Low t3 with high t4, graves.

[happyp]

I'm not sure what's happening. I've had one episode of toxic nodule hyperthyroidism back in 2015, hemithyroidectomy in 2018. Then I got graves (unrelated apparently) in 2022. My t4 was 63, my t3 was 30! so was on carb until June 2023. I've not been on any meds since. Following my thyroid through private blood tests, tsh has been dropping significantly the past couple of tests (always taken same time of day) and is now hitting borderline low at 0.4 (0.35 is the low level limit), t4 has risen to 19.5 (21 high limit) but t3 is only 3.95 (3.1-6.8) a slight rise since Jan where it was 3.8. This is on the real low end and has remained there. How can t3 be low while tsh drops and t4 climbs? I'd estimate I'm about 4-6 months away from being out of range again, looking at my numbers. Why is my t3 struggling along? Or is my remaining thyroid just totally messed up now?

[SlowDragon Administrator]

What are your most recent vitamin D, folate, ferritin and B12 results

Low vitamin levels could be affecting Ft3

[happyp in reply to SlowDragon]

I haven't had vit d tested in ages, but it was 74 last check and I take a supplement daily. Folate is always low as i have a double whammy of the MTHFR gene, ferritin was only 12 last check with iron of 9 but I've been taking some food quality heme iron supplements. B12 was fine I think.

But I suppose low vitamin levels could be the cause as I have a fair issue absorbing these things and need to use a digestive enzyme.

[SlowDragon Administrator in reply to happyp]

So you need to test folate, B12 and ferritin at least annually

Vitamin D ideally twice a year

Optimal vitamin levels are

Vitamin D at least over 80nmol and between 100-125nmol might be better

Serum B12 at least over 500

Active B12 at least over 70

Ferritin at least over 70

Folate towards top of range

B12 and folate

serum B12 result below 500, (Or active B12 below 70) recommended to be taking a separate B12 supplement

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 supplements

thyroidpharmacist.com/artic...

B vitamins best taken after breakfast

Igennus B complex popular option. 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...

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

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 high enough

Post discussing how biotin can affect test results

healthunlocked.com/thyroidu...

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

[SlowDragon Administrator in reply to happyp]

It’s far more common with Graves’ disease to have high ferritin, not low ferritin

Have you ever had ultrasound scan of thyroid

You need TSI or Trab tested for Graves’ disease

[happyp in reply to SlowDragon]

Thanks for such a detailed reply, that's all super helpful. I'll try to get persuade my doctor to do all the vitamin tests or I'll pay privately again. My iron has pretty much always been low even as a child, I have to stay on iron supplements pretty much permanently. My daughter is the same, I feel like it's something genetic, but my stomach gets upset with supplements, so I end up stopping them. They won't give me an infusion as I have one hemochromatosis gene too.

My last thyroid scan when i was diagnosed with graves showed diffuse changes and thyroiditis on my remaining thyroid.

My t3 has been this low since last june. I was wondering if my remaining thyroid just totally messed up after all the issues I've had. Graves disease caused early menopause too. If that's relevant.

[SlowDragon Administrator in reply to happyp]

Request testing for coeliac disease too

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 in reply to happyp]

ferritin was only 12 last check with iron of 9 but I've been taking some food quality heme iron supplements.

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

Stop iron supplements 5-7 days before test

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

[greygoose]

That sounds more like Hashi's than Graves' to me. Which antibodies have you had tested?

[happyp in reply to greygoose]

They tested anti tpo and anti tg. Both negative. But my tsh is low enough to cause me concern that I'm heading towards another graves episode, or the ongoing graves episode since they never tested my trab antibodies to negative.

[greygoose in reply to happyp]

OK, I see. So your have already been diagnosed with Graves' due to high TRAB. That changes everything. But, you know, it's not low TSH that makes you hyper. It's very high Frees. And although your FT4 is high-ish, your FT3 is very low. So I'm no expert, but it seems to me that you're a long way off hyper. As to why your T4 is high and T3 low, that is something that can happen with Hashi's, which is why I said it looked more like Hashi's to me. But I really don't know how that scenario fits in with Graves'. So, just pretend I didn't say anything. OK,

[pennyannie in reply to happyp]

Hello Happyp:

With Graves Disease it does tend to wax and wane throughout one's life - with stress and anxiety being common triggers :

If you did have a positive TRab at some point in time - we are looking at an auto immune disease, which is for life, and for which mainstream medical have no answers nor cure, though there was some research looking into producing a vaccine some years ago .

I'm not aware the NHS see the need to keep rechecking the antibodies - as the cause has already been established by over range antibodies and the medical evidence and proof of diagnosis to commence the most appropriate treatment.

With Graves we must be monitored on T3 and T4 levels - as we have both stimulating and blocking antibodies circulating in our blood vying for control of our thyroid function - which is the target of an attack by your immune system -

so you can experience a myriad of symptoms - and for some people - given enough time -

Graves naturally burns itself out - as the blocking and stimulating antibodies cancel each other out -

rather than having the invasive medical treatment of a thyroidectomy or RAI thyroid ablation and loosing your thyroid function completely.

It is quite possible that Graves antibodies are still circulating in your blood and sitting on your TSH receptor sites encouraging more T4 production but also blocking and causing this proportionately low T3 :

We do now have some research you might like to consider -

pubmed.ncbi.nlm.nih.gov/338...

ncbi.nlm.nih.gov/pubmed/306...

For all things Graves Disease and AI - elaine-moore.com

[dan70]

"In healthy humans the thyroid gland produces predominantly the prohormone T4 together with a small amount of the bioactive hormone T3." (source: Metabolism of Thyroid Hormone, National Library of Medicine).

The conversion of T4 to T3 occurs predominantly outside the thyroid via different enzymatic pathways. In that sense there might be nothing wrong with the remaining part of your thyroid (as long as you stay symptom free and don't proceed towards an episode of hyperthyroidism caused by your Graves' disease).