# Thinking disjointed but can someone help me?



## Reporter (Mar 17, 2011)

Hi everyone. I need help understanding Hashimoto's. I'll start out here with the labs:

June 2013 
FREE T3 3.6 (2.2 - 4.3)
FREE T4 1.02 (0.57 - 1.25)
TSH 0.01 (0.34 - 5.60)

Feb 2013
Anti Thyroglobulin 113 (<4)
Anti TPO 86 (0-9)

2012 lab
TSI result 103 with ref range of <140 got two opinions about that, both endos say they consider that to be normal.

I've also had ultrasounds (get those regularly) and an FNA of a small hypoechoic nodule within the left lobe. That FNA was negative. Follicular cells found. Colloid nodule.

Got the results of my recent scan and uptake due to that low TSH.

Mine was normal. Therefore, endo (my new one here in Seattle) feels "this is a transient phenomenon." I asked him if it was thyroiditis, said it may have been, but did not show at the time of the scan.

Over the years I've received a trial of Levo and one of Tirosint, both were the lowest doses. Both made me hyper and I ended up in the hospital four days on the Levo. At the time my TSH always ran on the low end of normal: 0.94 with the highest being 1.36. FREES were low at that time as well. FT4 0.87 was the highest (0.70 - 1.90) and FT3 2.69 (2.00 - 4.20) was the highest for about a year of testing. My endo in NC demanded that I take meds. Ultimately the doctor at hospital said I didn't need the meds with normal frees and low TSH. That endo continued to disagree. Left him.

I've since relocated to Seattle. Labs have been tested three times this year. Back in Feb, everything was normal. This past month, however, two occassions my TSH remains 0.01. Frees are somewhat higher than past years, yet normal.

What does any of this mean? Is this the progression of Hashi's destroying my gland? Am I subclinically hyper? Overtly hyper? Doctor just said hyper, but overtly if I have symptoms....

Basically I don't understand the seriousness of of my "ailment" and want to know if have something to be concerned about and should I stop running? My pulse is never above 70 other than the occasional palpitation. Cardiac workup: echo, stress test, EVEN heart cath says I'm a healthy 40-year-old woman.

Any input is appreciated.

Thanks!


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## joplin1975 (Jul 21, 2011)

The presence of TSI is not normal. It continues to stimulate the thyroid, regardless of what you TSH or frees are, making you, in effect, hyper. Likely, as your thyroid function diminishes, levels of the TSI may rise. Or, it could be a transient thing.

I've attached a link to an article that essentially calls for anti-thyroid meds to be used in the hyper stages, then going back to levo during hypo phases. It's a tough see-saw kind of a road.

http://www.thetrp.net/article.asp?i...0;issue=4;spage=5;epage=6;aulast=Unnikrishnan

You might want to ask your doctors if there's anyway they'd refer for ablation/removal. I had 129% TSI which also was considered normal, but I simply could not tolerate the meds. Luckily, I had cancer, so we moved right to surgical removal and I've been able to tolerate the meds very well since and have felt "normal" for the first time in years.


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## Andros (Aug 26, 2009)

Reporter said:


> Hi everyone. I need help understanding Hashimoto's. I'll start out here with the labs:
> 
> June 2013
> FREE T3 3.6 (2.2 - 4.3)
> ...


Having TSI is not normal; you should not have any. This would indicate hyperthyroidism.

TSI
Normally, there is no TSI in the blood. If TSI is found in the blood, this indicates that the thyroid stimulating immunoglobulin is the cause of the of a person's hyperthyroidism.

Negative test results means that the autoantibodies are not present in the blood at the time of testing and may indicate that symptoms are due to a cause other than autoimmune. However, a certain percentage of people who have autoimmune thyroid disease do not have autoantibodies. If it is suspected that the autoantibodies may develop over time, as may happen with some autoimmune disorders, then repeat testing may be done at a later date.
http://labtestsonline.org/understanding/analytes/thyroid-antibodies/tab/test

Have you ever had this test?

Trab
http://www.ncbi.nlm.nih.gov/pubmed/17684583

What about a T3 Uptake test (protein), have you had that? And the RBC?

High RBC, hyper
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(76)91920-6/abstract

T3 Uptake test
http://www.drstandley.com/labvalues_thyroid.shtml (high, hyper---low, hypo)

The T3 uptake explained.
http://www.nlm.nih.gov/medlineplus/ency/article/003688.htm

What criteria was used to diagnose you w/Hashimoto's?

