# TSH must be above 10 to consider treatment?



## sharkie (Jun 20, 2011)

Is waiting until TSH is above 10 and waiting for TPO antibodies to go higher...normal before considering treatment for hypothyroidism?


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## northernlite (Oct 28, 2010)

Absolutely not!! I was symptomatic (almost non-functional) with a TSH of 8.44. Extreme fatigue, serious joint and muscle pain, shortness of breath, etc.

Treatment should begin in anyone that exceeds the upper max of 3.0 and has hypothyroid symptoms. I am still mildly symptomatic when my TSH is in the low 2's and feel best with it below 1.0.

What you are quoting is in the AACE clinical guidelines and is fine for a person that is asymptomatic. But I am betting most people will be symptomatic before their TSH hits 10 based on my experience.

https://www.aace.com/sites/default/files/hypo_hyper.pdf


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## lainey (Aug 26, 2010)

Well, if you go to Mayo it is. They have their own standards of practice.

Actually, in the research, under 10 is usually considered subclinical for classification purposes and in some studies, they look for a TSH over 20.

That said, a vast majority of the normal population has a TSH of less than 5. The upper limits of the ranges by testing labs for diagnosis have shifted down somewhat from that in the last few years, true.

Why do you ask?


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## Andros (Aug 26, 2009)

sharkie said:


> Is waiting until TSH is above 10 and waiting for TPO antibodies to go higher...normal before considering treatment for hypothyroidism?


I personally would not consider that normal. AACE recommends the range for TSH to be 0.3 to 3.0 and "most" of us feel best @ 1.0 less which is fine with most doctors who are informed and who also run the FREE T3 and FREE T3 lab tests.

What's going on with you? Can you explain?


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## sharkie (Jun 20, 2011)

Well, I went to my Dr. as a follow up from the ER as they suggested I do so to get a referral for an endo (heart palps.) because my TSH was just above 5. But when I went, my Dr. said because my TSH was not above 10 and my antibodies were not high enough, he would not treat me. Instead he offered me antidepressants. I was just wanting to know if this approach is normal. It does not feel normal. I have my labs but on the ER labs (ER did the TSH and free T4), there are not any ranges.


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## Andros (Aug 26, 2009)

sharkie said:


> Well, I went to my Dr. as a follow up from the ER as they suggested I do so to get a referral for an endo (heart palps.) because my TSH was just above 5. But when I went, my Dr. said because my TSH was not above 10 and my antibodies were not high enough, he would not treat me. Instead he offered me antidepressants. I was just wanting to know if this approach is normal. It does not feel normal. I have my labs but on the ER labs (ER did the TSH and free T4), there are not any ranges.


What was the FREE T4? It is best to have ranges because different labs use different ranges. But, maybe the number is so unusual one of us can comment anyway.

Are you in the USA? If so, I strongly recommend that you find another doctor. Most of us would be incapacitated at anything above a 4.0 really!


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## McKenna (Jun 23, 2010)

> Dr. said because my TSH was not above 10 and my antibodies were not high enough, he would not treat me. Instead he offered me antidepressants. I was just wanting to know if this approach is normal.


Normal in the sense of "should it be this way". NO! Common practice among doctors who really don't know what they're doing...yes, unfortunately. Throwing psych meds at someone who has an obvious thyroid problem is quite common.

My endo treats with tsh around 3 or higher, lower frees and with the presense of antibodies.


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## sharkie (Jun 20, 2011)

These are the tests I have done so far:

ER:
TSH: 5.195 (I think the ER Dr. said this should not be over 3)
T4 Free: 1.05

One week follow up with regular Dr.
TSH: 2.74 (.35-3.30) Why is this going all over the place within a week?
T3 Free: 2.7 (2.3-4.2)
Thyroglobulin Antibodies <20 (<=40)
TPO AB 84 (<35) This was flagged as high.

Thyroid ultrasound: The right thyroid lobe measures 4.0 x 1.6 x 1.4 cm and the left thyroid lobe measures 3.7 x 1.4 x 1.3 cm. Two small nodules with benign characteristics are identified in the mid pole of the left thyroid lobe one measuring 4 and the other measuring 2 mm in greatest dimensions.

This is all I have had done. I do have many other symptoms that have shown up over the last 4 years. Now they have just reached the point where they are greatly interfering with life.

Forgot to say yes, I am in the USA.


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## Andros (Aug 26, 2009)

sharkie said:


> These are the tests I have done so far:
> 
> ER:
> TSH: 5.195 (I think the ER Dr. said this should not be over 3)
> ...


The ER doc impresses me; quite up to date on things.

