General Medicine

» station26 - Thyroid test

In response to Hyperthyroidism and running posted by tdove52:

Hello,
I have a question regarding an autoimmune disease. What if you have borderline high TSH (using 3rd generation assay) and 1.3 Thyroid Stimulating Immunoglobulins (TSI).
Can this be an early sign of having both subclinical hyper & hypothyroidism simultaneously?
Thanks!

-- posted by station26

» Elaine Moore - Thyroid test

In response to Thyroid test posted by station26:
Hi,
Even though the major thyroid groups recommended lowering the TSH range to 0.3-3.0 most test kit manufacturers are still using the old ranges. Some labs use ranges as high as 4.5.

So I'll assume by borderline that your TSH is slightly higher than 3.0 and that both your FT4 and FT3 levels are in the normal or reference range. This would be considered subclinical hypothyroidism.

If you have thyroid antibodies your condition would be considered autoimmune. If you were tested for other antibodies and only TSI was positive, it could be that you're in the hypothyroid phase or first stage of Graves' disease.

If you have other thyroid antibodies and have subclinical hypothyroidism it would be subclinical Hashimoto's thyroiditis. The presence of TSI suggests Hashitoxicosis, a condition that's primarily related to hypothyroidism with transient hyper symptoms caused by bursts of TSI raising thyroid hormone levels.

If you have blocking thyroid antibodies as well as TSI you may have atrophic thyroiditis that's being kept from becoming overt hypothyroidism because of TSI. When both of these antibodies are present you can have simultaneous symptoms of both hypothyroidism and hyperthyroidism but have normal thyroid levels. If you have these antibodies and devel the associated eye disease but continue to have normal thryoid hormone levels you'd be said to have euthyroid Graves' disease.

In your case most doctors would repeat the thyroid function tests in 2-3 months and run other thyroid antibody levels if you haven't had them yet. If symptoms changed, the tests could be run sooner. Best, Elaine

» station26 - Thyroid test

In response to Thyroid test posted by daisyelaine:

Thank you Elaine for this clear description. I may need to run the test again considering it is borderline. My TSH level is actually 4.14 using a reference range of .4 to 4.0. Interestingly, I have "hyper" symptoms, not "hypo" symptoms. And my TSI is right on 1.3. So, I don't know if further investigation is warranted but I would assume that if it's 3rd generation, it must be highly sensitive and the test probably wouldn't be a false positive? (My T3 is normal but a T4 and other antibody tests were not performed. FSH, LH & Testosterone are all normal too.)

-- posted by station26

» Elaine Moore - Thyroid test

In response to Thyroid test posted by station26:
Hi,
Symptoms often change before lab results become abnormal. Thyroid hormone is very potent. Even a slight change from your usual levels can cause symptoms.
It's very possible that you had been in the hypothyroid phase of GD, which would explain your TSH result, and are now experiencing a rise in FT4. Even FT3 could be rising but not yet be abormally high. This, along with your elevated TSI, would account for your symptoms of hyperthyroidism. And it would fit with the expected TSH lag.
There wouldn't be any effect on your FSH, LH or testosterone in this case.
Ideally, you'd have the FT4, FT3 and TSH levels tested in 2-3 months or sooner if symptoms worsen. Best, Elaine

» station26 - Thyroid test

In response to Thyroid test posted by daisyelaine:

Hi Elaine,
In response to your reply, I would like to share w/ you additional data that are WNL. From speaking w/ my physician over the phone, he did perform a T4, which I presume is a free thyroxine? That is 1.48 (range: .8 to 1.9) and the T3, Free is 3.69 (range: 1.8 - 4.2) - don't know if you would consider this as a high end of normal. Lastly, the Antithyroid Peroxidase Antibodies is 23.6 (range: 35)
Would this clinical picture be of more help in diagnosing a probable Thyroid problem? I am a bit concerned about fertility issues too that my physician brought up. (Didn't know you can still menstruate and not ovulate) Unfortunately he did discuss the tests in great detail. LH/FSH is 6 and FSH is 6.11.
What concerns me a little is the fact that since it's borderline and may be insignificant, he said the results were definitely abnormal and wanted me to have the test repeated in a month. Just wanted to see if this is really warranted. Again, thank you for sharing your knowledge in this area.

-- posted by station26

» Elaine Moore - Thyroid test

In response to Thyroid test posted by station26:
Hi,
You had an FT4 and a FT3 level. These tests measure the free or available form of your major thyroid hormones. Neither test would be considered elevated. They're both over mid-range and nearer the high than the low end. This suggests that your levels have risen recently since your TSH level was high.

Besides the possibility of moving into Graves' disease, you may have had a temporary condition of thyroiditis that has resolved on its own.

Your TPO antibody test is negative. This test is positive in nearly everyone with Hashimoto's thyroiditis and it's positive in about 70 percent of people with Graves' disease.

I'd have the repeat thyroid function tests at some point in the next 6 months or sooner if symptoms change. In most cases, odd results like this resolve on their own.

