# Elevated TSH versus Optimal Free T3/Free T4



## bigfoot

I've got a question for the experts out there... I was going to post in my own ongoing thread, but it's really more of a general question. Sorry if this is a little confusing, I am trying to clarify this myself.

Can your Free T3 & Free T4 be at the optimum spot in their ranges, but still have an elevated TSH from not taking enough thyroid medication?

Or, in other words, is Free T3 & Free T4 really an indication of what your body is _doing with_ any given dose of levothyroxine, and not _how much_ levothyroxine you may need?

For Example - My Recent Labs (and Ranges):
TSH 3.649 (0.3-4.0)
Free T3 4.0 (2.3-4.2)
Free T4 1.49 (0.84-1.51)

Obviously my TSH here is elevated, but my Free T3 and Free T4 are looking great. However, despite them looking great, I still felt pretty awful on 62.5 MCG of generic levothyroxine and it wasn't lowering my TSH. So I get boosted up to 75 MCG of brand-name Levoxyl and am starting to feel better pretty quickly.

Theories? Ideas? True? False? :confused0031:


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## lainey

TSH is produced by the pituitary. T4 and T3 by the thyroid. It is a feed back loop--if your TSH hasn't fallen even though your thyroid hormones are at good levels in the blood, the problem is with the pituitary's response, not with your need for thyroid hormone. That is reflected by the presence or absence of the hormones themselves in your bloodstream.

I have read recently (so if you find other studies, post a link) studies that basically said that people on replacement tend to have slightly higher free T4's than those who are normal ie: without a thyroid problem--see section 4.2.2

http://www.thyroidmanager.org/Chapter6/Ch-6b-4.htm

and:

http://www.ncbi.nlm.nih.gov/pubmed/18753096

Patients can use this information to demand more replacement if necessary, but honestly, once you get into the upper third of the ranges for T4 and T3, symptoms can just as easily be from over medication as from under at this level because they are essentially the same for hypo and hyper.

So, I don't think you have to do math to your numbers, quite frankly.

I also don't think there is a narrow set point of numbers you are aiming for--thyroid hormones fluctuate in amount and availability based on a lot of other factors--female hormones, other medications, general wellness. Because of this, over analyzing lab results may leave out these other influences and ignore the dynamic nature of hormone regulation in the body. Your numbers can vary somewhat, and small changes overall should not be of great influence.

I see a lot of people "chasing" their numbers, examining them with calculators, evaluating where they fall in the ranges. I think if you feel well, and your numbers in range, you shouldn't worry that it falls somewhere specific, or adjust your dose _ad infinitum_ to get to a point that someone on the internet suggests you should be. Dosing is individual, response is individual.


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## bigfoot

Thanks! Appreciate those links, too...

I guess the concern I (as well as the naturopath doc, not so much the endocrinologist) have is that with the good-looking Free T3 and Free T4 tests recently, I didn't want to slide into being hyperthyroid, with any additional added levothyroxine pushing in me that direction.

But what I'm reading from your response is that someone could still be significantly hypothyroid, even with Free T3 and Free T4 being at optimal levels? Thus, the elevated TSH level from the pituitary. (If so, this would explain why I'm feeling vastly better on 75 MCG versus 62.5 MCG, regardless of my Frees.)

Like you said, it's really on an individual case-by-case basis and you can't chase lab numbers forever. Each rock I turn over just seems to show a bigger rock underneath! There is a lot to understanding this "stuff".


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## lainey

In cases of central hypothyroidism, the pituitary does not respond properly to replacement medication and then the patient must be titrated on the basis of their T4 and T3.

So yes, it is possible to have good values for the free thyroid hormones, yet elevated TSH.

Ultimately, whether you are "over medicated" is judged by the relationship of your free T4 and T3 to the range values. Once those reach the top of the range, you are technically "hyper", regardless of the TSH value.


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## bigfoot

What I find interesting is that by having Hashimoto's, this is suggestive of primary hypothyroidism. (However, they feel the chemo treatment or family history may have caused it.) Yet I seem to feel far better with a lower TSH, rather than optimal FT3 & FT4 levels, suggesting secondary/tertiary hypothyroidism.

I suppose this brings me to the next question -- how quickly can FT3 and FT4 levels fluctuate? I wonder if that was just a temporary spike and not indicative of long-term levels.

