Hi, I’m after some advice, I’m a 40 year old male and this year I’ve not been feeling great. I’m tired a lot, depressed, anxiety, no energy, high cholesterol and just generally feel awful much of the time. I’ve not been diagnosed with Hypothyroidism and didn’t even know what it was at the start of the year. My GP suggested we run some tests back in March.
FT4 7.4 (7.7 to 15.1) pmol/L -4%
TSH 4.16 (0.36 to 5.6) mu/L 72.5%
This test was done at 10:30am after I’d had breakfast, coffee etc. The GP advised me the low FT4 was nothing to be concerned about as the TSH was well within range and is more important. I then started my journey of learning more about thyroid conditions as I wasn’t so convinced about the FT4 result.
I returned to the GP in April as I still felt I wasn’t coping and asked to be tested again. The test was done fasted 8:10am
FT4 8.5 (7.7 to 15.1) pmol/L 10.8%
TSH 4.63 (0.36 to 5.6) mu/L 81.4%
This time I’d learned from here of the importance of the early morning timing of the test. The GP was happy both tests were now within ranges and reassured me no treatment is required. I’d looked up the guidelines at this point so I knew I’d just have to accept that.
I next started to look elsewhere after someone suggested to get my testosterone levels checked. Low testosterone can result in similar symptoms. I paid for a private test in late April which provided a more comprehensive panel, the draw was fasted at 8:00am.
TSH 5.87 (0.270 - 4.2) mu/L
FT4 11.9 (12 - 22) pmol/L
FT3 5.1 (3.1 - 6.8) pmol/L 54%
Ferritin 294 (30 - 518) 54%
Folate 17.2 (>7)
Vit D 90 (50 - 250) 20%
Active B12 85.8 (37.5 - 188) 32%
Total cholesterol 7.4 (<5)
LDL 4.6 (<3)
Triglycerides 3.4 (<2.3)
Testosterone 16.30 (8.64 - 29) 37.6%
Free Testosterone 0.357 (0.198 - 0.619)
The private test included a short call with the doctor to discuss the results. My testosterone level is on the lower side but would only require treatment if it was below 12 so no further action required. The private doctor advised I go back to my GP with the thyroid results as in his opinion this is likely to be the root cause for my symptoms. He also advised that thyroid and testosterone are linked so addressing my thyroid issue would likely see my testosterone improve from its sub optimal level.
So back to the GP in May armed with my private results as a talking point my GP agreed to another test and to include cholesterol, testosterone and antibodies for good measure. This test was done 8:30am, again fasted.
FT4 9.7 (7.7 to 15.1) pmol/L 31%
TSH 5.4 (0.36 to 5.6) mu/L 96.1%
Testosterone 15.1 (10 - 27.6) 28.9%
Folate >25 (2.9 - 20.6) - GP comments to be reviewed next appointment
Ferritin 152 (23.9 - 336) 41%
B12 396 (> 160)
Haemoglobin 154 (130 - 170) g/L
Haematocrit 0.477 (0.4 - 0.5) L/L
Se thyroid peroxidase Ab conc <4 (0 - 30) iu/ml
As my TSH is just within range my GP feels no thyroid based action is required. Instead he suggested to start taking a statin to reduce my cholesterol and start a different antidepressants to improve my mood. I can’t help feeling these are a sticky plaster rather than addressing the root cause but at the same time my results don’t support starting thyroid medication.
I’m not sure what to do now, I want to feel better but knowing both my thyroid and testosterone are less than optimal is difficult to ignore. I’ve looked into supplements along the way and now take Vitamin D 8000iu, multivitamin, omega 3, magnesium and eat a few Brazil nuts each day for selenium. Maybe I just need to wait and see if it gets worse but it doesn’t sound like a great plan.
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LabradorFan22
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So, first of all, your doctor doesn't know much about thyroid, does he!
The GP advised me the low FT4 was nothing to be concerned about as the TSH was well within range and is more important.
That's his first mistake. TSH isn't even a thyroid hormone. It is a pituitary hormone. When the pituitary senses there isn't enough thyroid hormone in the blood, it increases production of TSH - Thyroid Stimulating Hormone - to stimulate your thyroid to make more thyroid hormone - T4 and T3. But your pituitary hasn't done that, has it. Meaning that your TSH is not the most important number. With an under-range FT4, the TSH should be much higher than that.
There's not much point in calculating the percentage of a TSH result. A TSH is always a TSH, whatever the range. And the TSH of someone without any thyroid problems - euthyroid - is around 1, never over 2, which shows the thyroid is struggling, and when it reaches 3 you are technically hypo. So, even without a fully functional pituitary, you are hypo. But the NHS doesn't see it that way and likes it to go over 10 before they will diagnose!
A euthyroid FT4 is around 50% through the range, so you can see yours is very low. Which is another indicator that you are hypo. And your level most certainly is something to be concerned about!
FT4 8.5 (7.7 to 15.1) pmol/L 10.8%
TSH 4.63 (0.36 to 5.6) mu/L 81.4%
So, in the April test, the FT4 has risen a little, and so has the TSH. But, even done under the right conditions this time, the result isn't high enough considering your low FT4. You are still hypo.
TSH 5.87 (0.270 - 4.2) mu/L
FT4 11.9 (12 - 22) pmol/L
FT3 5.1 (3.1 - 6.8) pmol/L 54%
TSH has risen a little more but your FT4 has gone under-range again. So the TSH is still low in comparison.
