Tired all the time

[Alex_p]

Lately I feel tired all the time, from when I wake up to when I go to bed in the evening, despite the fact that I sleep more than 8 hours per night. I take a lot of supplements (calcium, D3, folate, complex B, magnesium glycinate, heme iron), the only value that was low was ferritin but I do take iron. I also take Novothyral, which is 100 mcg T4 and 20 mcg T3.

My latest thyroid blood test results are:

FT3 5.6 (range 3.1-6.8)

FT4 19.9 (12-22)

TSH <0.01 (0.27-4.2)

I work out, I do both strength training and jogging, 4-5 days per week, but lately I find it difficult to do it since I have low energy. I cook my food myself and don’t eat after 6PM. I’ve also gained around 3kg in the past 3 months. As far as I can see, my thyroid results are fine. Any idea what else to look at? I feel like it’s really impacting my life, I don’t feel like doing anything because I’m just so tired.

[SlowDragon Administrator]

please add most recent results and ranges for

Iron

Ferritin

B12

Folate

Vitamin D

[Alex_p in reply to SlowDragon]

Vitamin D 135 nmol

Folate 9.2

Active B12 103

Ferritin 41

I don’t see ranges for them, they were done with MonitorMyHealth.

I don’t have results for iron. I do supplement for all of these anyway, and the only one that is low is ferritin.

[SlowDragon Administrator in reply to Alex_p]

Low iron will make you tired

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

Stop iron supplements 5-7 days before testing

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...

Posts discussing Three Arrows as very effective supplement

healthunlocked.com/thyroidu...

healthunlocked.com/thyroidu...

Iron patches

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...

Inflammation affecting ferritin

healthunlocked.com/thyroidu...

Updated reference ranges for top of ferritin range depending upon age

healthunlocked.com/thyroidu...

Thank you for your incredible patience while you have been awaiting the outcome of our ferritin reference range review. We conducted this with Inuvi lab, which has now changed the reference ranges to the following:

Females 18 ≤ age < 40 30 to 180

Females 40 ≤ age < 50 30 to 207

Females 50 ≤ age < 60 30 to 264

Females Age ≥ 60 30 to 332

Males 18 ≤ age < 40 30 to 442

Males Age ≥ 40 30 to 518

The lower limits of 30 are by the NICE threshold of <30 for iron deficiency. Our review of Medichecks data has determined the upper limits. This retrospective study used a large dataset of blood test results from 25,425 healthy participants aged 18 to 97 over seven years. This is the most extensive study on ferritin reference ranges, and we hope to achieve journal publication so that these ranges can be applied more widely.

[Alex_p in reply to SlowDragon]

That’s a lot of info, thank you! I will go through the posts. But I’ve had anemia for as long as I can remember and hair loss is not an issue for me anymore. The tiredness however is new.

[SlowDragon Administrator in reply to Alex_p]

Work on getting ferritin at least over 70 minimum

[pennyannie]

Hey there :

I'm sorry to read this and before you get upset with me -

why not conserve your energy and stop this exercise regime - until you feel more able :

I understand you probably feel better for ' doing it ' but you are likely exhausting yourself in the process and when with a thyroid health issue recovery takes longer and we do not bounce back and our bodies do not respond in the ' normal ' way to any undue stress.

The weight likely water - please cut yourself some slack - though know only too well it's easier said than done.

[Alex_p in reply to pennyannie]

I feel like I need the dopamine that comes from exercise 😄 And I need to preserve muscle. Exercising doesn’t tire me too much to be honest, I do it around 40 minutes 4-5 times per week. If it’s just water weight, why is it not going away now that my thyroid values are back to normal?

[TiggerMe Ambassador in reply to Alex_p]

Do you use a fitness tracker? Really useful to monitor recovery and training schedules

[Alex_p in reply to TiggerMe]

I have a garmin watch, but it doesn’t say anything about recovery. It does show how well I sleep, and I seem to have only around 30 minutes of deep sleep per night, which is not great.

[TiggerMe Ambassador in reply to Alex_p]

No that doesn't sound great...mine gets narky with me if I have less than an hour of deep sleep.... how's your resting heart rate and heart rate variability?

[Alex_p in reply to TiggerMe]

Resting heart rate is on average 58. But it’s mostly around this usually, unless I get hypo and it drops.

[pennyannie in reply to Alex_p]

Well - your levels may look good - but it doesn't mean to say that your T3 and T4 are where they need to be for you to be well :

I think the T3/T4 ratio in Novothyral is at 1/5 isn't it - can you check this on the box as to how much T3 and T4 is in the tablets please :

I think you tried NDT and that T3/T4 ratio is around 1/4 - T3/T4 :

So maybe you might be better suited to dosing T3 and T4 independently and maybe your unique set point is closer to 1/3.50 - T3/T4 :

Or, I guess the other option is to try T3 only.