Good to hear from you but sorry you are having a battle w/your health!


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## Reporter (Mar 17, 2011)

Thank you both.
Andros, I've not had or heard of any of those tests above.
Just a bit of history: I've had a goiter almost 20 years and have been followed by endos in Georgia.

An uptake and scan in 2005 showed thyroiditis with TSH around .3 at that time. No evidence of nodules. No treament indicated. I was told many years ago that I was both hyper and hypo. I've had an MRI of my pituitary. Seems something is out of order, but all endos said treatment was not indicated.

The Hashi diagnosis , the P.A said is because I have TPO antibodies. The FNA diagnois has no mention of HURTHLE cells. It reads: 'NEGATIVE FOR MALIGNANT CELLS. SPECIMEN CONSISTS OF BENIGN FOLLICULAR CELLS, HEMOSIDERIN-LADIN MACROPHAGES, COLLOID, AND BLOOD. THIS PATERN IS CONSISTENT WITH A COLLOID NODULE."

Do I have Hashimotos? 
And with my Frees normal and TSH suppressed, does that make me clinically in a hyperthyroid state?
Considering that this recent (June 2013) scan and uptake are normal does that mean I do NOT have Graves even with "some" TSI in the blood? 
Do I need to worry about a thyroid storm?
Can I continue my running? (pulse is fine)

Sorry to do this....so many loaded questions, but on my own, the research I do doesn't make the right amount of sense to me.

thanks


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## joplin1975 (Jul 21, 2011)

I had 129% result for my TSI. I ran 20-25 miles per week with it and had no ill effects. But I also did not have heart palps. If you ever have those, I would advise against running.

Surgery has given me a new lease on life. I cannot imagine living with a thyroid. So, I'm biased -- I'd go for surgery. Block and replace is going to be tricky to deal with. It honestly feels like I've gained 10 years back, chronologically. So, if you can find a surgeon will to do it...go for it.


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## Andros (Aug 26, 2009)

Reporter said:


> Thank you both.
> Andros, I've not had or heard of any of those tests above.
> Just a bit of history: I've had a goiter almost 20 years and have been followed by endos in Georgia.
> 
> ...


I don't think you do have Hashimoto's. The FNA would have been definitive in that regard. (there are 2 kinds of Hurthle cells, info to follow)

Histologic diagnosis of Hashimoto's
http://emedicine.medscape.com/article/120937-diagnosis

Hashimoto's Hurthle cells
http://www.pathconsultddx.com/pathCon/diagnosis?pii=S1559-8675(06)71549-2

http://www.thyroidmanager.org/chapter/hashimotos-thyroiditis/

http://www.mayoclinic.com/health/hurthle-cell-cancer/DS00660

Cancer Hurthle Cells
http://www.thyroidmanager.org/Chapter21/ch01s12.html

http://www.mayoclinic.com/health/hurthle-cell-cancer/DS00660

TPO Ab is "suggestive" of many things...............

TPO Ab
Mild to moderately elevated levels of thyroid antibodies may be found in a variety of thyroid and autoimmune disorders, such as thyroid cancer, Type 1 diabetes, rheumatoid arthritis, pernicious anemia, and autoimmune collagen vascular diseases. Significantly increased concentrations most frequently indicate thyroid autoimmune diseases such as Hashimoto thyroiditis and Graves disease.
http://labtestsonline.org/understanding/analytes/thyroid-antibodies/tab/test

A lot to read but this is the only way I know to help you advocate for yourself.

And I do so badly want you to get help.

I live in Georgia (South of Atl.) and the endos were trying to kill me. Thank God I found a good doctor and she in fact did save my life. A Rheumatologist, no less! Go figure; but she knows her stuff inside and out.

How is your heart; do you have arrhythmia? If you do, it is not wise to push yourself like that for you could damage your heart. Many of us have ended up w/mitral valve prolapse and other conditions of the heart due to mismanagement of thyroid disease.


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## Reporter (Mar 17, 2011)

Hi Everyone. I had to go away for awhile because I find it terrifying dealing with this thyroid issue. I'd always heard, simple fix, just one pill daily.