My predicament is this: I want to lower my TSH, but not by being symptomatic of hyperthyroidism along the way by being over-medicated. Perhaps it's better to lean on the increased T4 medication (75 vs. 62.5 MCG) instead of trying to optimize how my body utilizes the medicine via the naturopath supplements.

Thanks for your patience and explanations -- it is hard to wrap my mind around all of this.


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## lainey

So, these are your labs from the top of the thread:

TSH 3.649 (0.3-4.0)
Free T3 4.0 (2.3-4.2)
Free T4 1.49 (0.84-1.51)

I think you may well be at or over the top on free T4 and T3 with the 75mcg (assuming these are from the lower dose of 62.5mcg).

I don't care what your TSH is at that point, free T4 and T3 at the top of the range are unhealthy levels.

You really are not on a very high dose. Either you process the medication very efficiently, or your thyroid is still producing hormone on its own. Medicating to the top that way is tricky in the sense that, you don't control the thyroid itself. If it puts out, you could be in trouble.


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## northernlite

Very interesting points and observations, bigfoot.

You are way beyond my expertise but my experience, like yours, shows that the way I feel is tied to my TSH level. Unfortunately, I've only had one FT3 run (and it was pretty low) but my FT4 has stayed fairly consistent both prior to starting levothyroxine and after various levels of levothyroxine. FT4 seems useless for me in relation to how I feel.

I have only been at this since November so I am still trying to find my optimal dose and then I am also trying to see what lab values correlate to that well feeling. I have determined that I am not satisfied with how I feel when my TSH is around 2.0. Although not the full blown symptoms I had prior to starting treatment, my fatigue is bothersome, my joints start to ache and my mood goes south.

My one good, "wow I feel great" time period was at a TSH of around 0.8. I am feeling pretty good right now and I am due for more blood work so I am curious if I am down at that level again. I am going to see if I can talk them into running another FT3 so I can see how that correlates to how I feel too. It was at the bottom of the range when my TSH was 2.0 so I am curious to see how high it is when I feel so much better.

I personally would stay up at the 75 mcg and get that TSH down. Hopefully your FT4 & FT3 won't cross over to hyper but I really think it is how you feel. Regardless of what your FT4 and FT3 are, if you get to the point where you have no hyper symptoms and feel well, I think you are at your optimal dose of T4.

Good luck, I appreciate the thought provoking questions on how this all works. As someone fairly new myself and someone that likes numbers, I have a lot of curiosity of where my "sweet spot" is in the range of numbers.


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## bigfoot

lainey said:


> You really are not on a very high dose. Either you process the medication very efficiently, or your thyroid is still producing hormone on its own. Medicating to the top that way is tricky in the sense that, you don't control the thyroid itself. If it puts out, you could be in trouble.


I'm hoping for the former, but suspecting the latter.

I'm following you -- so if my thyroid is producing, let's say, 50 MCG of T4 and I am adding in 75 MCG of T4 medication, I'm up to 125 MCG total. But if my thyroid gives out, all of a sudden I drop down to only the 75 MCG I am taking. Whammo.

So, by working up to a larger dose of T4 medicine over time (112, 125 MCG, etc.), I am suppressing the need/desire for my thyroid to work on its own (it's getting lazy), thus ensuring consistency by relying solely on medication. A side-benefit of this being a reduced TSH level, thus reduced antibody activity with Hashi's.

What's interesting is my naturopath is very concerned about possibly going hyper. He is surprised my endocrinologist didn't _lower_ my T4 med dose. I am hesitant to do something like that based on exactly what you described. He knows of folks who have put Hashi's into remission and don't need much, if any, thyroid medicine. Being the pessimist that I am, I highly doubt that would be my kind of luck!

Sorry I'm getting long-winded with all of this, but I really do appreciate the brainstorming and info. If anything, this pushes me closer to focusing on increasing my T4 dose over time, rather than trying to optimize and decrease it, for fear of being left up a creek without a paddle.