When did you have the ultra-sound? Clearly you have an unhealthy thyroid but from the write-up on the ultra-sound, it does not look like there is suspicion of cancer.

Antibodies are constantly playing the numbers. They attack and back off; therefore the TSH, FT4 and FT3 are receiving mixed signals and are usually in a jumble.


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## sharkie (Jun 20, 2011)

Yes. I liked the ER doc. He has been the only one so far to take me seriously. Although, he did admit this area was not his specialty so was very reluctant to tell me too much other than he believed my thyroid was causing the problem rather than the problem actually being my heart.

The ultrasound was done two weeks ago.

That is interesting about the antibodies. Three to four years ago I would have a day of lots of energy then I would crash. My energy level would go up and down all the time. Then in the last two years it has been no energy at all most of the week, pretty much flat line then I would have a spike of energy for one day. On the day of the follow up appointment, I did not feel to bad. Not good, but not nearly as bad as the ER visit. I wonder what my TPO ab would have been on the day of the ER visit.


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## Andros (Aug 26, 2009)

sharkie said:


> Yes. I liked the ER doc. He has been the only one so far to take me seriously. Although, he did admit this area was not his specialty so was very reluctant to tell me too much other than he believed my thyroid was causing the problem rather than the problem actually being my heart.
> 
> The ultrasound was done two weeks ago.
> 
> That is interesting about the antibodies. Three to four years ago I would have a day of lots of energy then I would crash. My energy level would go up and down all the time. Then in the last two years it has been no energy at all most of the week, pretty much flat line then I would have a spike of energy for one day. On the day of the follow up appointment, I did not feel to bad. Not good, but not nearly as bad as the ER visit. I wonder what my TPO ab would have been on the day of the ER visit.


TPO was probably high. Wonder if that ER doc can refer you to someone? Ya' think?

The antibodies do this and it can go on for months or even years until "one" of them wins out and it's usually the one you don't want. They fight each other to the bitter end w/ the body constantly trying to right it's self.

If you were being treated with thyroxine replacement (provided we knew for sure that you are hypo), you no doubt would feel a lot better.

And if you are hyper and there is every possibilty as things are in the confusing state right now; conversely, the proper medical intervention would help.........................a lot.

That is why these tests are so important. To find out; hypo or hyper.

TSI (thyroid stimulating immunoglobulin),TPO (antimicrosomal antibodies) TBII (thyrotropin-binding inhibitory immunoglobulin), Thyroglobulin Ab, ANA (antinuclear antibodies), (thyroid hormone panel) TSH, Free T3, Free T4.

You can look this stuff up here and more.........
http://www.labtestsonline.org/

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.


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## sharkie (Jun 20, 2011)

I think I can try and find a specialist without a referral because my insurance is a ppo. I think it will be just a matter of the specialist not wanting the referral.

So I still need to have more tests done to determine if I am hypo or hyper? I wonder why the regular Dr. mentioned hypo. Maybe because the TSH was high?

I do know I have more hypo symptoms than hyper. My symptoms are: constipation, cold, sore muscles (muscles will burn with minor activity like brushing teeth, mowing lawn, etc.), stiff neck, headaches, hair constantly falling out, tired all the time, memory problems, nausea, throat tightness, and now heart palpitations. I know there are even more symptoms that I have, but some of them don't show up all the time so I don't always remember them until they happen again.


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## Andros (Aug 26, 2009)

sharkie said:


> I think I can try and find a specialist without a referral because my insurance is a ppo. I think it will be just a matter of the specialist not wanting the referral.
> 
> So I still need to have more tests done to determine if I am hypo or hyper? I wonder why the regular Dr. mentioned hypo. Maybe because the TSH was high?
> 
> I do know I have more hypo symptoms than hyper. My symptoms are: constipation, cold, sore muscles (muscles will burn with minor activity like brushing teeth, mowing lawn, etc.), stiff neck, headaches, hair constantly falling out, tired all the time, memory problems, nausea, throat tightness, and now heart palpitations. I know there are even more symptoms that I have, but some of them don't show up all the time so I don't always remember them until they happen again.


See.............the symptoms don't always hold true; they can and do cross over. That's the conundrum. You do sound hypo but I am not fond of guessing. Not to mention that you should know the "why" of it and it would be good to have "baseline" lab results to refer to to see if there is any movement up or down w/ the antibodies once treatment commences.

Sounds like you have peripheral neuropathy which is metabolic in origin.

peripheral neuropathy
http://www.ninds.nih.gov/disorders/peripheralneuropathy/detail_peripheralneuropathy.htm

(when they say autoimmune, that does include thyroid disease)


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## sharkie (Jun 20, 2011)

Ok. Thanks so much for your help I really appreciate it.

