Hashimotos - understanding latest blood test re... - Thyroid UK

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Hashimotos - understanding latest blood test results - any advice for next steps?

Ehal89 profile image
6 Replies

Hi all, my partner (44F) has been struggling with hypothyroid / possible PCOS symptoms for ~18 months (thinning hair all over, some hirsutism and weight gain). She was diagnosed with Hashimotos in October 2022.

We have been trying an approach to tackle both the thyroid issues and the hyperandrogenism.

We did a set of blood tests this last fortnight and followed the recommended 24h gap before testing:

TSH 4.19 (range 0.35-5.5)

FT4 13.8 (range 11.9-21.6)

FT3 5.54 (range 3.1-6.8)

Anti-TPO 72.6

Anti-TG 276

Ferritin 63 (range 13-150)

Folate 5.2 ug/l (range 3.9-9999)

B12 420 Ng/l (range 197-1000)

Vitamin D 70 nmol/L

Lymphocytes 3.6 10*9/l (range 1.0-3.0)

October sex hormone results:

DHEAS 4.5 umol/l (range 1.65-9.15)

Oestradiol 209 pmol/l

FSH 9.2

LH 7.0

Prolactin 202 (102-496)

Testosterone 0.648 nmol/l (0.29-1.65)

SHBG 45.7 nmol/l (32-128)

Free androgen index 1.4 (0.3-5.6)

She is taking the following daily:

75mcg levo (T4)

6.25mg T3 (tiromel)

200mg spironolactone

4000iu vitamin D

210mg ferrous fumarate

100mg vitamin C and 20mg zinc

1 teaspoon of nigella sativa

50ml aloe Vera juice

1000ug of methylfolate (very recent addition)

In addition to 0.5mg dutasteride every other day.

What would be your recommended next steps for us? Does it look like she needs a dose increase of T4 given that her dosage has not been increased in the last year?

The addition of T3 may have increased her SHBG and has clearly lifted her FT3 levels (they were 4.0 last year). Should we add another quarter tablet (6.25mg) to her regimen?

Any advice/thoughts would be welcome. Thanks all!

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SlowDragon profile image
SlowDragonAdministrator

followed the recommended 24h gap before testing:

Ideally she should have split 6.25mcg of T3 ….taking half 12 hours before test…..but it would be speck of dust

Clearly she’s currently under medicated and first step is to dose levothyroxine increase to 100mcg daily

On correct dose levothyroxine she may not need any T3

But only change one thing at a time

Which brand levothyroxine is she currently taking

Rather than just methyl folate

With serum B12 result below 500, (Or active B12 below 70) recommended to be taking a separate B12 supplement and a week 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 profile image
SlowDragonAdministrator

Didn’t realise this was your first post….welcome to the forum

Anti-TPO 72.6

Anti-TG 276

No ranges on TPO and TG antibodies

They look high

She was diagnosed with Hashimotos in October 2022.

she should have been tested for coeliac at Hashimoto’s diagnosis…..

Assuming in U.K.

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

if not been tested….get test via GP next BEFORE considering trial on gluten free diet

Hashimoto's affects the gut and leads to low stomach acid and then low vitamin levels

Low vitamin levels affect Thyroid hormone working

Poor gut function can lead leaky gut (literally holes in gut wall) this can cause food intolerances.

Most common by far is gluten.

Dairy is second most common.

A trial of strictly gluten free diet is always worth doing

Only 5% of Hashimoto’s patients test positive for coeliac but a further 81% of Hashimoto’s patients who try gluten free diet find noticeable or significant improvement or find it’s essential

A strictly gluten free diet helps or is essential due to gluten intolerance (no test available) or due to leaky gut and gluten causing molecular mimicry (see Amy Myers link)

Changing to a strictly gluten free diet may help reduce symptoms, help gut heal and may slowly lower TPO antibodies

While still eating high gluten diet ask GP for coeliac blood test first or buy test online for under £20, just to rule it out first

Assuming test is negative you can immediately go on strictly gluten free diet 

(If test is positive you will need to remain on high gluten diet until endoscopy, maximum 6 weeks wait officially) 

Trying gluten free diet for 3-6 months. If no noticeable improvement then reintroduce gluten and see if symptoms get worse

chriskresser.com/the-gluten...

amymyersmd.com/2018/04/3-re...

thyroidpharmacist.com/artic...

drknews.com/changing-your-d...