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## lainey

>>What's interesting is my naturopath is very concerned about possibly going hyper. He is surprised my endocrinologist didn't lower my T4 med dose. I am hesitant to do something like that based on exactly what you described.<<

I'm with your naturopath on this. You said in a previous post you were hyper on 100mcg. There really isn't much distance between there here so to speak..... Granted, it's only 12.5mcg from 62.5 to 75mcg, but I think the endo should have left your dose alone. It's enough to change from the generic to the brand, let alone increase it when your frees are so near the top.

>>So, by working up to a larger dose of T4 medicine over time (112, 125 MCG, etc.), I am suppressing the need/desire for my thyroid to work on its own (it's getting lazy), thus ensuring consistency by relying solely on medication. A side-benefit of this being a reduced TSH level, thus reduced antibody activity with Hashi's.<<

Uh, no. I don't see you doing such a thing in the very near future. Based on your current labs your dose at the moment has nowhere to go but down, IMHO. There is no reason to "suppress" your thyroid, it's already not working properly. You are supplementing it's production with replacement medication. Most people go for long periods on a stable dose as their thyroid slowly winds down--a very few have both sets of antibodies and their levels swing on their own, true, but from what I read looking back on your history, that's not how it came about for you--ie, you are pretty much straight low grade hypo, you were hyper on a higher dose and now you are fiddling around trying to find what works in between--do I have this correct?.

Personally, I don't look at the TSH, I look at the free T4. That is the measure of the available hormone, the medication that you take. If that is in a good spot, leave it alone. The endless "tweaking" and dose adjustments end up having consequences of their own, leaving you not knowing if you are coming or going with it because each time you shift it can set off symptoms just from the dose change.


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## bigfoot

northernlite said:


> I personally would stay up at the 75 mcg and get that TSH down. Hopefully your FT4 & FT3 won't cross over to hyper but I really think it is how you feel. Regardless of what your FT4 and FT3 are, if you get to the point where you have no hyper symptoms and feel well, I think you are at your optimal dose of T4.


I think I agree with you! 

Like you, I've gone back and compared how I felt to my past TSH and other lab values. There is definitely some truth to having a lower TSH and feeling better. The endocrinologist said a TSH of 2.0 would be a good starting point, and to go from there. The only time I ever came close was a TSH of 1.89 in the last five years.

There is so much tied into all of this, and a steep learning curve!


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## bigfoot

Yep, I felt pretty hyper and sick on 100 MCG. The 75 MCG I seem to be tolerating just fine at the moment. Like you said, the brand change could be attributable to that, too. However, in a few more weeks when the higher dose starts to peak, who knows how I'll feel.

The new endocrinologist doesn't think there is much to the FT3 and FT4 labs as far as treatment value, seems more concerned with TSH. He was actually pretty persistent that I needed to be bumped up to 75 MCG, thus the increase.


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## bigfoot

lainey said:


> Uh, no. I don't see you doing such a thing in the very near future. Based on your current labs your dose at the moment has nowhere to go but down, IMHO. There is no reason to "suppress" your thyroid, it's already not working properly. You are supplementing it's production with replacement medication.


Oops, that was bad wording on my part. I suppose what I was getting at was thinking that with an increased dose of levothyroxine, the thyroid isn't going to want to work as hard, in turn relieving some of the overdrive state it may have been in, in turn lowering TSH secreted by the pituitary, and maybe reducing antibody attacks and levels.

I still find it really weird that my FT3/FT4 numbers a month ago were perfect, maybe even too perfect, yet I only felt a slight improvement. Now my T4 med brand gets changed and upped slightly, and things are feeling pretty good. Less fatigue, less nausea, less irritability/mood issues, less brain fog, etc.

I should add that I do have other things going on, such as low testosterone, a borderline diabetic A1C, and high triglycerides. Lo and behold, my estrogen level is also high, potentially complicating things, too. I'm sure some of these aren't playing nicely with the thyroid / endocrine system.