Just for reference :- If on T4 monotherapy -

the accepted conversion ratio is said to be 1 / 3.50 - 4.50 T3/T4 with most people feeling at their best when they come in this ratio at 4 or under :

and likely why NDT works very well for very many people -

Not sure about Novothyral as we rarely get any feedback on this option but since NDT suits me - I take this to mean I need around a 1/4 ratio T3/T4 - but haven't tested out this theory with synthetic options - yet !!

I've seen posts on here of people buying Thybon Henning from Roseway Pharmacy -

you 'll likely have to pay initially for a consultation but it's much cheaper than seeing an endo

and if my memory serves me right you have a prescription though probably in a foreign language - so more than 1/2 way there - and the feedback about Roseway is positive and supportive of the patient - so hopefully a relatively stress free experience.

I felt absolute rubbish when my ferritin came in at 22 - it took me over a year to build up to over 70 - which I read is around the magic number and the absolute minimum reading one needs before any thyroid hormone replacement works well for the patient.

[Alex_p in reply to pennyannie]

I got a prescription from a private GP and sent it to Roseway labs, however they said they don’t take private prescriptions anymore. I might try seeing an endo from them and getting a prescription this way, I hope they still offer that.

[FancyPants54 in reply to Alex_p]

It's not an endo. it's a prescribing pharmacist and when I last had to speak to her she was lovely.

[Sparklingsunshine in reply to FancyPants54]

Actually she's an NHS GP.

[FancyPants54 in reply to Sparklingsunshine]

At the time I started with the service (which was pretty much when they started offering it) she was described as a prescribing pharmacist. Perhaps it’s not the same person now.

Before I can get another prescription written out I have to do bloods and have another follow-up consultation over the phone so I should find out then if it’s the same person.

[wellness1 in reply to FancyPants54]

Is she 'flexible' about TSH or guided by the reference interval?

[pennyannie in reply to Alex_p]

Oh - I'm sorry for that - very strange - will take a look as I would have thought that is their main business as a pharmacist :

but yes, I've read of forum members who first arrange a consult with the Roseway prescriber / pharmacist and then it's pretty much a ' done deal ' :

[pennyannie in reply to pennyannie]

Glad to see 2 other forum members have ' popped up ' who use Roseway :

Hopefully you've been advised how to take this forward with the pharmacy.

[FancyPants54 in reply to pennyannie]

Yes, see my reply above a few seconds ago. It looks like they are happy to renew prescriptions on blood results but want an annual chat via a full phone consultation. I’m fine with that.

[wellness1 in reply to Alex_p]

That's odd. Roseway currently take private prescriptions from endos. Is it because it was prescribed by a private GP, rather than an endocrinologist?

[Alex_p in reply to wellness1]

I don’t know. I sent them the prescription and all they said was that they aren’t accepting private prescriptions at the moment 🤷‍♀️

[wellness1 in reply to Alex_p]

You might want to follow up with them and ask about the policy. Maybe they're trying to steer people to their in-house prescriber, but you could mention that you've heard of people who are having their private prescriptions accepted.

[greygoose]

If it’s just water weight, why is it not going away now that my thyroid values are back to normal?

They might be within the so-called 'normal' range, but who says they're normal for you? Perhaps you need your FT3 higher and your FT4 lower. But, the problem with Novothyral is that it's not flexible. You cannot change the ratio. And that ratio isn't right for everyone. I took it for a while but found there was much to much T4 and not enough T3. You might be better off on levo + T3.

How much Novothyral are you taking?

FT3 5.6 (range 3.1-6.8) 67.57%

FT4 19.9 (12-22) 79.00%

There is certainly room to increase your T3.

But, with that low ferritin, it's hardly surprising that you're tired. It's much too low. Do you take vit C with your iron to help absorption?

I agree with pennyannie about the exercise. It could be affecting your conversion of T4 to T3.

[Alex_p in reply to greygoose]

I do take vitamin C along with the iron, I forgot to add it to the list of supplements.

I take 150 mcg Novothyral. But I see your point about the ratio. I moved to a new GP, which from my correspondence with them before moving, they said they would be ok with getting T3 from outside UK. I have an appointment next week and will see if that’s actually true.

From the T3 options that I’ve tried in the past, Thybon Henning seemed to be the best for me. But not sure I could get that again.

[greygoose in reply to Alex_p]

Sorry, I'm afraid I have no idea what you can and can't get in the UK because I don't live there.

[SlowDragon Administrator in reply to Alex_p]

You can realistically only get Thybon Henning on private prescription

Cost £60-£80 per 100 tablets

NHS options

Teva 20mcg - lactose free

Mercury Pharma (Advanz) 20mcg

Morningside Healthcare 20mcg, 10mcg and 5mcg

[Alex_p in reply to SlowDragon]

Any recommendations for any of the above? In case I get my new GP to prescribe through NHS. Teva probably doesn’t do well since I didn’t get along with the levothyroxine from them. Mercury levothyroxine was ok, but not as good as Accord.