I think your doctor is talking about an anovulatory cycle. This doesn't necessarily mean that every cycle is anovulatory. The ranges for FSH and LH vary during your cycle but for most of the cycle these would be normal levels. Best, Elaine

» cynthia62 - Graves' treatment??

Help! I was diagnosed in 2000 with Graves'. My Dr is pushing for me to take RAI for my hperthyroidism. I have exopthallamus and have read instances of more complications from RAI.I am looking to try alternative treatments for this disease. I currently take 30mg Tapazole. Anyone have any suggesions of websites or practioners who can assist with this?Any information would be greatly appreciated. Thank you!

-- posted by cynthia62

» Elaine Moore - Graves' treatment??

In response to Graves' treatment?? posted by cynthia62:
Hi,
Many studies have shown a worsening of thyroid eye disease after RAI. For this reason, RAI isn't recommended for people who already have eye signs or symptoms.
I have to wonder why you're still on a high dose of Tapazole after 6 years. This suggests that your doctor may not realize that a low TSH is expected in Graves' disease, and that a low TSH doesn't mean that you're still hyperthyroid.

The initial starting dose for Tap is 10-30 mg daily, and this dose is used for the first 6-8 weeks after starting meds. As soon as FT4 (the active component of your major thyroid hormone level) falls into the normal or reference range, you're considered euthyroid. At this time the dose is increased to prevent hypothyroidism.

Most people get by on a maintenance dose of 2.5-10 mg daily, just enough to block production of new hormone, and just enough to keep FT4 near the high end of the range regardless of the TSH level.

Some doctors get confused by this and think that a low TSH means that the patient is still hyperthyroid. This causes them to keep patients on too high of a Tap or PTU dose, which in turn causes thyroid hormone levels that are too low for the body's needs. This will cause increased thyroid antibody production as the thyroid gland increases its activity trying to raise thyroid hormone levels. Increased antibody production leads to the development or worsening of eye symptoms and prevents remission.

Please ask for copies of all your lab results and start keeping these copies, noting what dose of meds you were on and what symptoms you had at the time of the blood draw. With a range of 0.8-1.8 ng/ml for FT4 most people with Graves' dsease need a level of at least 1.6 to cover their body's needs. Levels lower, while considered normal, can easily cause hypothryoidism, eye symptoms, and the other problems I mentioned.

Your doctor can't force you to have RAI, and you have a right to question your treatment dose, you have a right to all your lab results and you have the right to seek a second opinion if you're not getting the best treatment available for your condition.

If you really do need a high dose of Tapazole the problem could be that you're still being exposed to the usual environmental triggers that cause GD such as excess dietary iodine in fast/processed foods, chronic stress, aspartame in Nutrasweet, low selenium levels or high estrogen levels. Best, Elaine

» cynthia62 - Graves' treatment??

In response to Graves' treatment?? posted by daisyelaine:

Hi Elaine,
Thank you so much for the information. I have felt like I have been butting my head against a brick wall quite often when dealing with some medical professionals.

I went to my endocrinologist the first part of February. At that time I was still taking 20mg Tapazole. After having blood work done, I was informed my TSH was undetectable and had a modestly elevated free thyroxine of 1.84 ng/dl. The endo had me increase the Tapazole to 30mg at that time. Does this seem appropriate?

I have a local primary care physician that is very cooperative and has standing orders at my local hospital so I can check my blood work as I feel it's needed. Do you have any suggestions as to how often I should have it checked and which tests I should request?

I have seen a couple different endocrinologists at a large teaching university hospital in the past 6 years and they both seem to follow the same protocol. It scares me to think they are teaching their students the same methods/protocols. I had seen a third endo at this same university when my first endo changed hospitals, and was told that I had to take the RAI at my first visit with him. To top it off, he spoke to my husband, not me! I immediately called for an appointment with my current endocrinologist.

Thank you for your knowledge and assistance with understanding what treatment is best for me.

-- posted by cynthia62

» Elaine Moore - Graves' treatment??

In response to Graves' treatment?? posted by cynthia62:
Hi,
With most labs using a range of 0.8-1.8 or 0.8-2.0 ng/ml for FT4, your level of 1.84 would have at best been considered slightly elevated. According to protocol, you would have been able to reduce your dose then to 10-15 mg daily or stayed on the 20 mg dose if you had troublesome symptoms.
It's poor management of treatment and an unreasonable view that being hypo is preferable to being hyper that causes many patients to give up. It's great that you're seeking information. With more patients showing a proactive stance, endos' views are starting to change. But when they're behind the times, it's a good idea to switch doctors, and often, family practice docs and general practitioners are more willing to learn what's new.

You'd want levels every 4 weeks while adjusting your dose. But once it starts staying stable at a certain dose and symptoms not changing, you can have labs every 6-8 weeks, lowering the dose slighly as needed. Hope this helps, Best, Elaine