Well I've been suffering from joint pain, tinnitus, memory and cognitive issues. Joplin I feel that, yes, I need to have this entire gland removed. The TSI has only increased since last checked, so it's not transient I don't think. I read that if you have high levels of TSI, total removal of the gland may cause thyroid eye disease. Because of that it was suggested to try Block and Replace to try getting the TSI down. More confusion. Don't know that I want to be bothered with some "specialist" experimenting with B&R.

My other concern: some years back, on two occasions, my Endo gave me a trial of Levo. Within a day or so I had muscle weakness, tinnitus, and what I thought was a very certain heart attack. There was squeezing and pressure, nothing like a regular palpitation. That sent me to the hospital. I ended up being admitted for four days. The treating doctor told me I didn't need the meds. This really angered me as I'd advised my endo's staff of the symptoms. They told me to give my body time to adjust that I really needed the meds because I was hypo (low TSH and low end of normal on the Free's).

I'm embarrassed to say that a few months later I allowed that same Endo (the only one in the town at the time) to start me on a small dose of Tirosint. He said I should do better and get to feeling better on that since it had no fillers. Okay.

Later that day I got the same symptoms as with the Levo so I haven't taken a pill since. Haven't seen that endo. It's been three years now. No meds. Still having ultrasounds of a multinodular goiter that appears all beat up on ultrasound. I've had this goiter twenty years. I'm 42. I've been folllowed by many endo's. Never treated. Always wait and see. Thyroiditis some said. Both hypo and hyper per others. No pituitary issue. Let's wait.

So my thought is to have this removed ASAP. If the entire thyroid is removed (as both sides have nodules and one has a mass that is ill-defined) won't I still have the three antibodies? If I got sick twice before, won't there still be an issue with me tolerating meds?

Right now per my cardiologist my heart is strong. The palpitations stopped about a year ago. Usually had them with panic attacks only.

These unanswered questions make it difficult for me to know how to choose and also I don't know my diagnosis. Hashimotos (the FNA did not mention Hurthle cells, only Follicular though read a positive TPO and TgAB confirms Hashimotos). Or do I have Hashitoxicosis since I have all three antibodies? But the problem with that, TSI confirms Graves, but two RAIU's were normal and I thought that ruled out Graves.

Thanks to you all. I really appreciate being able to come here for advice.

TSH 0.179 0.350-4.500

Free T3 2.7 2.3-4.2

Free T4 1.04 0.80-1.80

TPO 67.9 <35.0

TgAb 159.0 <40.0

TSI 329 <140

Vit B12 621 211-911

Vit D (25-Hydroxy) 34 30-89

Ferritin 22 10-291

ANA - Negative

....Andros I did not have the other tests done and had to go to my regular doctor just to get the Tgab and TSI.

Thx


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## joplin1975 (Jul 21, 2011)

The antibodies will be present, but there's not a target of the attack, so they tend to simmer down substantially. I haven't had any antibody tested since I've have my thyroid removed except Tg and TgAB (for cancer screening). Both are undetectable, which says a lot, to me. I also don't have the symptoms that I associate with TSI (namely fevers, heart palps, tremors, and anxiety).

I was always under the impression that TED is exacerbated by RAI, not surgery. I've had no issues with my eyes since surgery. I'll have to defer to the folks on this board who have a much higher TSI level than I do.


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## Reporter (Mar 17, 2011)

I'm pretty sure I need to get this taken out but wanted to include these reports.

Ultrasound 03/11/2015:

Right thyroid lobe 2.0 x 5.2 x 1.6 cm. Left 1.6 x 4.9 x 1.8 cm. Within the mid pole posteriorly, there is a 6 x 4 x 6 mm hypoechoic mass. With the lateral mid pole left thyroid there is an 8 x 2.4 x 0.5 cm hypoechoic mass. The larger mass is more ill-defined and demonstrates an irregular margin with the adjacent gland. Because of the poorly defined features of the second nodule I would advise fine needle aspiration for further assessment should prior films be unavailable to document stability. The right thyroid gland was mildly heterogeneous without a discrete mass.

Impression: Irregular hypoechoic nodule within the anterior mid to lower pole of the left thyroid gland. Advised FNA. Smaller nodules within the posterior mid pole. This finding could also be aspirated as clinically warranted or followed at annual intervals as clinically appropriate based on the underlying clinical risk for malignancy.

