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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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
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
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
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
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
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
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
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
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
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).
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...
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
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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