had to take a lower amount in liquid/capsule. I don't know how manufacturers get away with saying their pills have X amount of thyroid hormone in it when the bioavailabilty is only 80%. Not sure how it is in the UK but here in the US they're only required to have 95%-105% of the active ingredient so add that onto the fact that they're not 100% absorbed. It's my belief this leads to a lot of patients being under dosed. It's a fact that your GP cannot ignore because it is explicitly stated in the pamphlet information for the Levothyroxine.

I gained weight 6 months ago because my hypo causes a severely low appetite and I was under eating (specifically low carbs and fasting) and had to increase calories. It made my TSH elevated and lower amounts of T3.