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## Andros

bigfoot said:


> I've got a question for the experts out there... I was going to post in my own ongoing thread, but it's really more of a general question. Sorry if this is a little confusing, I am trying to clarify this myself.
> 
> Can your Free T3 & Free T4 be at the optimum spot in their ranges, but still have an elevated TSH from not taking enough thyroid medication?
> 
> Or, in other words, is Free T3 & Free T4 really an indication of what your body is _doing with_ any given dose of levothyroxine, and not _how much_ levothyroxine you may need?
> 
> For Example - My Recent Labs (and Ranges):
> TSH 3.649 (0.3-4.0)
> Free T3 4.0 (2.3-4.2)
> Free T4 1.49 (0.84-1.51)
> 
> Obviously my TSH here is elevated, but my Free T3 and Free T4 are looking great. However, despite them looking great, I still felt pretty awful on 62.5 MCG of generic levothyroxine and it wasn't lowering my TSH. So I get boosted up to 75 MCG of brand-name Levoxyl and am starting to feel better pretty quickly.
> 
> Theories? Ideas? True? False? :confused0031:


What time did you take your Levothyroxine on the day of your labs and what time did you have your labs?

I need this answer first. LOL!! (You know; it's a process!)


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## bigfoot

No sweat! (Everything in the endocrine arena is a "process", haha.)

The labs were fasting, drawn at 0730, and I took my 62.5 MCG generic levothyroxine exactly an hour earlier.


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## lainey

>>Oops, that was bad wording on my part. I suppose what I was getting at was thinking that with an increased dose of levothyroxine, the thyroid isn't going to want to work as hard, in turn relieving some of the overdrive state it may have been in, in turn lowering TSH secreted by the pituitary, and maybe reducing antibody attacks and levels.<<

Your wording is wrong again.

When you are hypo, your thyroid is not in overdrive, it is under producing. The TSH is due to the LACK of T4 and T3 in the blood (low in the reference range).

I question any doc that doses on TSH only. I wonder that you are going to try to "force" your TSH lower--from your labs it looks like your pituitary has not yet responded itself to the high levels of free T4 and T3 in your blood at the moment--however there is a lag to the feed back system, so that could change quite soon. It works in the other direction too--there are plenty of people who have a fine TSH but whose T4/T3 values leave a lot to be desired. Your doc needs to be looking at the whole picture in order not to miss something.

In a man, the low testosterone can have a big impact. You need to normalize those hormones also, or you are not going to get the "relief" you think you should from thyroid medication--most of the symptoms of low testosterone are the same as hypothyroidism.


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## Andros

bigfoot said:


> No sweat! (Everything in the endocrine arena is a "process", haha.)
> 
> The labs were fasting, drawn at 0730, and I took my 62.5 MCG generic levothyroxine exactly an hour earlier.


Yep! There you go! Especially fasting. It could be entirely possible that you got a surge. I had that happen once and now I take my Armour as soon as I get in my vehicle "after" I have my labs. (Because I do take in the morning and prefer morning appts.)

It usually takes 4 hours for the thyroxine to "peak" after ingesting it but with fasting and depending on how absorbable the filler is for Levothyroxine, I think your labs got bolixed.

Now...................since I told you this; what do "you" think?

If you have some time on your hands, do some research on this. Better yet, call the Pharmaceutical Co. that makes your Levoxyl and inquire. They usually have a toll-free number.


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## bigfoot

lainey said:


> Your wording is wrong again.
> 
> When you are hypo, your thyroid is not in overdrive, it is under producing. The TSH is due to the LACK of T4 and T3 in the blood (low in the reference range).
> 
> I question any doc that doses on TSH only. I wonder that you are going to try to "force" your TSH lower--from your labs it looks like your pituitary has not yet responded itself to the high levels of free T4 and T3 in your blood at the moment--however there is a lag to the feed back system, so that could change quite soon. It works in the other direction too--there are plenty of people who have a fine TSH but whose T4/T3 values leave a lot to be desired. Your doc needs to be looking at the whole picture in order not to miss something.
> 
> In a man, the low testosterone can have a big impact. You need to normalize those hormones also, or you are not going to get the "relief" you think you should from thyroid medication--most of the symptoms of low testosterone are the same as hypothyroidism.


This endo uses TSH and T4, but his own words were that he didn't see Free T3 and Free T4 as a reliable indicator of things. I'm with you, I don't necessarily agree with that. I am pretty sure this is why he brushed off the naturopath's concerns at my last visit. Still, he seems to be a good doc and open-minded otherwise, so I'm reluctant to change.

The hormone issue is definitely tricky. Apparently some of my testosterone is being shunted off into estrogen, hence the elevated Free E3 estrogen labs. Naturopath has just started me on a supplement to help reduce that effect, which should (hopefully) increase the availability of my body to use the testosterone. You're totally right -- last year when they only put me on levothyroxine I didn't feel much effect. When they put me on testosterone replacement (Androgel) I almost immediately felt better.


