# I need some guidance please



## Befany (Jan 22, 2018)

Hi everyone, I'm new to this Board and still quite new to my November Hashimoto's diagnosis. I'm not new to my body being out of whack, so I'm glad to finally have an answer as to some of the cause anyway. I would greatly appreciate any input on my labs and if I should be regulated with natural thyroid hormone replacement. My symptoms are no energy/chronic fatigue, I'm freezing all the time, frequent nausea, brittle, peeling nails with ridges, some hair loss, digestive issues, brain fog, occasional palpitations, not sleeping through the night, tinnitus and chronic migraines. 
My lab results were:
TSH 1.36 0.27-4.20
T4 1.27 0.81-1.70
T3 2.9 2.6-4.4
Thyroglobulin AB 40 0-115
Thyroid Peroxidase AB 15.5 0.0-34

Iron 32 37-145
TBIC 247 250-450
Iron Saturation 13 15-60
Ferritin 70.5 10-150
Vitamin B12 644 211-946

My Doctor told me to supplement with iron due to the iron deficiency. She is also having me supplement with Vitamin C, Zinc, N-Acetyl-L Tyrosine and Selenium. I'm also taking Vitamin D3 5000 IU daily. I have supplemented for almost two months and feel no improvement in hypo thyroid symptoms. I also have a Kim on the left side on my thyroid that I can see externally. When swallowing harder foods and certain supplements it's giving me a little grief. My throat has been sore for well over a month. Should I request a referral to an Endocrinologist and ask for an Ultrasound? I don't like medications and prefer holistic treatment whenever possible, However, I also would like to get my strength and energy back so I can function again. I'm sorry I'm so long winded. Any suggestions are greatly appreciated ????


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## joplin1975 (Jul 21, 2011)

I rarely think its a good idea to jump to "natural" (used in quotes because that's a really deceptive term, IMO) hormones. Desiccated meds are a great option for people who need it. How do you determine if you need it? Try the t4 meds first and see what your labs do. If you consistently have low t3 after being on the t4 meds for a number of months, then explore the possibility of desiccated meds. Desiccated meds can be very powerful -- there's no reason to add rocket fuel to you car's gas tank if you don't need it.

Your t3 is very low, but your t4 is, technically, in the "good" part of the range, albeit in the lower end of the optimal range. Your thyroid antibodies are present, but still not totally out of whack. I always think a baseline ultrasound is good, especially with a nodule (which I assume Kim was a typo for?  ). You don't need an endo to get a u/s. Your GP should be able to order that. You might have a hard time finding an endo willing to review your case until your labs are much worse.


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## Befany (Jan 22, 2018)

Thank you so much for your reply! Yes, Kim was a typo for nodule. I have no clue how that happened and plead brain fog Okay, so stay away from natural hormones. My Doctor didn't suggest treating my Thyroid at all with T4 because she felt it was still in the functional range. Yet I remain miserable. I forgot to mention my leg cramps earlier. I just don't think there is a reason to stay miserable if it's treatable. She wants to keep my Thyroid working whatever that means. I didn't think the meds would damage it. 
I'll ask for the ultrasound and won't worry about an Endocrinologist. Thank you so much again. I have an appointment tomorrow.


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## joplin1975 (Jul 21, 2011)

No, I don't think thyroid meds will harm things. You can do some googling and will probably find articles that support the idea that early use of thyroid meds can limit the progression of the disease.


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## Befany (Jan 22, 2018)

That’s what lead me here to ask. Everything I read indicated that a lot of Doctors treat only the numbers and not the symptoms. Often what is their normal or in range according to the labs is not normal according to our symptoms. Seems that early treatment can be hard to get if the Doctor is solely focused on TSH and not symptoms too.


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## Lovlkn (Dec 20, 2009)

> I forgot to mention my leg cramps earlier.


 Increasing your iron levels will likely help.

Has anyone tested your Vit D? Many are also deficient in D.


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## Befany (Jan 22, 2018)

Hi, no Vitamin D levels were drawn, but I will ask for those tomorrow then. Thank you so much!


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## Befany (Jan 22, 2018)

Good morning Joplin,
So my Doctor ran my TSH, Free T4 and Free T3 again. I also asked for a Vitamin D draw but don't have the results yet. She did want to test IGA Antibodies for Celiac disease as well. Here are my new results:

TSH 1.56 .27-4.20
Free T4 1.2 .81-1.70
Free T3 2.8 2.6-4.4

She felt my nodule on the left side and ordered an ultrasound so I'm waiting for that appointment. She also agreed to start medication after she reviews the labs and ultrasound. I'm hoping to get a call for the us soon. Still so miserable.