FNA from 2012: a discrete dominant nodule was not seen within the right lobe of the thyroid gland. Review of prior ultrasound showed a questionable nodule versus underlying heterogeneity. This likely just represents heterogeneous parenchyma in this region without a discrete nodule. Within the left lobe of the thyroid gland, there is a solid hypoechoic nodule seen superficially within the mid portion which was targeted for FNA. The tips of the needles are identified within the nodule....it was NEGATIVE for malignancy. Follicular cells.


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## joplin1975 (Jul 21, 2011)

I would absolutely advise getting it out. I think you will be very happy with the results long term (I qualify that with long term because it can take a while to get things settled after surgery).


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## Reporter (Mar 17, 2011)

Hi you two 

I really appreciate your quick replies and your enthusiasm to get me to doing better. I have had a million-dollar workup. I'm an otherwise healthy person, so I'm finally convinced my thyroid is the culprit of these symptoms:

Memory and cognitive impairment (daily for over a year now)

Muscle twitches all over (some times worse than others)

Stabbing muscle pain

Joint Pain, comes and goes

Eyelid twitching and dry eyes (Ophthalmologist said just eye strain, not TED) - worried abt developing TED.

Tinnitus (past 6 months)

Palpitations started again (but rarely. The most recent one had an EKG while having palps, no prob) Stress test normal.

Any rate tomorrow morning I have a consultation w/a Duke Surgeon and have an upcoming appointment w/an endocrinologist in Durham as well. I know I need to remove this entire gland but I have some questions concerning my diagnosis.

I have TSI, TPO, TgAB. My TSH has been very low for years, about the range listed above. FREE's usually low normal.

Do I have Graves?

(but two RAIU's did not confirm Graves, just thyroiditis)

DO I have Hashimotos?

(I thought TPO and TgAB together confirms the diagnosis but FNA found no Hurthle cells, only follicular)

Do I have Hashitoxicosis?

Have you all ever seen results posted with low TSH and low Free's? Does that make me Hypo or Hyper? or Strange?

Any opinion on this is appreciated and, certainly, let me know if any of this is incorrect.

Thanks!


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## joplin1975 (Jul 21, 2011)

My guess is that you have both Graves and Hashi's - it's entirely possible and that would make the most likely diagnosis hashitoxicosis. I can't account for the negative hurtle cell result.

I don't mean to sound flip by saying this, but...at this point I honestly don't think it matters. I had TSI, TPO, and TgAB, too, and all I can say is that I was not feeling well then but feel so much better now. I was told Hashi's, then cancer, then Hashi's, maybe Graves and cancer. Again, at the end of the day, when the dust settled, it really didn't matter. Finding a good surgeon (sounds like you've got that covered) and someone to help you with the post-op med process (again, sounds like you are on the right path) is the focus now.

Let us know how you make out, ok?


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## Reporter (Mar 17, 2011)

Sorry for my long delay. I have been frustrated, scared, uncertain and, at other times, in denial.

My update:

The ultrasound results noted above was full or errors. Therefore, the Duke surgeon did their own. The tech left the room and said several radiologists would review mine prior to my leaving....

The Duke surgeon referred me to one of their endos who did the usual labs, not much diff than those listed above: low TSH, low frees, but normal. Told me with the TSI and TPO can be positive with GRAVES and TSI can be positive with thyroiditis, some of the normal populations has TPO, so we got to find out why you have all three TSI TGab and TPO so I need the RAIU.

I had that this past Thursday/Friday. (Note: Duke uses a small dose of I-131, NOT I-123. I told my doctor I was only comfortable with I-123. She approved. Nuc Med said it's expensive though and that Duke only uses I-131 because it has a half-life longer than the I-123 and is also less expensive.)

Results of my uptake, I've not seen but was told it was 58% uptake with cut off being 30%. I have Graves.

I was given 5mg of Methimazole. Take once a day.

I don't understand why my TSH is always in the basement and my Frees are always low normal. Other Graves patients seem to have high Frees. I didn't inquire about that but was told I have SUBCLINICAL HYPERTHYROIDISM. I was told I should not be having symptoms even with high antibodies (see levels above). Do I have GRAVES but not hyper. Does having TSI mean that I'm hyper or just that I have GRAVES???

