Thyroid Hormones on T4:T3 - please help

[Shkmigmo]

Hi, all!

I've been following this forum for quite some time, finding help within these pages - I'm very grateful for all of your contributions!

I need your advice again, as I'm facing a dead end here.

I'm hypothyroid (Hashi) and have been on combo pill (T4:T3) Prothyrid and Novothyral for the last 4 years.

My hormones when I was on 150mcg T4 + 15mcg T3:

TSH = 0.06 [0.27 - 4.2] uIU/mL

FT4 = 12.5 [12.0 - 22.0] pmol/L

FT3 = 2.9 [3.1 - 6.8] pmol/L

I’ve been on 150mcg T4 + 25mcg T3 for the last 3 months, and my hormones are:

TSH = 0.053 [0.55 - 4.78] uIU/mL

FT4 = 11.48 [11.5 - 22.7] pmol/L

FT3 = 3.1 [3.5 - 6.5] pmol/L

The last dose was taken 24h before the blood work.

Other supplements I take:

D vitamin, which I keep in the upper third of the range; B12 vitamin and Myo-Inositol with Folic Acid.

Magnesium glycinate, zinc, selenium, and Omega-3 are taken every day.

I measure only D vit, as it is not easy to find a lab here for other vitamins and minerals.

I’d like to experiment more, upping the intake of T4+T3, but I’m not sure if it makes sense and if it is safe. I have access only to combo pills (not levo or lio separately), so I can make a dose combination only out of these two:

Prothyrid (T4:T3 ~ 100:10 mcg)

Novothyral (T4:T3 ~ 100:20 mcg).

I would appreciate any thoughts on this. What would you do? <3

[jimh111]

I would expect your thyroid hormone levels to be higher on this dose unless you are quite heavy. If not you mzy have poor absorption. Do you have any gastrointestinal issues?

[Shkmigmo in reply to jimh111]

Thank you for replying!

I'm normal weight (163cm, 55kg) but I think I have poor absorption. I've been having gastrointestinal issues for the last year (slow motility), and that's the reason I upped the dose 3 months ago. Every specialist I visited (edno, gastro...) said it is because I'm hypo, so - you know - "that's your destiny"..."take some laxatives."

I read somewhere that in the case of poor absorption, you can dissolve the pill under the tongue - so that is the way I've been taking the medication (though, it seems with not much effect).

I'm having gastroscopy and colonoscopy in a month, so maybe it brings more insights.

[jimh111 in reply to Shkmigmo]

See what the gasto says. You could try taking your hormone with fruit juice, the acidity can help absorption. If you do keep an eye on your symptoms in case they improve and you go hyper. Your doctor could also prescribe liquid levothyroxine although it is expensive for the NHS. I would let the gastro know you there's the possibility of poor absorption as it's better to get to the root of the problem.

[Shkmigmo in reply to jimh111]

Yes, I agree totally. Definitely will investigate it further. Thanks!

[McPammy]

Your TSH is saying you’re on too much

Your T3 is probably that low as you’ve left it out 24hrs before the blood test. I would do the blood test again and this time do it 2hrs ‘after’ you’ve taken your medication. I bet your levels will be much higher. If they’re not higher then it may be absorption issue. But I doubt that really as your TSH is suppressed.

I definitely wouldn’t increase until you’ve checked out a further blood test 2hrs after taking your t4 and t3 combined medication.

[Shkmigmo in reply to McPammy]

I will definitely consider that! Thank you for the suggestion!

[Hidden in reply to McPammy]

There is no way you can be overmedicated with such low free Ts. Even small amounts of T3 can cause the TSH to drop below range. The TSH is NOT a reliable indicator when on T3. You should go by symptom-relief and make sure you have adequate levels of T4 and, more importantly, T3. If the OP decreases meds to get the TSH in range, her free Ts will drop even further. Shkmigmo , what are your current symptoms?

[McPammy in reply to Hidden]

When you haven’t taken T3 for 24 hrs before a blood draw the level will be low. Usually it’s advised to only leave about 8hrs not 24hrs. But as this member is on combination t4/t3 24hrs was left

I take 10mcg T3 daily and my TSH is never suppressed so I completely disagree with you.

I suggest the member gets bloods done 2hrs after taking her meds to see how high her levels go.

[Hidden in reply to McPammy]

The OP clearly has hypo symptoms. I said T3 often suppresses the TSH, not always. You will find countless posts here by people on T3 with a suppressed TSH told by doctors to go off it for that reason.

10 mcg of T3 is a pretty low dose. In order for that to work, you need good absorption and adequate T4 to T3 conversion. Many hypos don’t have that.

The advice here is usually to have labs 8-12 hours after taking T3, not 2 hours. Why would a T3 peak after 2 hours be a better indicator of thyroid health than low T3 after 24 h?

Also, labs only measure what is in our blood. Thyroid hormones exert their metabolic action in the cells, and T3 stays in the cells for around three days.

