Subclinical hypothyroidism

[Emt81]

Hi I recently attended the doctors for blood tests regarding irregular periods, I am 42 I maybe thought it could be the start of perimenopause. After discussing the results with my doctor she has diagnosed subclinical hypothyroidism and reffered me for another blood test in 3 months. Is there anything I can do to help the situation or could the tsh level decrease on its own. I have attached my blood results. Thanks in advance for any advice xx

[greygoose]

Hi Emt81, welcome to the forum.

Contrary to what doctors think. It's not the TSH level that makes you hypo. It's low thyroid hormone - T4 and T3. The TSH is a pituitary hormone that tells the thyroid when to make more hormone. Your thyroid is obviously incapable of increasing its output because our TSH is high, but your FT4 is low.

The TSH might well be lower next time - although probably not by much - because all sorts of things can affect it. Which is why it's pointless just testing TSH, as some doctors do, because the results can be deceptive.

For example, TSH fluctuates throughout the day. It is highest before 9 am, then drops slowly to its lowest point around midday. Then, slowly rises again to its highest point around midnight. So, what time of day did you have the blood draw for this test?

Also, drinking caffeine before the blood draw can lower the TSH. Did you drink coffee or tea that morning? So, lowering the TSH won't make you any less hypo.

Your nutrient levels are much too low. Did your doctor say anything about those? As the ferritin is below range, she should be doing an iron panel. You must feel ver tired with that low ferritin! Was vit D tested?

[Emt81 in reply to greygoose]

Hi thanks for the quick response, does this mean that because my t4 level is within range I do not have subclinical hypothyroidism, sorry I dont quite understand it all at the moment.I had the test done at 8.30 in the morning and didnt consume tea or coffee beforehand. My doctor briefly mentioned it being low but said it wasn't concerning as my other results were fine I have attached these. Yes I am very tired most of the time often having to have a nap around 12pm and 5pm. I work nights 50hrs a week and just put it down to this.

Blood test results

[humanbean in reply to Emt81]

does this mean that because my t4 level is within range I do not have subclinical hypothyroidism

No.

Subclinical hypothyroidism = Above range TSH AND Free T4 still in range.

Overt hypothyroidism = Above range TSH AND Free T4 under range.

Some doctors will insist that TSH must be 10+ for a diagnosis of overt hypothyroidism although I can't remember whether that is a requirement according to the guidelines.

Some useful links :

CKS = Clinical Knowledge Summaries

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

The NICE guidance :

nice.org.uk/guidance/ng145

[greygoose in reply to Emt81]

does this mean that because my t4 level is within range I do not have subclinical hypothyroidism,

No, it doesn't mean that. I'll try and explain...

The thyroid mainly makes two hormones: T4 and T3.

The pituitary makes lots of hormones, but the most important one where the thyroid is concerned is TSH - Thyroid Stimulating Hormone.

When the pituitary senses that there is not enough thyroid hormone in the blood, it increases its output of TSH to tell the thyroid to make more hormone.

Usually, a little nudge is all that is needed to get the thyroid increasing its output, so a 'normal' (euthyroid) TSH is around 1, but never over 2.

When the thyroid is failing for some reason, it takes more and more TSH to get it to make enough hormone. So, hypothyroidism is defined by high TSH and low thyroid hormones.

Your TSH is high, but your FT4 is not even euthyroid (normal), it is too low because the thyroid cannot fully respond to the stimulation.

So, your FT4 is in range only because the TSH is so high.

And if your FT4 is low, your FT3 is also probably going to be low (although not always) and it's low T3 that causes symptoms.

So, you really do have 'subclinical' hypothyroidism - although with a TSH that high, I object to the label 'subclinical'! But that's just me.

[Emt81 in reply to greygoose]

Thank you so much for this explanation this is the best explanation I think I've read/understand!!

[greygoose in reply to Emt81]

I'm glad it's helpful. It does all seem very complicated when you first start, but you'll soon get used to it.