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## joplin1975 (Jul 21, 2011)

Yeah you are definitely hypo. Even though your results are "in range" they are not in optimal range. Here are where your numbers should be:

Free t4 should be somewhere between 1.255 - 1.9025.

Free t3 should be somewhere between 3.5 - 3.95.

An ultrasound is a good step forward!


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## Befany (Jan 22, 2018)

Thanks so much Joplin! The ultrasound can’t come fast enough. My throat has been terribly sore for so long and the trouble swallowing is a try pain. I feel like I have less breathing room in my throat if that makes any sense. In any case I’m glad things are moving along  Thanks so much for all you help!


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## Befany (Jan 22, 2018)

Greetings Joplin,

So I have my Ultrasound results, but I haven't talked to my Doctor yet. I just received email notification of the test result. The report says I have a 2.1x1.3x1.3 cm smoothly marginated cystic structure in the mid portion of my left lobe. They also note a tiny cyst on the mid portion of my right lobe. I'm assuming it's too small to be measured.
Per report both thyroid lobes show normal homogeneous echogenicity. 
Size is normal with right lobe being 4.6x1.3x1.4cm and the left lobe 3.2x1.3x1.5cm. The thyroid isthmus is thickened 6mm. 
Their impression is that the nodule is a large, benign cystic structure.

What do you think? What are some questions I should ask my Doctor? The nodule/ cyst is certainly troubling as it's causing problems swallowing. My throat stays sore as well and I randomly go hoarse. 
I wonder why my Isthmus is thickened? Any input and guidance is greatly appreciated! ????


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## joplin1975 (Jul 21, 2011)

You should probably have that nodule biopsied. Anything over 1cm should be biopsied. I wouldn't be too worried - the characteristics don't seem overly concerning.

And yes, it can absolutely be the case of your hoarse threat.

Often times, once you get on medication and get your labs stabilized, your nodules can shrink and you might be more comfortable.

????


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## Befany (Jan 22, 2018)

Thank you Joplin, that would be fantastic. I definitely don't want a permanent sore and hoarse throat???? I'm certainly looking forward to getting medication. I'm assuming my Dr. will start Levothyroxine or something similar. Since she agreed to start something if my labs didn't improve and after seeing my ultrasound results. I'll be so happy once I'm not so terribly fatigued anymore ????
I'll ask for a biopsy. I like that the cyst is smoothly marginated. Seems like a good sign.


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## Befany (Jan 22, 2018)

Hi again,

So I received a call from my Doctor's nurse who told me she basically wants to watch the nodule to see if it gets bigger. I asked about a biopsy and asked if an ultrasound can declare a nodule benign with certainty. The nurse wasn't sure and said she'd get back to me once she talks to my Doctor. 
It's my understanding an ultrasound cannot rule out malignancy entirely. I agree that my ultrasound looks promising, I'd just like to know for sure. Of course the discomfort issue remains. 
I also asked to be started on something to adjust my levels so I can hopefully start feeling normal again. 
I thought a biopsy for a nodule over 1cm was automatic? This sure seems like a long journey


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## jenny v (May 6, 2012)

You've got it right, an ultrasound cannot confirm or deny malignancy, only a biopsy can. And yours is large enough to warrant a biopsy (anything over 1cm qualifies).


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## Befany (Jan 22, 2018)

Thank you Jenny, I appreciate you response! Hopefully my Dr. is willing to agree to a biopsy.


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## joplin1975 (Jul 21, 2011)

Yes, the standard of care is any nodule over 1cm should be biopsied.


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## Befany (Jan 22, 2018)

Thank you Joplin, I haven’t heard back from my Doctor’s Nurse yet. Hopefully my Doctor will agree to the standard of care and not solely place her reliance on the ultrasound.


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## Befany (Jan 22, 2018)

Okay, so here I am with more questions. I've been googling like crazy, but I'm not really getting anywhere. I got a call from my Doctor's nurse again who told me that the cyst in my thyroid cannot be biopsied, it can only be drained or removed. She offered a referral to ENT which I took. 
When I asked about thyroid hormone replacement she told me my Doctor wanted to wait until I see my Neurologist as she wants to be sure my fatigue is not or is neurological. I got frustrated and reminded her that my FT4 and FT3 Levels aren't where they need to be despite showing up as "Low Normal" . I reminded her fatigue is not my only symptom. She said she'll ask the Doctor again. In the meantime I stay cold and exhausted while my hair falls out and my nails keep breaking. Any suggestions as to what I can do? I don't like taking medication and here I am fighting for T4 replacement. Does anyone have experience with a cyst on their thyroid as opposed to a nodule? I'd like to hear about your experience. I think I'm done ranting now, sorry ????