[SlowDragon Administrator]

FT4: 19.9 pmol/l (Range 12 - 22)

Ft4 79.00% through range

FT3: 5.6 pmol/l (Range 3.1 - 6.8)

Ft3 67.57% through range

Recommended that all thyroid blood tests early morning, ideally just before 9am, only drink water between waking and test and last dose levothyroxine 24 hours before test

T3 ….day before test split T3 as 2 or 3 smaller doses spread through the day, with last dose approximately 8-12 hours before test

is this how you do your tests

[Alex_p in reply to SlowDragon]

Since they’re on the same pill, I can’t split them like this. Before the test I did what I usually do, which is to take one dose at 5 AM and one at 1 PM. The test was at 8 AM the next day without the dose at 5AM.

[SlowDragon Administrator in reply to Alex_p]

So in reality FT3 is higher than results show

[FancyPants54 in reply to SlowDragon]

As soon as I read this post and saw the results (without the time of dosing) I wondered if in fact this fatigue is due to too much T3. And now we know that the results show a false low T3, this might be the case and perhaps a slight dose reduction might help?

[FancyPants54 in reply to FancyPants54]

Too much T3 makes me fatigued to death.

[Alex_p in reply to FancyPants54]

I had T3 much closer to the upper limit and felt fine, so not sure if that’s the issue. I tend to believe it’s the low ferritin that’s causing this, based on other comments.

[thyr01d in reply to FancyPants54]

That's really interesting FancyPants. Is it because you do more when T3 is high so then are fatigued?

[FancyPants54 in reply to thyr01d]

Oh gosh no! I have zero energy if my level gets a bit high, and I'm not talking high numbers, just high for me. I have never had my T3 close to the top quarter of the ref. range.

I think the D3 enzyme has a lot to answer for in my case. I can't think what else it might be.

[FallingInReverse]

hi Alex_p adding this comment to the bottom so it doesn’t get lost.

Do NOT take iron supplements (especially heme supplements) without regularly testing your Iron.

Ferritin and Iron are not always correlated and it’s very common to have in range/high iron and very low ferritin.

If that’s the case you need to stop supplements and correct with an iron rich diet. There are no “ferritin supplements.”

Iron toxicity causes permanent damage over time. It’s not something to take lightly.

At the very least, please find out your serum iron level and make an educated decision about how to correct.

[Alex_p in reply to FallingInReverse]

I’ve received my iron test results. Iron levels don’t look too bad but the ferritin does.

Iron test

[humanbean]

Having problems with weight gain could be related to your low iron. This video is worth watching :

youtube.com/watch?v=PtczW43...(Not working as expected?)

[Alex_p in reply to humanbean]

Very interesting video, thank you! I think my iron is low, it always tends to be like that and I remember taking iron supplements during my pregnancy. I am taking heme iron supplements and hope they will increase my iron levels.

[SlowDragon Administrator in reply to Alex_p]

But essential to test full iron panel regularly

At least every 4 months

[Alex_p in reply to SlowDragon]

Ordering a test now.

[Alex_p in reply to SlowDragon]

Update: here are my iron test results

Iron tests

[FallingInReverse in reply to Alex_p]

Your iron is at a “good” level. We aim for 55-70% in range. So there is a little room for it to increase, knowing also that serum iron does vary over the days/weeks as your iron intake changes. I’ve seen iron go from under range to over range in about a month with supplements.

Your Ferritin is low - and raising that is a long term commitment. There are no ferritin supplements. You need to carefully keep your serum iron optimal consistently over time for your body to feel comfortable sending some to “storage.” Which is what ferritin is.

See this reply for some more info on how to think about supplements and eating an iron-rich diet to start working on your ferritin.

healthunlocked.com/thyroidu...

[FallingInReverse in reply to FallingInReverse]

I found this chart helpful in explaining how some of my symptoms may be related to my low ferritin. You’ll see a huge overlap with hypothyroid symptoms, so it’s important to concurrently work on optimizing thyroid, while working on our iron/ferritin (and folate, d, b12.)

Hypo makes it hard for our bodies to absorb the nutrients we eat… and that in turn makes our thyroid not work as well as it should. And so on and so on. That’s the cycle.

Ferritin

[FallingInReverse]

Your other iron numbers reflect the same story - you are at bare minimum on the ranges, but not iron anemic because of your serum iron. Arguable your Ferritin level doesn’t clinically say anemia either… consider for many of us (me included m) my ferritin is stuck at 5-11. But all yours on the low side nonetheless.

Transferrin saturation is one other important facet to consider in the big picture. Optimal is 35-45%. Because Transferrin is the protein that iron attaches to to get to where our bodies need it. It “transfers” it to the right places. Iron is needed to make transferrin proteins, and yours showing 38% says you have enough iron for those proteins to be saturated with iron as they move around your bloodstream and get delivered to your cells and organs that need them .

35% is the minimum saturation threshold for the iron to do it’s job. Over 45% and we start to look at having too much iron, which as said earlier has different but equally negative impact.

[Alex_p in reply to FallingInReverse]

Thank you for sharing your extensive knowledge on iron and ferritin. I remember having anemia for a long portion of my life, but I’ve always had only ferritin measured and was given iron supplements. I’ll try to eat more iron rich foods and see how that goes. But at least now I know what to look for.