[jimh111]

fT4 15.6 is within its reference interval and TSH is elevated. This is defined as subclinical hypothyroidism. This is an arbitrary definition that doesn't really tell you if there are clinical signs and symptoms. If your only signs are irregular periods it's unlikely you have a thyroid problem.Your elevated TSH could be a sign of early stages of thyroid failure or a temporary elevation, hence the second test in three months.

Do you have other signs and symptoms?

[Emt81 in reply to jimh111]

I do have other symptoms, weight gain, tiredness, brain fog/forgetfullness, hate the cold however sometimes feel so hot when others are cold and not a symptom I can find that is linked to hypothyroidism but everyday I suffer from an extremely itchy scalp which brings my scalp out in hives.Thanks for responding x

[jimh111 in reply to Emt81]

These are signs and symptoms of hypothyroidism. Although not documented in text books feeling hot is also a symptom of hypothyroidism, it happens in about 10% of cases. If you can afford it you can get TSH, fT3, fT4 tested at a reasonable price thyroiduk.org/testing/priva... but try to avoid the Christmas post. It woud be useful to test for TPO anitibodies also but this is more expensive, maybe your GP could request it for you.

Your TSH and fT4 are inconsistent, so something strange is happening. What supplements / medicines are you taking?

[Emt81 in reply to jimh111]

Hi thanks for the reply, I plan on private testing after the Christmas period. I don't currently take any supplements/vitamins. I'm not a big meat eater but eat plenty of veg. I suffer from cervical spondylosis so only medication I take is pain medication when necessary.

[jimh111 in reply to Emt81]

A private test will be well worth it thyroiduk.org/testing/priva... . If cost is not a problem choose one which does TPO and TBG antbodies also. There is no benefit in measuring antibodies more than once.

[SlowDragon Administrator]

Repeat blood test should be 6 weeks after first abnormal test

Next test

Request GP include testing thyroid antibodies to check if cause of your hypothyroidism is autoimmune

Book early morning, ideally just before 9am, only drink water between waking and test

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

Starting levothyroxine - flow chart

Technically GP is correct you need 2 tests with TSH over 5

gps.northcentrallondonccg.n...

suggest you get vitamin D tested asap via GP or here

NHS easy postal kit vitamin D test £31 via

vitamindtest.org.uk

Meanwhile you need to start improving low B12 and folate levels

GP should be treating your anaemia

[Emt81 in reply to SlowDragon]

Thanks for the reply, I plan on ordering a private test after the Christmas period. I wasn't told I had anemia by the doctors, although some levels were low my other bloods came back fine so said there was no further action needed. 😊

[SlowDragon Administrator]

About 90% of primary hypothyroidism is autoimmune thyroid disease, usually diagnosed by high thyroid antibodies

Autoimmune thyroid disease with goitre is Hashimoto’s

Autoimmune thyroid disease without goitre is Ord’s thyroiditis.

Both are autoimmune and generally called Hashimoto’s.

Low vitamin levels are extremely common when hypothyroid, especially with autoimmune thyroid disease

20% of autoimmune thyroid patients never have high thyroid antibodies and ultrasound scan of thyroid can get diagnosis

In U.K. medics hardly ever refer to autoimmune thyroid disease as Hashimoto’s (or Ord’s thyroiditis)

Low B12 and folate

Low B12 symptoms

b12deficiency.info/signs-an...

methyl-life.com/blogs/defic...

With serum B12 result below 500, (Or active B12 below 70) recommended to be taking a separate B12 supplement and a week or so later add a separate vitamin B Complex 

Then once your serum B12 is over 500 (or Active B12 level has reached 70), you may be able to reduce then stop the B12 and just carry on with the B Complex.

If Vegetarian or vegan likely to need ongoing separate B12 few times a week

Highly effective B12 drops

natureprovides.com/products...

Or

B12 sublingual lozenges

uk.iherb.com/pr/jarrow-form...

cytoplan.co.uk/shop-by-prod...