I've been having eye twitching and pain, red eyes, dry eyes and puffiness in the a.m. so I went to ophthalmologist. I have high eye pressure but no glaucoma and no optic neuritis. Endo says, I don't think you have TED. Very nice doctor. Gave me all the time in the world but even at DUKE their lack of knowledge.....

Back to RAIU on the day of diagnosis, last week, they said they could immediately give me the I-131 to ablate my thyroid. I said, no for the apparent reason, the worsening of TED. I elected to try the Methimazole, 5mg and have had worsening of eye symptoms with this. I awoke this morning with extreme puffiness. It had never been that bad in the six months I've been having symptoms.

Do you all think the med has further decreased my Frees pushing me into hypo. I did read that being hypo can contribute to TED, just as having Graves can.

What remains unanswered for me:

1). If Graves means having TSI, high uptake, low TSH and high Frees, why then is my TSH, Free T3 and Free T4 low?

2.). Will the 5mg of Methimazole lower my already low Frees and possibly exacerbate TED? I find it strange that my eyes which seem to have been improving got worse after starting Methimazole.

Joplin1975 I'm calling tomorrow to schedule surgery. I knew it would come down to me needing this but they wanted the RAIU, understandably.


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## Reporter (Mar 17, 2011)

Not sure if I need to move this post to the Graves forum.


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## jenny v (May 6, 2012)

I think getting it out is your best bet. Graves can swing around from being active (where your TSH is suppressed and your Frees are high) to being inactive (where your Frees are low and you feel hypo). If your Frees are currently low, I'm confused as to why they gave you methimazole since that would make you even more hypo.

And I was lucky enough to avoid TED, but I've read that once you've got it any changes in thyroid levels, hyper or hypo, can affect it. I'd definitely let your doctor know the methimazole is making your eyes worse asap.


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## creepingdeath (Apr 6, 2014)

With an 8 X 2.4 X 0.5 centimeter mass it must be quite noticeable.

Unless you meant millimeter ???

If it is that big, have it removed....


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## Reporter (Mar 17, 2011)

Thank you both. Actually, the 8 x 2.4 x 0.5 is as it was on the report. The Duke surgeon said there is no way that could be and said the entire report is useless. Therefore I had another one. My goiter is very small and hardly visible and I have just the one nodule and it's too small even to be biopsied.

Jenny V thanks. Me, too. I could not understand for the life of me why they gave me that. I took it for about three days, woke up feeling like my arm was broken and like I had knives in my thigh. My eyes ached and were swollen. That was yesterday morning. This morning I awakend the third this year and for a moment I didn't know where I was. My daughter who sleeps with me it was so sad I could not recall her name. I watched her as she was asleep and could not recall her name. My short term memory is disappearing. I told my doctor but he says with my Free's being low but normal I should not be having any symptoms.

Any rate I called this morning to make an appointment to have my thyroid removed. That, hopefully, will be on June 9th or 16th. It is not yet confirmed. But no RAI for because I know for certain that I have TED. It's mild but I don't want it to get worse.

Once my thyroid is removed what effect will that have on my TSI Tgab and TPO?

Will it really be easier and safer to tolerate meds once the thyroid is gone?

If my Free T3 and Free T4 levels are already low, will they become lower immediately after surgery?

Anything else I should expect or need to know?

Thanks for any and all opinions.


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## joplin1975 (Jul 21, 2011)

Most of your antibodies should be significantly reduced (often considered undetectable) once your thyroid is gone. This is an autoimmune reaction. Once the source of the reaction is gone, you should be able to stabilize much, much easier. What happens to your frees will depend on post-op medication. Have they told you their plans?


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## Reporter (Mar 17, 2011)

Hey Joplin.

I have such foggy thoughts. Most of the time it is so hard for me to string together a sensible, lucid reply. I don't know if that's the impact of Graves on my brain. I don't know if it can be reversed. I will say, though, that it's really affecting my self-esteem more than anything.

I spoke with a surgeon at Tulane some years back who performs the transaxillary thyroidectomies. In speaking with him, his level of knowledge, patience and honesty were all really very reassuring for me. So long as insurance approves, I will elect to have that surgery. I've sent updated records and am awaiting a call once he returns to the office on Monday.

A few questions:

How soon after surgery will I begin meds to keep from becoming hypo?