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## jenny v (May 6, 2012)

It seems odd to me that she says they can insert a needle and drain a cyst but they can't insert a needle and get a sample for testing (i.e., a biopsy). Also, I don't think you can just remove a cyst, you have to remove the whole lobe it's in. I'm not totally confident the nurse knows what she's talking about but I would keep calling her to remind her of your other symptoms and push for meds.


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## joplin1975 (Jul 21, 2011)

I agree with Jenny. People do get cysts drained often, but you can test the fluid for the presence of cancer cells.

A cyst is a nodule. There are three kinds of nodules: fluid-filled, complex - partially fluid/partially solid, and solid.

Being within range but on the low end of things and not getting taken seriously by doctors is, unfortunately, common. Keep advocating for yourself. If you can, get a second opinion.


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## Befany (Jan 22, 2018)

Thank you Jenny and Joplin! I honestly don’t think my Doctor knows what to do. I don’t think she expected me to push for a FNA and referring to it as the standard of care. I have an appointment with an ENT on the 23rd. Hopefully he will be more helpful. I will keep pushing for medication with my Doctor in the meantime. I didn’t expect her to be stuck on “normal ranges”, especially since she pointed out I’m in the low range and she suspected My thyroid is under functioning. What a mess! Thank you so much ladies, for sharing your knowledge with me????


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## jenny v (May 6, 2012)

Unfortunately, we have to be very assertive in demanding care with a lot of doctors. It stinks, esp. when you don't feel well. An ENT is a great next step, they are much more educated on the neck and open to things like FNAs and ultrasounds. An ENT did my thyroid surgery and he helped me more in 6 months than years of endos.


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## Befany (Jan 22, 2018)

Thank you Jenny, that’s encouraging to hear that your ENT was so helpful. Hopefully the ENT I’m going to see will prove to be just as helpful. I’m already exhausted enough but it seems when I assert myself it lends the impression that i must not be doing so bad. Just the “little” phone calls with the nurse had me out of breath afterward and feeling worse. Someone has to listen. Perhaps the ENT won’t mind a trial basis of T4. Thanks so much again, I need all the pointers I can get????


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## jenny v (May 6, 2012)

Let us know how the appointment with the ENT goes.


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## Befany (Jan 22, 2018)

I sure will Jenny, thanks so much!


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## Befany (Jan 22, 2018)

Hello again Joplin and jenny,
I saw the ENT today and he drained my cyst. He said it could refill within a week or it may not ever return. The fluid drained will not be sent to pathology because it's just fluid per ENT, no cells to analyze. 
He didn't want to get into my hypothyroidism symptoms as he said my PCP or an Endocrinologist should handle that. 
He insisted my Thyroid is fine per labs. I disagreed with him. 
He prescribed antacid pills for my difficulty swallowing saying he's convinced my cyst didn't cause the trouble. Funny how it all happened at the same time. He'll see me again in one month. 
I'll see my PCP on March 6. She will draw thyroid labs again and I pray she will put me on a trial of Levothyroxine. I started gaining weight and I've not changed my diet. I'd hate to have to try to find a new Doctor.


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## jenny v (May 6, 2012)

Well, at least you got the cyst drained. I'll be interested to see if it fills back up or not.

It sounds like you're going to have to get assertive with your PCP to get a trial of Levo. It's unfortunate, but it's not uncommon for thyroid patients. I had a knock down, drag out fight with one endo to get my dosage increased by a slight amount and had to practically swear I wasn't using thyroid drugs as a weight loss tool. It's very frustrating.


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## Befany (Jan 22, 2018)

Hi jenny,

I will keep you posted. I too am eager to find out if the cyst will refill. It's certainly easy to get discouraged with labs that are hypo but still within "normal range". 
I realize Doctors have a license to watch out for and I'd like to think they are genuinely interested in protecting patients' health. 
However, it seems unfair and discriminatory to have to go outside of the insurance model to see a conventional Doctor who is more informed and doses according to symptoms and labs. Not everyone can afford to do so. Good healthcare should not be a luxury, or based on the type of insurance one has. 
Something has to be done to change this. 
I'm looking forward to my appointment with my PCP so I can make my case for a trial of Levothyroxine in person. 
Thank you for replying jenny. I'll continue to fight for the care I need.
Have a great day ????