B12 range in U.K. is too wide

Interesting that in this research B12 below 400 is considered inadequate

healthunlocked.com/thyroidu...

Low folate

supplementing a good quality daily vitamin B complex, one with folate in (not folic acid)

This can help keep all B vitamins in balance and will help improve B12 levels too

Difference between folate and folic acid

healthline.com/nutrition/fo...

Many Hashimoto’s patients have MTHFR gene variation and can have trouble processing folic acid.

thyroidpharmacist.com/artic...

B vitamins best taken after breakfast

Thorne Basic B recommended vitamin B complex that contains folate, but they are large capsules. (You can tip powder out if can’t swallow capsule)

Thorne currently difficult to find at reasonable price, should be around £20-£25. iherb.com often have in stock. Or try ebay

Igennus B complex popular option too. Nice small tablets. Most people only find they need one per day. But a few people find it’s not high enough dose

Post discussing different B complex

healthunlocked.com/thyroidu...

IMPORTANT......If you are taking vitamin B complex, or any supplements containing biotin, remember to stop these 7 days before ALL BLOOD TESTS , as biotin can falsely affect test results

endo.confex.com/endo/2016en...

endocrinenews.endocrine.org...

In week before blood test, when you stop vitamin B complex, you might want to consider taking a separate folate supplement (eg Jarrow methyl folate 400mcg) and continue separate B12 until over 500

Post discussing how biotin can affect test results

healthunlocked.com/thyroidu...

helvella.blogspot.com/p/hel...

[SlowDragon Administrator]

only add one vitamin supplement at a time then wait 10-14 days to assess before adding another

Are you currently taking a vitamin D supplement

NHS Guidelines on dose vitamin D required

ouh.nhs.uk/osteoporosis/use...

GP will often only prescribe to bring vitamin D levels to 50nmol.

Some areas will prescribe to bring levels to 75nmol or even 80nmol

leedsformulary.nhs.uk/docs/...

GP should advise on self supplementing if over 50nmol, but under 75nmol (but they rarely do)

mm.wirral.nhs.uk/document_u...

But with Hashimoto’s, improving to around 80nmol or 100nmol by self supplementing may be better

pubmed.ncbi.nlm.nih.gov/218...

vitamindsociety.org/pdf/Vit...

Once you Improve level, very likely you will need on going maintenance dose to keep it there.

Test twice yearly via NHS private testing service when supplementing

vitamindtest.org.uk

Vitamin D mouth spray by Better You is very effective as it avoids poor gut function.

There’s a version made that also contains vitamin K2 Mk7.

One spray = 1000iu

amazon.co.uk/BetterYou-Dlux...

It’s trial and error what dose we need, with thyroid issues we frequently need higher dose than average

Vitamin D and thyroid disease

grassrootshealth.net/blog/t...

Vitamin D may prevent Autoimmune disease

newscientist.com/article/23...

Web links about taking important cofactors - magnesium and Vit K2-MK7

Magnesium best taken in the afternoon or evening, but must be four hours away from levothyroxine

betterbones.com/bone-nutrit...

medicalnewstoday.com/articl...

livescience.com/61866-magne...

sciencedaily.com/releases/2...

Interesting article by Dr Malcolm Kendrick on magnesium

drmalcolmkendrick.org/categ...

Vitamin K2 mk7

betterbones.com/bone-nutrit...

healthline.com/nutrition/vi...

[Emt81 in reply to SlowDragon]

I am currently taking no vitamins, only pain medication when necessary. Thank you so much for all the information it is really appreciated. Have got more from this sure in less than 24hrs than I ever have from my doctor.

[SlowDragon Administrator]

Scalp psoriasis or hives

Suggests your hypothyroidism is autoimmune

GP should be doing coeliac blood test too at next test

nice.org.uk/guidance/ng20/c...