I hear that people who have the entire gland removed never really get to feeling better. Is there any truth to that or can doctors treat low thyroid adequately after TT?

In the meantime my great concern is having Graves and being on such a small dose. I don't know enough about Graves to know what is considered as having severe Graves disease. Being on such a small dose of Methimazole, 5mg once/day, is that okay until I can have surgery.


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## joplin1975 (Jul 21, 2011)

Everyone's experience was and will be different. If you are hyper going into the surgery, it often can take longer to "settle down." Your thyroid will likely "dump" excess hormone during the surgery and you go immediately hyper. So sometimes they like to give it a week or two before starting you on meds.

There is some truth to the idea that people never feel well after surgery and its mostly because many doctors 1) only test free t4 and not free t3 and 2) refuse to prescribe t3 meds along side t4 meds and/or will not consider desiccated medication (which has both t4 and t3).

I wish I could help with your concerns re: medication, but that's something I am not familiar with...


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## Reporter (Mar 17, 2011)

Hi everyone. I'm so fortunate to be able to come here and thank each of you immensely for your advice, your direction, and for sharing your experiences.

To update: In *May* I was diagnosed with nodular Graves disease due to having high TSI antibodies as well as the scan and uptake showed Graves. At the time I was having difficulty climbing stairs, I felt like crawling out of my skin, I was having palpitations along with a high resting heart rate at times. I was prescribed .5 of Methimazole though my Frees at the time of diagnoses were high normal. TSH was slightly surpressed. At follow-up these were my results:

Solstas - *June 13th*

TSH 0.534 (0.350 - 4.500)

Free T4 0.81 (0.80 - 1.80)

Free T3 2.3 (2.3 - 4.2)

Because they were low at this point, I elected to discontinue taking the .5 because I was so close to becoming hypo and was surely feeling the effects of that. However, my endo at Duke said I needed to continue taking, if only .25 of the Methimazole until surgery. He explained that not doing so could put me at risk of having a stroke or heart attack. So I took .25 felt more hypo and my eye got worse it seems, just morning swelling, pain, and slight pressure in the left eye. The right is not so bad. Worried about my eyes and some symptoms I was having, I went to an Internist while in Atlanta to get my labs done. My results:

LabCorp on *August 8th*

TSH 0.060 (0.450 - 4.500)

Free T4 1.03 (0.82 - 1.77)

Free T3 2.7 (2.0 - 4.4)

TSI 242 (TSI in May at time of diagnosis was around 330)

Based on the above, this Internist says that I'm NOT hyper in spite of the supressed TSH. My endo at Duke says the opposite, that the suppressed TSH has me hyper. She recommends that I continue taking the MMI and begin the *Potassium Iodide *today. That's recommended by the surgeon. Says that is supposed to make my gland less vascular, less bleeding during surgery and prevent thyroid storm after surgery. Says all of his Graves patients must take that.

What I'm having is the *robotic transaxillary thyroidectomy.*

*My questions*: If I take the Methimazole, I get more hypo. If I don't take it I become hyper. If I'm too much in either direction, my eyes, I feel are getting worse, more a.m. swelling, more pain,

*Based on the August labs, am I hyper or hypo?*

*Do I discontinue the Methimazole over the next week, til 8/28 surgery?* (The labs don't show that I'm hypo on the August 8 results but after having taking the meds now for well over a week, I feel that I'm now hypo)

*Will the Potassium Iodide aggravate my eyes? *

Hoping surgery will lower the TSI.

Hoping the Iodide won't make them worse.

Hoping the doctor will not leave me hypo for long after surgery.

Hoping the doctor won't dose based on TSH. I read you cant rely on that in Graves patients/

Doing everything I can so that my eyes won't get worse: Taking Flax oil, Cod Liver oil, fresh turmeric, ginger, lemon and limes. I use compresses. I sleep elevated.

Thanks for your time and advice.


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## joplin1975 (Jul 21, 2011)

According to your frees, you are hypo.

I don't know about the potassium iodine issue -- I'm not familiar with that. I do think that most of your eye issues are related to the very high antibodies, and not so much due to your hypo labs.

It's very likely in the short term after your surgery that you'll feel crummy. They'll probably delay the start of medication so that your body can "calm down" a bit...and you are hypo so you could feel more hypo. But it does get better long term. Did they talk to you about post-op meds?


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