The FT3, on the other hand, is euthyroid - i.e. around mid-range. BUT it is higher in range than the FT4, which isn't euthyroid. Normally, the FT3 would be slightly lower than the FT4. But, when the thyroid is failing, it tends to make more T3 than T4 to keep you alive. So, one more indication that you are hypo. And, be aware that the thyroid cannot do that forever. Sooner or later the FT3 level is going to drop, too.
And then we have the high cholesterol. Cholesterol is made in the liver. And it's made in the liver because the body needs it. And the liver does its best to keep levels stable by making more when you consume less, and vice versa. However, when the FT3 is too low - and given that you are hypo it is too low for your needs - the body cannot process cholesterol correctly and it tends to build up in the blood. So, high cholesterol levels are another hypo symptom. And you do not need statins, you need thyroid hormone replacement - and probably a new doctor, too!
Not much change in the May test, but your ferritin and B12 are a bit too low, and will be partly responsible for your symptoms.
Se thyroid peroxidase Ab conc <4 (0 - 30) iu/ml
This is a negative results, and so low that you are unlikely to have Hashi's. But, did you know that there is a second Hashi's antibody - Thyroglobulin antibodies - and if that is high you have Hashi's, even if the TPO are low.
But, I rather doubt that autoimmune thyroiditis is your problem. It looks more to me like Central Hypo - i.e. a pituitary problem. But, I very much doubt your GP would ever have even heard of that, let alone recognise it when it's staring him in the face!
I can’t help feeling these are a sticky plaster rather than addressing the root cause but at the same time my results don’t support starting thyroid medication.
It's not even a sticking plaster, it's a complete fob-off. Doctors hand out antidepressants and statins like sweeties because it's more lucrative than spending the time to find out what is actually wrong. And your results absolutely do support starting thyroid hormone replacement! In fact, the sooner the better. So, if I were you, I'd go straight back to my doctor and present him with a few thyroid facts, and tell him it's time he got his head out of his computer and started actually looking at his patient, because I'm willing to bet that your condition shows for those that know how to recognise it. Has he given you any sort of physical examination? Felt your neck, or checked your reflexes? Looked at your tongue or your finger nails? I bet he hasn't.
I’ve looked into supplements along the way and now take Vitamin D 8000iu, multivitamin, omega 3, magnesium and eat a few Brazil nuts each day for selenium.
Are you taking vit K2-MK7 with your vit D?
Multi-vits are discouraged on here, for many reasons. Especially if they contain iodine, which can make hypothyroidism worse.
You should only eat two Brazil nuts a day because they are very rich in vit A, and you don't want too much of that. You don't want too much selenium, either, actually.
So, I think that what you should do now is read up a bit about Central Hypo, so that you know what you're talking about when you go back to your doctor. Because pretty sure he won't know.
Thank you. But pretty sure they wouldn't take much notice. They are firmly wedded to the idea that the TSH is the most important number - the only number to consider! And they like that because it makes life a lot easier for them than having to juggle three numbers at the same time! They may be clowns but they're no circus act.
If you have an underactive thyroid (hypothyroidism), treatment may be delayed until this problem is treated. This is because having an underactive thyroid can lead to an increased cholesterol level, and treating hypothyroidism may cause your cholesterol level to decrease, without the need for statins. Statins are also more likely to cause muscle damage in people with an underactive thyroid.
With two NHS tests with TSH over 5 and symptoms you should be offered trial on thyroid replacement hormones
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.
Some people need a bit less than guidelines, some a bit more
Graph showing median TSH in healthy population is 1-1.5
There’s no autoimmune disease in my family that I know of. I suspect my mother may have a thyroid condition. She was tested many years ago (~1990s) and the GP told her the results were normal. She never got to see the results though, I’m suggesting she get more up to date ones.
Here’s link for how to request Thyroid U.K.list of private Doctors emailed to you, but within the email a link to download list of recommended thyroid specialist endocrinologists
Ideally choose an endocrinologist to see privately initially and who also does NHS consultations
Normal healthy TSH is usually around 1-2 depending on time of day/night so that is definitely a red flag plus low FT4 and High FT3 and no sign of thyroid antibodies suggests unusual cause of what seems to be, at the least, sub clinical hypothyroidism/thyroid stress….. OFf the wall considerations could be….. low iodine? with the raised TSH trying to compensate and boosting free T3 first, because that’s what it does, to keep things functioning but the blood levels dont really tell us what is happening at the cellular organ tissue level (and intracellular conversion) given abnormally low fT4…. Low fT4 normally increases rate of intracellular T4 - T3 conversion through the T4 feedback loop - so maybe your highish levels of fT3 are coming from that as well as increased thyroidal production from raised TSH. Maybe your thyroidal production of T4 and T3 is limited because of TSH resistance (a bit like insulin resistance when the body stops responding to it in the way it should) so maybe your fT3 is coming from conversion of T4. (Which may account for the low fT4 - its being converted!) YOU NEED TO SEE A REALLY SWITCHED ON PRIVATE ENDOCRINOLOGIST. In my experience thyroid issues can also hammer testosterone and free testosterone but the overall endocrinology is so complicated it needs a thorough clinical work up. Sadly relying on GP or even NHS endos is limited by their slavish adherence to anachronistic clinical guidelines that are decades out of date. Your presentation could be responded to by a GP prescribing a trial of thyroxine supplementation and close careful monitoring of the symptom and blood parameters…. BUT even though it is T4 that is weirdly low supplementing T4 could raise your fT3 even further, to a point which would be hyper thyroid and possibly dangerous regardless of what the TSH level is telling your body and the doctors! Although it would be interesting to see the response (so long as it doesn’t cause harm). Anyway, it needs much more careful and clever and expert medical thought than probably any of us here can give it. There is also the possibility that all this is normal and not pathological for you!
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