1.1 Recognition of coeliac disease

1.1.1 Offer serological testing for coeliac disease to:

people with any of the following:

persistent unexplained abdominal or gastrointestinal symptoms

faltering growth

prolonged fatigue

unexpected weight loss

severe or persistent mouth ulcers

unexplained iron, vitamin B12 or folate deficiency

type 1 diabetes, at diagnosis

autoimmune thyroid disease, at diagnosis

irritable bowel syndrome (in adults)

first‑degree relatives of people with coeliac disease.

[SlowDragon Administrator]

Any obvious reason for low ferritin

Are you vegetarian or vegan?

Low ferritin very common result of being hypothyroid

cks.nice.org.uk/topics/anae...

Serum ferritin level is the biochemical test, which most reliably correlates with relative total body iron stores. In all people, a serum ferritin level of less than 30 micrograms/L confirms the diagnosis of iron deficiency.

Never supplement iron without doing full iron panel test for anaemia first and retest 3-4 times a year if self supplementing. It’s possible to have low ferritin but high iron

Test early morning, only water to drink between waking and test. Avoid high iron rich dinner night before test

Medichecks iron panel test

medichecks.com/products/iro...

Look at increasing iron rich foods in diet

Eating iron rich foods like liver or liver pate once a week plus other red meat, pumpkin seeds and dark chocolate, plus daily orange juice or other vitamin C rich drink can help improve iron absorption

List of iron rich foods

dailyiron.net

Links about iron and ferritin

irondisorders.org/too-littl...

davidg170.sg-host.com/wp-co...

Great in-depth article on low ferritin

oatext.com/iron-deficiency-...

drhedberg.com/ferritin-hypo...

This is interesting because I have noticed that many patients with Hashimoto’s disease and hypothyroidism, start to feel worse when their ferritin drops below 80 and usually there is hair loss when it drops below 50.

healthunlocked.com/thyroidu...

Thyroid disease is as much about optimising vitamins as thyroid hormones

healthunlocked.com/thyroidu...

restartmed.com/hypothyroidi...

Post discussing just how long it can take to raise low ferritin

healthunlocked.com/thyroidu...

Iron and thyroid link

healthunlocked.com/thyroidu...

Posts discussing why important to do full iron panel test

healthunlocked.com/thyroidu...

Good iron but low ferritin

healthunlocked.com/thyroidu...

healthunlocked.com/thyroidu...

Chicken livers if iron is good, but ferritin low

healthunlocked.com/thyroidu...

Shellfish and Mussels are excellent source of iron

healthline.com/nutrition/he...

Iron deficiency without anaemia

healthunlocked.com/thyroidu...

Ferritin over 100 to alleviate symptoms

healthunlocked.com/thyroidu...

healthunlocked.com/thyroidu...

Great research article discussing similar…..ferritin over 100 often necessary

ncbi.nlm.nih.gov/pmc/articl...

Low Iron implicated in hypothyroidism

healthunlocked.com/thyroidu...

Ferritin range on Medichecks

healthunlocked.com/thyroidu...

Inflammation affecting ferritin

healthunlocked.com/thyroidu...

healthunlocked.com/thyroidu...

We have received further information the lab about ferritin reference ranges. They confirm that they are sex dependent up to the age of 60, then beyond the age of 60 the reference range is the same for both sexes: 

Males 16-60: 30-400 ug/L

Female's: 16-60: 30-150

Both >60: 30-650 

The lower limit of 30 ug/L is in accordance with the updated NICE guidance and the upper limits are in accordance with guidance from the Association of Clinical Biochemists. ‘

[Emt81]

After reading all the information on this site I think the only way forward is A private blood test Inc. Antibodies this I think will put me in a better position. Thank you again you are all very kind to take time out of your day x

[Emt81 in reply to Emt81]

And no I'm not vegetarian, however I'm not a big meat eater. Do ear plenty of veg though

[SlowDragon Administrator in reply to Emt81]

So look at increasing red meat, liver pate, etc to try to improve low ferritin