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## Befany (Jan 22, 2018)

Greetings jenny and Joplin,

I saw my PCP today and the visit was promising. She agreed that my last two labs show a steady (her words) decrease in Free T3 and Free T4, while my TSH increased. She said she is open to a trial dose of Levothyroxine if my labs drawn today have either the same result, or Free T4 and Free T3 have decreased again. 
She also checked my Vitamin D levels which somehow didn't happen during my last appointment despite her agreeing to do so. I doubt this was intentional. Hopefully I'll get a call this week still informing me that i'll be starting Levothyroxine. 
As far as my cyst is concerned, it has not refilled so far. I hope that's a good sign. Though I still deal with random hoarseness, but I can live with that.


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## jenny v (May 6, 2012)

If your labs haven't shown another decrease and she's hesitating on the trial of levo, bring up that you've got a ton of symptoms and you feel bad enough to try regardless of whether your labs show you "need" it or not. Good luck!


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## Befany (Jan 22, 2018)

I sure will let her know jenny, thank you! I’ve reminded her during the appointment how lousy I’m feeling as well. Hopefully she won’t hesitate.


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## Befany (Jan 22, 2018)

Greetings jenny v and Joplin,

It seems like forever since my last post. I am happy to report that I just received an email from my Drs. Nurse that Levothyroxine 50mcg and Cytomel 5mcg are being prescribed for me. I am so relieved the fight for treatment is over- at least for now. I'll try to take it as early as possible as I also take vitamins and magnesium. If I recall correctly I have to wait at least four hours before taking those after taking my thyroid meds. 
My last labs on March 6 were:
Free T4 1.17 .81- 1.70
Free T3. 2.9 2.6-4.4
I'm to have my FT4 and FT3 tested six weeks after starting the medications. I just hope this is the road to recovery


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## joplin1975 (Jul 21, 2011)

Great news!

Yes on waiting four hours ????


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## Befany (Jan 22, 2018)

Thank you Joplin????


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## jenny v (May 6, 2012)

That's great news!


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## Befany (Jan 22, 2018)

Thank you jenny, I’m thrilled????


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## Befany (Jan 22, 2018)

Greetings everyone,

So it's been a while. I was just wondering about the improvement of my labs. So on March 6 my results were:

Free T3 2.9. (2.6-4.4)
Free T4 1.17 (.81-1.7)

At the time of my re-testing after having taken 50mcg of Levothyroxine and 5mcg of Liothyronine for six weeks on May 11 my results were:

Free T3 3.0 (2.6-4.4)
Free T4 1.16 (.81-1.7)

I still struggle with fatigue, loss of energy, some constipation, migraines, lack of ability to focus and memory issues. My cold sensitivity has slightly improved but I still freeze occasionally when everyone else is burning up.

My Vitamin D results were 46 (30-100) I take 5000IU daily.

Is the change in my labs reasonable for the time I have been on Thyroid meds or can I expect there to be more improvement on the same dose? I see my Doctor Thursday and i would like to be prepared if I need to ask for an increase in meds. 
Any input is greatly appreciated.

Thanks a million!


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## Lovlkn (Dec 20, 2009)

> Is the change in my labs reasonable for the time I have been on Thyroid meds or can I expect there to be more improvement on the same dose? I see my Doctor Thursday and i would like to be prepared if I need to ask for an increase in meds.


Goal is to fall closer to 3/4 of the range.



> Free T3 3.0 (2.6-4.4) *((3.5-3.95))*
> Free T4 1.16 (.81-1.7) *((1.25-1.48))*


I've edited the 1/2-3/4 range within the range in bold above.

If it were me - I would ask to double the Lilothyronine to 5mcg 2x a day and retest in 6 weeks. By increasing your T3 hormone your FT-4 should naturally increase.


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## Befany (Jan 22, 2018)

Thank you Lovlkn,

I appreciate the prompt response! I will ask for an increase of Liothyronine to 5mcg twice daily. Since my Free T3 has only minimally increased could I have a conversion issue from T4 to T3?


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## Lovlkn (Dec 20, 2009)

Likely


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## Befany (Jan 22, 2018)

Thank you


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