Not sure about the Peripheral Neuropathy. For me, it is the repetition of the activity like you have been working out...my muscles just seem to get tired more easily or faster and that is what I mean by muscles burning. I don't have that if I am sitting still. The information you provided makes it sound like it happens as soon as you do the activity or are not doing any activity at all and the symptoms come on. For me, I have to be doing something that is repetitive for the symptom to occur.

:sad0049: I don't know.


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## Andros (Aug 26, 2009)

sharkie said:


> Ok. Thanks so much for your help I really appreciate it.
> 
> Not sure about the Peripheral Neuropathy. For me, it is the repetition of the activity like you have been working out...my muscles just seem to get tired more easily or faster and that is what I mean by muscles burning. I don't have that if I am sitting still. The information you provided makes it sound like it happens as soon as you do the activity or are not doing any activity at all and the symptoms come on. For me, I have to be doing something that is repetitive for the symptom to occur.
> 
> :sad0049: I don't know.


Could also be electrolyte deficiency and I don't just mean potassium. This is common also in thyroid patients.

http://www.drstandley.com/labvalues_electrolyte.shtml


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## sharkie (Jun 20, 2011)

Hmm that is interesting. In the ER my potassium was low at 3.3. I think my thyroid is causing problems all over my body. I am going to see if I can get to an endo on my own without the referral. I think I am going to have to start with my thyroid and work from there to see which symptoms get eliminated with thyroid treatment...if I can find a Dr. that will help me.


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## Andros (Aug 26, 2009)

sharkie said:


> Hmm that is interesting. In the ER my potassium was low at 3.3. I think my thyroid is causing problems all over my body. I am going to see if I can get to an endo on my own without the referral. I think I am going to have to start with my thyroid and work from there to see which symptoms get eliminated with thyroid treatment...if I can find a Dr. that will help me.


Yes; thyroid causes problems everywhere. It's like a domino effect.

Get you some Electrolyte Essentials. I have taken them for years. On-line at Vitamin Express. Very inexpensive. Take 2 a day.

Zero in on fruits and veggies (fresh.)


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## sharkie (Jun 20, 2011)

Thank you so much for all of the help. I have a question about the ultrasound, are the findings in my ultrasound enough to eliminate the possibility of cancer? Or should I have more tests? If the ultrasound is enough, then with positive TPO antibodies, does that indicate my immune system is the cause for my whacked out thyroid?


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## Joolzy (May 29, 2011)

Hi sharkie and welcome!

Your symptoms do sound hypo and I'm not keen on the presence of nodules either, with the autoimmune involvement it is very difficult to treat until you know exactly what is going on I think. My doctors too, did wait until i was 'result wise' hypo. I too was put onto antidepressants for the first few months and nothing was changing. I had a pretty scary up and down hyper/hypo few months until I was finally started on a low dose of thyroxine. My labs then were TSH 14.8 and the frees very low.

But even now, I am reading a book about the immune system and emotions, It seems that to me (I'm still learning and NOT a doctor, just a 7 year thyroid patient!) The adrenals have a lot to do with thyroid problems, I'm just not sure which way round it works yet. I.e If it's adrenal/metabolic energy/emotions first or thyroid first! :S

Anyhoo, I wish you well on your path to good health and hope that you can find a good doctor that will help you get there hastily!

Best wishes Joolzy :hugs:


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## Andros (Aug 26, 2009)

sharkie said:


> Thank you so much for all of the help. I have a question about the ultrasound, are the findings in my ultrasound enough to eliminate the possibility of cancer? Or should I have more tests? If the ultrasound is enough, then with positive TPO antibodies, does that indicate my immune system is the cause for my whacked out thyroid?


When you had this ultra-sound will influence my input. When did you have it.? It shows benign characteristics but that is subject to change. Plus, sometimes ultra-sounds don't pick up everything.


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## sharkie (Jun 20, 2011)

I had the ultrasound done two weeks ago.


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## Andros (Aug 26, 2009)

sharkie said:


> I had the ultrasound done two weeks ago.


Thank you; if that is the case, for the time being, things appear to be non-threatening.

There should be follow-up maybe once or twice a year. I don't know what the protocul is on that.

Things to look for would be swollen lymph nodes in the neck/clavicle area, hoarseness, trouble swallowing, sleep apnea, a choking feeling and the appearance of a goiter.

TPO is "suggestive" of autoimmune thyroid disease.


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## sharkie (Jun 20, 2011)

I just wanted to say thanks for all of the help.