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## bigfoot

Andros said:


> Yep! There you go! Especially fasting. It could be entirely possible that you got a surge. I had that happen once and now I take my Armour as soon as I get in my vehicle "after" I have my labs. (Because I do take in the morning and prefer morning appts.)
> 
> It usually takes 4 hours for the thyroxine to "peak" after ingesting it but with fasting and depending on how absorbable the filler is for Levothyroxine, I think your labs got bolixed.
> 
> Now...................since I told you this; what do "you" think?
> 
> If you have some time on your hands, do some research on this. Better yet, call the Pharmaceutical Co. that makes your Levoxyl and inquire. They usually have a toll-free number.


I think you could be right -- and it would certainly easily explain things. Especially if more time passes and I don't really go hyper, despite the increased levothyroxine, and the top-end FT3 & FT4. This was my first early AM fasting lab in a long, long time. I have always been pretty sensitive to medication, whether OTC or RX.

Your idea to call the pharma. company is a good one, thanks! I think I will try that and see if they can shed any light on things.

Either way, I'm watching things pretty closely just in case.


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## Andros

bigfoot said:


> I think you could be right -- and it would certainly easily explain things. Especially if more time passes and I don't really go hyper, despite the increased levothyroxine, and the top-end FT3 & FT4. This was my first early AM fasting lab in a long, long time. I have always been pretty sensitive to medication, whether OTC or RX.
> 
> Your idea to call the pharma. company is a good one, thanks! I think I will try that and see if they can shed any light on things.
> 
> Either way, I'm watching things pretty closely just in case.


Let us know if you call!

And.........................consistency is "key" here in all things. Try your best to always get your labs about the same time of day and if it is in the morning like last time, you now know what to do about that. Take it after. No matter what you do, it is very important to always do the same thing; and that is not just with our labs.

TD is a finicky disease (as is diabetes, RA and host of others) and our bodies do respond very favorably to consistency.

I am very fussy; I go to bed at the same time, I rise at the same time, eat in a very timely manner and eat only the things I know are good for me. I never deviate and I feel good every single day. It's like really setting your circadian cycle big-time. Do you know about your 3rd. eye? The Pineal Gland?


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## bigfoot

Pineal gland -- that's a new one to me. Just Googled it. Nobody can say they log on here and don't learn anything! LOL

Yep, I try to be as consistent as possible. Called Pfizer and ran it by them, this was their response:

Take the thyroid medicine as you normally would, and that it wouldn't be enough to impact labs being drawn on that same day.


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## Andros

bigfoot said:


> Pineal gland -- that's a new one to me. Just Googled it. Nobody can say they log on here and don't learn anything! LOL
> 
> Yep, I try to be as consistent as possible. On hold w/ Pfizer as I type this...


Pineal is a very very important gland and the circadian cycle is very important. Find yours; what works for you!

Can't wait to hear what they have to say...................


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## bigfoot

As I explore more, I looked into the Androgel <-> levothyroxine interaction. I'm finding statements like these below as far as FDA info.

From the Androgel side of things...
"Androgens may decrease levels of thyroxin-binding globulin, resulting in decreased total T4 serum levels and increased resin uptake of T3 and T4. Free thyroid hormone levels remain unchanged, however, and there is no clinical evidence of thyroid dysfunction."

From the Levoxyl side of things...
"Drugs that may alter T4 and T3 serum transport - but FT4 concentration remains normal; and, therefore, the patient remains euthyroid:

Drugs that may decrease serum TBG:
concentration:
Androgens / Anabolic Steroids
Asparaginase
Glucocorticoids
Slow-Release Nicotinic Acid"


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## lainey

Okay, a couple of things.

I have always gone with the idea that fasting labs for thyroid don't make any sense. On T4 medication, there really isn't the immediacy as far as the dosing--ie, T4 medication builds up in the body, replacement medication keeps it stable---it's not like alcohol, where if you drink it you really measure the effects shortly after--you are measuring the built up thyroid hormone circulating in your blood--this varies slightly by the day and the hour anyway, so taking your medication before the labs should really make no difference.