2 h after taking T3, it has probably peaked in blood but not yet reached the cells. After 24 h, most of it probably has made it into the cells, hence the lower T3 in blood.

[McPammy in reply to Hidden]

I suggest getting bloods done ‘after’ taking meds so the member knows if the medication is actually getting through. My guess is it is as her TSH is very low. But they need to know to what level it’s getting. TUK states leave medications number of hours prior to a blood draw giving false lows. I suggest you do it after taking meds and alternate without taking meds. This is to know you are keeping in range and therefore your TSH too. I don’t think it’s the norm as you state. My TSH is around 1.00( 0.35-5,50). My t3 with taking it 2hrs previously is 5.6 (3.7-6.0). Prior to introducing T3 medication my T3 was 3.9 only 8% conversion rate. If my TSH goes suppressed I feel dreadful with many symptoms. A healthy persons thyroid results t4, t3 and TSH would never be out of range and that’s what I’ve aimed and managed for which leaves me symptom free. I come on here and want to tell people of my success in order to help them achieve their own success. It is possible to be symptom free and full of energy if you manage your levels and mirror those of a healthy persons levels. I have had Hashimoto’s for 25 years and have the DIO2 faulty gene all my life. I know about the pitfalls of this chronic disease and have suffered greatly in the past. I was naive and followed GP’s poor advice until I finally went private 6 years ago and got the much needed help and support by a private only endocrinologist on TUK list. I’ve followed his advice the last 6 years and never felt so well and energised in a good 25 years. I’m sticking with that advice of staying in range = symptom free and happy.

[Hidden in reply to McPammy]

I see several problems with the ‘aim for the levels of a healthy person’ approach:

1. The TSH is very sensitive and reacts to even tiny changes in thyroid hormone excreted 24/7 by a healthy thyroid gland. The TSH was not designed to have a whole day’s dose of thyroid hormone dumped into the bloodstream in one go or even twice daily. Also, a healthy thyroid gland can increase or decrease hormone production as needed, whereas we supply the body with a constant dose of thyroid hormone every day. So the TSH in a person on thyroid hormone replacement is likely to be lower than in a healthy person secreting thyroid hormone day and night. In order to keep the TSH in range to please their doctors, many thyroid patients remain under medicated.

2. People with a healthy thyroid gland have midrange FT4. A person with midrange FT4 on levo may not have enough T4 for sufficient conversion to T3. Even if the TSH is in range, she is likely to be hypo.

3. Some of the daily T3 comes from the thyroid itself (T4 is converted to T3 in the gland before being released into the bloodstream). Once the thyroid is gone (due to a TT, RAI, or end stage Hashimoto’s), that conversion is lost and needs to be replaced by T3 in many patients.

4. Many people with autoimmune hypothyroidism have poor conversion and simply cannot use T4 effectively.

5. Some patients produce higher than average amounts of T3 even in health, and are likely to need more T3 on thyroid hormone replacement.

6. Before the TSH and levo were invented, doctors went by symptoms and prescribed NDT which contains more T3 than a human thyroid gland produces. Many patients who did well on NDT deteriorated when switched to levo and forced to have a TSH in range.

You are very happy to have recovered on a dose of thyroid hormone that keeps your TSH in range, but judging by the most frequently asked questions here you seem to be an exception to the rule.

[Shkmigmo in reply to Hidden]

Thanks a lot for sharing it, this is useful information!

[Shkmigmo in reply to Hidden]

Thanks for response!My digestion is horribly slow, food just stopped moving through my intestines as is used before; then, unpredictably I have enough energy to walk around , but sometimes I cannot climb 5 stairs or get out of bed, like a life is sucked out of my body; sleep is poor; weird feeling that my cells are undernourished - even though I eat very healthy (a lot of lean meat, vegetables and healthy fats, I prepare all my food; taking care of my blood sugar levels). Mentally, I'm a fraction of the person I used to be, it's very hard to focus on a text (I switched from reading to audiobooks now because of that).

[Hidden in reply to Shkmigmo]

To me, those sound like symptoms of hypothyroidism so too little thyroid hormone.

I am sorry you have received conflicting advice. I am afraid only you can decide what to do next. You could try to increase either T3 or T4 or both, or lower one or both. Whatever you choose to do, you should stick with the plan for at least 6-8 weeks and then retest.