Non Coeliac Gluten sensitivity (NCGS) and autoimmune disease

pubmed.ncbi.nlm.nih.gov/296...

The predominance of Hashimoto thyroiditis represents an interesting finding, since it has been indirectly confirmed by an Italian study, showing that autoimmune thyroid disease is a risk factor for the evolution towards NCGS in a group of patients with minimal duodenal inflammation. On these bases, an autoimmune stigma in NCGS is strongly supported

nuclmed.gr/wp/wp-content/up...

In summary, whereas it is not yet clear whether a gluten free diet can prevent autoimmune diseases, it is worth mentioning that HT patients with or without CD benefit from a diet low in gluten as far as the progression and the potential disease complications are concerned

restartmed.com/hashimotos-g...

Despite the fact that 5-10% of patients have Celiac disease, in my experience and in the experience of many other physicians, at least 80% + of patients with Hashimoto's who go gluten-free notice a reduction in their symptoms almost immediately.

Similarly few months later consider trying dairy free too. Approx 50-60% find dairy free beneficial

With loads of vegan dairy alternatives these days it’s not as difficult as in the past

Post discussing gluten

healthunlocked.com/thyroidu...

SlowDragon profile image
SlowDragonAdministrator

75mcg levothyroxine only one step up from starter dose

What were her results BEFORE adding T3

Guidelines on dose Levo

guidelines on dose levothyroxine by weight

Even if we frequently start on only 50mcg, most people need to increase levothyroxine dose slowly upwards in 25mcg steps (retesting 6-8 weeks after each increase) until eventually on, or near full replacement dose

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.

Many on just levothyroxine find they need Ft4 at least 70% through range or higher

TSH should be under 2 as an absolute maximum when on levothyroxine

gponline.com/endocrinology-...

Graph showing median TSH in healthy population is 1-1.5

web.archive.org/web/2004060...

Comprehensive list of references for needing LOW TSH on levothyroxine

healthunlocked.com/thyroidu....

onlinelibrary.wiley.com/doi...

If symptoms of hypothyroidism persist despite normalisation of TSH, the dose of levothyroxine can be titrated further to place the TSH in the lower part of the reference range or even slightly below (i.e., TSH: 0.1–2.0 mU/L), but avoiding TSH < 0.1 mU/L. Use of alternate day dosing of different levothyroxine strengths may be needed to achieve this (e.g., 100 mcg for 4 days; 125 mcg for 3 days weekly).

Heloise profile image
Heloise

This doctor is an expert on PCOS and recently had a series about it. It brought out that it is related to hypothyroidism and has books on the topic as well. integrativemgi.com/about-dr...

TiggerMe profile image
TiggerMeAmbassador

Hi, with results like that I'd say an increase of T4 would be the way to go, increasing to 100mcg would be my suggestion... I don't see anything in those results that suggest high androgen levels?

Oestrogen level is on the low side with low FSH so assuming she isn't post menopause? What time of the month were these results from?

Also add another 1000iu of Vit D aiming for 100-150

Ehal89 profile image
Ehal89

Thanks for your help on this, everyone. Particular thanks to SlowDragon for the detailed recommendations. We have slowly titrated up to 100mcg Euthyrox and added the B-complex.

Unfortunately progress has been pushed back significantly as she has also been recently diagnosed with glandular TB, and has to take a 6-9 month series of powerful antibiotics that have major impacts on Levothyroxine absorption by the liver, as well as increasing testosterone synthesis 6-fold. This is a documented side effect of Rifampin.

We will continue to titrate up slowly during this period in an attempt to get the frees up to their optimal levels.

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