TSH results - advice please

[Moonwalker43]

Good morning

I've posted before and had some really good advice so hoping someone can help me with my next conversation with my GP.

In September my GP called me in to discuss reducing my dose of levothyroxine from 175mcg daily to 150mcg daily because of my low TSH (see below). I wasn't feeling ill but she was concerned. In the end she agreed that I could take 175mcg / 150mcg on alternate days.

My latest blood results are below and I'm not sure if they have improved enough to stop her reducing my dosage again.

Also is the T4:T3 ratio ok?

Thanks for any advice you can give.

September 2024

TSH 0.02 mIU/L (0.3 - 4.2) -7.2%

Free T4 (fT4) 19.2 pmol/L (9 - 23) 72.9%

Free T3 (fT3) 5.4 pmol/L (2.4 - 6) 83.3%

T4:T3 Ratio 3.556 

C-Reactive Protein (CRP) 4.9 mg/L (0 - 5) 98.0%

January 2025

TSH 0.04 mIU/L (0.3 - 4.2) -6.7%

Free T4 (fT4) 16.7 pmol/L (9 - 23) 55.0%

Free T3 (fT3) 4.2 pmol/L (2.4 - 6) 50.0%

T4:T3 Ratio 3.976 

C-Reactive Protein (CRP) 4.9 mg/L (0 - 5) 98.0%

[tattybogle]

Hi , most GP's will think they should reduce dose further with TSH 0.04 ,

your fT4 and fT3 are both significantly lower though , so if you really don't want to reduce further at the moment , you could try using this :

( but obviously it all depends how you feel symptom wise, if you still feel ok , then it's worth trying a very slightly lower dose as the aim is to take the lowest dose we need to fee well , not the highest dose we can tolerate ....... and if you can feel well on a dose that keeps TSH just within range , you'll have a lot less hassle when you have any dealings with the medical profession )

healthunlocked.com/thyroidu... useful-evidence-that-tsh-between-0.04-0.4-has-no-increased-risk-to-patients-on-levothyroxine-updated-new-study-does-show-small-risk

.also , you can try and discuss the following concept with GP ( or use it to baffle them into submission ) Taking T4 causes a slight shift in TSH in relation to T4 levels , compared to people who get their T4 (and some T3) from their thyroid ~ patients on levo tend to have relatively higher fT4 / relatively lower fT3 / relatively lower TSH~ meaning 'low TSH' does not mean quite the same thing once someone is taking levo : healthunlocked.com/thyroidu.... tsh-is-just-the-opinion-of-your-pituitary-about-your-dose-but-your-pituitarys-opinion-is-a-bit-warped-once-you-take-thyroid-hormone.

[Moonwalker43 in reply to tattybogle]

Thank you Tattybogle. That’s really interesting and I’ll use the information as a reason to not just drop the dose without considering the impact if I need to when I see the GP.

What is the ideal T4 to T3 ratio or isn’t there one?

[SlowDragon Administrator]

How do you feel

Were both tests early morning, ideally just before 9am, only drink water between waking and test and last dose levothyroxine 24 hours before test

What vitamin supplements are you taking

Request/politely insist GP test vitamin D, folate, B12 and ferritin

[Moonwalker43 in reply to SlowDragon]

Yes both tests were 9am and I didn’t take levothyroxine until afterwards.

I take vitamin D but looking back I haven’t had a test for any vitamins or iron for a while. I’ll ask the GP to check these too.

I feel ok(ish) but have RA and type 1 diabetes so never sure whether the hot/cold, fatigue, poor sleep etc relate to what condition lol

Thank you SlowDragon.

[SlowDragon Administrator in reply to Moonwalker43]

Are you on gluten free and/or dairy free diet

[Moonwalker43 in reply to SlowDragon]

Gluten free but not dairy free.

[Tina_Maria]

The problem is, that your TSH might not come into range again, even if you are reducing your levothyroxine right down - however, it will probably make you very unwell. Some people have a low or suppressed TSH even with small doses of levothyroxine.

How are you feeling at the moment? Do you feel the same than when you were on the higher dose or is there any difference? If you feel the same without any ill effects, that's great. However, most people need their levels a bit higher between 60 and 70% through the range.

I would definitely insist not to reduce any further down and if you are getting some symptoms, you may want to think about increasing your dose slightly again. You can argue with the GP that a general replacement dose is 1.6mcg per kg of weight (prescribing guidelines), so a person weighing 63kg would need around 100 mcg levothyroxine.

cks.nice.org.uk/topics/hypo...

Check your nutrients as well such as folate, iron, Vitamin B12 and Vitamin D, as these will help you making the most of your medication.

[Moonwalker43 in reply to Tina_Maria]

Thank you for your advice Tina Maria.

I think I probably feel ‘different’ for reducing the dose slightly as I recognise now that I was having some heart palpitations at night which I’m not now. However I’m now suffering from hot/cold and tiredness more.

I weigh 64.5kg and so am taking more levothyroxine than the 1.6mcg per kg

I don’t want to reduce my dose anymore as cutting down 25mcg every other day only increased my TSH by 0.02

I will definitely get my nutrient levels checked.

Juggling the dosage and levels is confusing so thank you for your help.

[Tina_Maria in reply to Moonwalker43]

Well, the 1.6 mcg/kg is just a rough guide - much more important is how you feel and even more importantly, at what levels your T4 and T3 are. Your T4 and T3 in September looked okay, if you can tolerate slightly less without ill effect, that's great but you should not feel that you have to reduce your medication to fit any numbers. How you feel with it is more important. For me both hormones around 50% would be too low, even if that would fit better with the 1.6 mcg... some people may need even more than that (for example some people may have more absorption problems, so they may need a higher dose to build up a similar level than some people get with a lower dose).

Cold and tiredness are clear signs of hypothyroidism, so that is an indication of too low hormones. You may find your sweet spot by increasing slightly (maybe just take 150mcg on 2 days), but like you have mentioned, reducing further should not be an option, as those hypo symptoms will increase and your TSH will not change much as a result of it either.