I found a doctor who would help me. I have been diagnosed with Hashimoto's thyroiditis based on all the lab work (including positive tpo), ultrasound and symptoms. I am on day three of 50 mcg levothyroxine and will increase slowly based on elimination of symptoms. I have a blood test and a new appointment in a month.

I am having a difficult time noticing if the medicine is making a difference yet. I think I notice a few minor things, but it is hard to tell because certain symptoms seem to come and go naturally. Today, the nausea is not good.

When did the medication start working for everyone? I know I need to be patient...but am also scared to think that this is not the correct diagnosis.


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## Andros (Aug 26, 2009)

sharkie said:


> I just wanted to say thanks for all of the help.
> 
> I found a doctor who would help me. I have been diagnosed with Hashimoto's thyroiditis based on all the lab work (including positive tpo), ultrasound and symptoms. I am on day three of 50 mcg levothyroxine and will increase slowly based on elimination of symptoms. I have a blood test and a new appointment in a month.
> 
> ...


It usually takes about 8 weeks for the T4 to build up. You should be getting labs at every 8 week mark for further titration in small increments until you feel well. This is on-going. Then when you are euthryoid, you only need to get labs about every 3 to 4 months. Whatever you and the doc agree on and if you don't feel good, you call and get labs sooner.


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## sharkie (Jun 20, 2011)

I am on my fourth week of thyroid medication and am wondering if anyone else has experienced an increase in hypoglycemia symptoms once on the medication. This is horrible. I crash so fast and with very little notice. I had hypoglycemia symptoms the last couple years before my diagnosis a month ago. But nothing like this.

I am also still on the propranolol for the heart palpitations.


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## Andros (Aug 26, 2009)

sharkie said:


> I am on my fourth week of thyroid medication and am wondering if anyone else has experienced an increase in hypoglycemia symptoms once on the medication. This is horrible. I crash so fast and with very little notice. I had hypoglycemia symptoms the last couple years before my diagnosis a month ago. But nothing like this.
> 
> I am also still on the propranolol for the heart palpitations.


It could happen because you are probably experiencing a change in carbohydrate metabolism due to your thyroxine replacement.

Maybe this article will be insightful.
http://journal.diabetes.org/clinicaldiabetes/v18n12000/pg38.htm

And I do feel that this is an issue that you should talk to your doctor about. It's a balancing act. Hypoglycemia can be dangerous.

Are you checking your glucose with a meter every day? What is the reading when this happens?

Do you keep glucose tablets handy? Are you eating mini meals?


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## sharkie (Jun 20, 2011)

Andros said:


> It could happen because you are probably experiencing a change in carbohydrate metabolism due to your thyroxine replacement.
> 
> Maybe this article will be insightful.
> http://journal.diabetes.org/clinicaldiabetes/v18n12000/pg38.htm
> ...


No. I am not checking with a meter every day. This was never mentioned by the doctor. I have had three glucose test since December and they have all come back in range. This issue has come up big time sense being on the thyroid medicine.

I did notice that hypoglycemia seems to be common with hashimotos. I have also seen some things about adrenal problems???


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## Andros (Aug 26, 2009)

sharkie said:


> No. I am not checking with a meter every day. This was never mentioned by the doctor. I have had three glucose test since December and they have all come back in range. This issue has come up big time sense being on the thyroid medicine.
> 
> I did notice that hypoglycemia seems to be common with hashimotos. I have also seen some things about adrenal problems???


Well, I would not delay in making an appt. with your doctor. And it would be a good idea to get a meter and start checking your glucose.

For one thing, you would want to be sure it is your glucose; yes?

There are other things that could cause similar symptoms such as low ferritin.


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## sharkie (Jun 20, 2011)

Andros said:


> Well, I would not delay in making an appt. with your doctor. And it would be a good idea to get a meter and start checking your glucose.
> 
> For one thing, you would want to be sure it is your glucose; yes?
> 
> There are other things that could cause similar symptoms such as low ferritin.


Yes. I agree. With the low ferritin, would eating make you feel a little better in terms of these symptoms? I just had blood work done yesterday to check iron, b12, folate, cortisol, celiac and a couple other things.


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## Andros (Aug 26, 2009)

sharkie said:


> Yes. I agree. With the low ferritin, would eating make you feel a little better in terms of these symptoms? I just had blood work done yesterday to check iron, b12, folate, cortisol, celiac and a couple other things.


Glad about the blood work; you must let us know when you get results.

I don't know the answer to your question. I doubt if eating would make one feel better if it was low ferritin. But again; I sure don't know.


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## sharkie (Jun 20, 2011)

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