[jimh111 in reply to McPammy]

That's a valid point but the fT3 and fT4 are still too low for these doses suggesting the possibility of poor absorption. It would be better to take T3 in divided dose and gave rhe blood taken about half way between doses

[McPammy in reply to jimh111]

They are low as 24hrs was left before the blood test for both T3 and T4 as they’re on combined medication. I suggest retake after taking meds

[jimh111 in reply to McPammy]

fT3 will halve after 24 hours. An average figure would be after 12 hours, midway. After 12 hours fT3 would fall to about 70% of the peak level. If we scale up the fT3 result by 70/50 it still isn't high and doesn't reflect the high dose being taken. fT4 only falls 10% after 24 hours and again we would expect a higher result given the dose being taken.Some endocrinologists recommend taking the blood three hours after the tablets, out of dishonesty or ignorance. This gives a peak free T3 figure because the T3 has been absorbed but not yet bound to proteins. This peak is not reflected in physiological response such as heart rate. It's a misleading result from the assay. I think the best approach is to measure fT3 midway between doses and if possible split the dose into two or three.

A blood test after two or three hours would be very useful to see if the tablets are being absorbed. This would establish whether there is poor absorption or rapid metabolism of hormone. The danger is an ignorant doctor would use it as a stick to beat the patient and deny treatment.

On reflection I think a trial of liquid levothyroxine with much less liothyronine would be a good move to restore typical hormone levels. The gastroenterologist may find a reason for poor absorption.

[McPammy in reply to jimh111]

I agree completely with all you’ve said. Firstly I thought absorption but then thought no with the TSH being low. So the only thing left I thought could be the number of hours left between taking med and blood draw. If another blood draw was done a couple or so hours after taking med then at least you’d know how high it’s getting. It can be viewed as false high or doing it the thyroid uk way advise of not taking med prior is a false low. So which is correct? Maybe neither really. All I know is that when my TSH is suppressed I feel dreadful with many symptoms. If I get it within range usually around 1.00 then I feel marvellous and I manage and hold it steady there. Which means my t4 or t3 levels are also range post taking meds or pre taking meds. After all a healthy persons thyroid TSH, t4 or t3 would never be out of range. And that’s what I aim for and it works well for me being symptom free. I try to offer other members my success in hope that my way of looking at things may help others. There are loads of people on here with suppressed TSH taking t3 but they all seem to have symptoms, surely that’s not where they want to be. They all want to be symptom free surely.

[Hidden in reply to McPammy]

And the blood sugar levels of a person without diabetes are never too low or too high because their pancreas produces exactly the amount of insulin they need, and the cortisol levels of healthy individuals will go up and down as needed and never lead to an Addisonian crisis in case of stress or illness…because their adrenal glands can adjust to meet their needs.

[McPammy in reply to Hidden]

That’s how the body operates naturally. It’s all just common sense.

[Hidden in reply to McPammy]

A healthy person will not have FT3 80% through range nor FT4 40% through range as stated in your profile. The fact is that your FT3 is higher in range than your FT4 which is probably why you feel so good. I am surprised you feel so good on so low a dose, but a healthy person will have FT3 and FT4 about 50% through range.

[McPammy in reply to Hidden]

Well good things happen and nice surprises too. What I try and do achieve is a healthy persons TSH of around 1.00 meaning t4 and t3 kept in ranges. That’s all, simple but hugely beneficial.

[tattybogle in reply to Hidden]

not directed specifically at you sunflower , cos lots of people on here say it , but i wish everyone would stop saying ' healthy person would have T4/T3 about 50%' , it gives the impression that anything else is automatically abnormal .

(edit to add ~ once someone is taking thyroid hormone replacement it obviously changes things and it's then more or less impossible to completely replicate the results of people who are not)

people without thyroid disease have their usual T4 and T3 setpoints right across the whole range , it' perfectly normal to find someone with them both around 25% and equally normal to find someone else with them both around 75% . (however they do tend to be close together , ie T4 and T3 both lowish in or both highish, or both middling )

from this small study (10 people tested repeatedly over 6 wks), they found about half of them have T3 slightly higher than T4 and about half with T4 slightly higher than T3. so there is nothing inherently abnormal about people without thyroid disease having T3 slightly higher than T4.

what you don't tend to find in people without thyroid disease is either T4 or T3 significantly higher / lower than the other. they tend to be similar % through range.

thyroidpatients.ca/2019/09/... (image of result of study by Ankrah- Tetteh et al , taken from this post )

.

[Hidden in reply to tattybogle]

I understand what you are saying. I think ‘setpoint’ is very important. We have our own setpoints in health, but not necessarily the same ones once on thyroid hormone replacement.

It is often claimed that the HPA axis is frequently dysfunctional in hypothyroid people, making the TSH an unreliable indicator once on thyroid hormone replacement.

[jimh111 in reply to McPammy]

Fully agree. Some patients have complex disorders other than a failing thyroid and they may need high hormone levels but it makes sense to initially target typical levels. There is evidence that TSH stimulates T4 to T3 conversion so having a normal TSH is desirable but not always possible.

[Hidden]

Well, our bodies do not operate naturally anymore thyroid-wise…

[Shkmigmo]

Yes, different types and brands, but none of them helped. I'm also gluten free and dairy free. The weird thing is that my gut just stopped working one day after years of being perfect and I literally hadn't changed anything in my diet or lifestyle.