T3 medication, is slightly different, however, as it is the active and used hormone, and it is metabolized and delivered more quickly, almost as needed.

Either way, I think you want to measure WHAT YOU ARE TAKING and it seems defeatist not to take it for labs. Otherwise, you are really falsely lowering your results.

Yes, there is an interaction between the androgens and serum thryoid hormone. Specifically, the progesterones free it up while the estrogens bind to it--for example, some women will notice more fatigue during that time during their cycle when the estrogens are high (binding thyroid hormone, so levels are ever so slightly lower).

If you are trying to raise your testosterone to a normal level, you may find (surprise!) that the result is a slightly higher free T4/T3 and lower TSH. That is why I suggested you manage that also, and not be so quick to ramp up the thyroid meds. They are going to interact a bit.


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## bigfoot

lainey said:


> Yes, there is an interaction between the androgens and serum thryoid hormone. Specifically, the progesterones free it up while the estrogens bind to it--for example, some women will notice more fatigue during that time during their cycle when the estrogens are high (binding thyroid hormone, so levels are ever so slightly lower).
> 
> If you are trying to raise your testosterone to a normal level, you may find (surprise!) that the result is a slightly higher free T4/T3 and lower TSH. That is why I suggested you manage that also, and not be so quick to ramp up the thyroid meds. They are going to interact a bit.


This is making a lot of sense, and puts an explanation behind what the naturopath is worried about. With my estrogen (free E3) elevated, as we treat that the estrogen binding should diminish, while testosterone hopefully increases.

As far as the fasting labs, this was due in part to testing of blood glucose and the other hormones.

I see my primary doc next week -- gonna run all of this by him, too. Nobody has ever tackled _why_ my testosterone is low, although it's a little late for that now, seeing as how I'm on hormone replacement therapy.

It's interesting how the cycle perpetuates itself:

hypothyroid & low testosterone -> less energy -> less exercise -> fatigue/mood -> poor diet -> more weight -> more estrogen -> reduced thyroid/testosterone effectiveness -> less energy -> etc...


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## melissa_24141

I have posted to another thread but I wanted to post here to get as much advice as possible. I am MISERABLE physically and emotionally. I will post my labs below. I have been on synthroid (generic) for awhile now. I went from .075 to 100 MCG (0.1 synthroid) is what the bottle says. Anyway from reading the post my T3 may be the problem. I still do not understand any of it except that the numbers don't look good and I def feel like (I'm living someone elses life) it's just weird. My doc has refused to add T3. I called and left another message and just wondering if anyone could give me pointers on how to convince her to just start me on like 5mcg? Thanks...heres the labs from about 2 weeks ago.

TSI 261 Range <130
TSH 40.9 Range 0.5 - 4.7
Thyroxine Free 0.99 Range 0.65-1
T3 (trliodothyronine) 77 Range 60-170


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## lainey

@melissa

For you it really isn't a matter of adding T3 yet--your TSH numbers are not even close to being in range and you need to have your dose increased (which it was).

Unfortunately, it does take time for the numbers to respond to the medication, and most doctors do like to increase the dose in small increments 1.) to avoid side effects from the sudden addition of thyroxine to your system 2.) to avoid overmedicating you.


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## Andros

bigfoot said:


> As I explore more, I looked into the Androgel <-> levothyroxine interaction. I'm finding statements like these below as far as FDA info.
> 
> From the Androgel side of things...
> "Androgens may decrease levels of thyroxin-binding globulin, resulting in decreased total T4 serum levels and increased resin uptake of T3 and T4. Free thyroid hormone levels remain unchanged, however, and there is no clinical evidence of thyroid dysfunction."
> 
> From the Levoxyl side of things...
> "Drugs that may alter T4 and T3 serum transport - but FT4 concentration remains normal; and, therefore, the patient remains euthyroid:
> 
> Drugs that may decrease serum TBG:
> concentration:
> Androgens / Anabolic Steroids
> Asparaginase
> Glucocorticoids
> Slow-Release Nicotinic Acid"


This is great information. We all need a heads up regarding other hormone supplementation and such.


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## bigfoot

As usual with anything medical I wind up going through, it's never "easy". There's always something to stump the docs or make things more difficult. LOL

Hey, if I'm going to pay them, they might as well earn it!


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