# Why would FT3 drop?



## Scanders (Sep 9, 2015)

New labs, and I'm not sure why my FT3 would have dropped this much. Historically my FT4 and FT3 seemed to have been relatively proportionate.

Past labs:
TSH (0.2-4.5) 4/18--.39, 6/18--.16, 7/31/18--1.90, 9/23/18--.70, 12/13/18--1.27
FT4 (0.7-1.5) 4/18--1.1, 6/18--1.2 (didn't know labs were happening and took levo), 9/18--.9, 12/13/18--1.0
FT3 (1.7-3.7) 4/18--2.4, 9/18--2.4, 12/13/18--1.8

I've been taking .75mcg of levothyroxine daily since early October. My endo had wanted me to keep taking .75mcg 6 days per week and a half tab on the 7th day, but I made a decision to just add the half tab back as I was starting to have hypo symptoms, and I had just had labs done the week before and felt they supported the minor increase. I do respond to minor changes in thyroid hormone, per my endo. She has left practice, so I will be dealing with someone who doesn't know me, but hopefully my endo left good notes.

Anyway, I thought I was feeling better until a few weeks ago where I developed muscle cramps and pain, increased fatigue, increased cold (the kind that is in my bones, not just because it's cold out), etc... I don't think I'm as mentally foggy as I've been in the past when I started moving toward hypo. My endo said my goal should be to keep TSH below 1.0, but I don't see any endo getting especially whipped up with 1.27. She hasn't always tested FT4, let alone FT3, but since she did order it this time, and I see this big dip in FT3--should I worry about it? Or should I just sort of ride this out and see if things level out? Would considering an increase in levo even be helpful? Or maybe something environmentally impacted FT3?

Thanks!


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## GOLGO13 (Jun 13, 2018)

From what I can tell from experience, FT3 may not follow the path of how you are feeling...or, maybe the body is trying to compensate for how it handles the T4

Your symptoms seem like hypo...or like I feel if I'm not on enough meds.

By the way I am also very sensitive to dose changes. I don't know why but it is interesting. Probably has to do with the gut. If I go from .88 to .94 (splitting pills) it makes a big difference within a day or two. My heart rate dips down on the .88 right away. My PCP thinks me taking split pills maybe something. Like I'm not absorbing as well on in tact pills. This could be true as I felt hypo when I was taking .50 in tact plus a half an .88 to make 94. I had to go back to taking half a 100 and half a 88. But that could also be the 50s have less power than the half 100s.

Either way super annoying to deal with.

For me I feel like I am on the bottom edge of normal. My TSH is pretty high though at 3.6ish. It will be interesting to see how my endo decides to adjust.

Bottom line, I'm wondering if FT4 and FT3 (especially FT3) could be misleading. If the body is working on compensating for how to handle the synthetic hormone.

I'm often told on here that some T3 (cytomel) could help me. That could be the case but I have not been willing to try it yet. And I havn't had doctors who are likely going to get it for me. I'm trying other methods for now, but may need to do some cytomel with my T4 meds in the future.


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## Lovlkn (Dec 20, 2009)

Scanders - both your FT-4 and FT-3 indicate that you are hypo.

Goal is to be somewhere between 1/2-3/4 of ranges for both FT-4 and FT-3


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## Scanders (Sep 9, 2015)

Next is the tricky part--getting a new doctor to increase replacement hormone. But still, why the big drop in FT3 after being stable--albeit low--for all this time?


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## joplin1975 (Jul 21, 2011)

Some times after you've been on meds for a bit, you end up being more active without realizing it and your body just needs more t3.


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## Lovlkn (Dec 20, 2009)

I've recently gone hyper 2x in the last 6 months on the dose I have been on for 15 years.

It was my FT-4 spiking, not my FT-3. Been chatting w a few thyroid veterans and the thought is there must be something up with the T4 hormones being dosed


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## Scanders (Sep 9, 2015)

Actually, with a recent project at work I'm working out fewer days per week. 
Anyway, being in between endos went about as I expected: "your labs look perfect, we can't/won't change anything, and you probably don't need a recheck for 6 months to a year." I explained symptoms to the nurse (not even the little things that I know typically mean I'm trending down lower, so as not to sound nuts, like hair falling out, louder ringing in my ears, itchy shins, joint pain, tingly toes, and increased "fire-eye" at night, which had been better until the last several weeks) and the answer from the doc, of course, was that there are many things that can cause fatigue, leg cramps, and cold. I asked if they would at least want to order labs before my next visit in March with my new endo? I mean, what would be the point of a visit without any current data, such as labs? They had to consider that, and the response was that made sense and they ordered the labs. I tried an end run with my PCP--she wants endo to manage.
I'm just sort of venting here, because while I'm not at my worst, I was in a horrible hypo-pit over the summer and I don't want to go back (couldn't do my job--it was that bad.) I just want to monitor and prevent and return to that state. If I have my own labs drawn if I start to feel worse, do endos typically accept them if they didn't order them? I live in MN and think I could do that. Hmm, I do have some leftover 50 mcg tablets and a pill cutter, but even if I attempt a small adjustment, and find it to be effective, what happens when I'm out of pills? And why don't they want us to feel well? One more venting note--my prior endo left a note with a TSH goal of less than 1.0. Yeah, that's not how the covering endos operate...Argh...


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## Lovlkn (Dec 20, 2009)

> Hmm, I do have some leftover 50 mcg tablets and a pill cutter, but even if I attempt a small adjustment, and find it to be effective, what happens when I'm out of pills?


;-) Not wanting to sound like a crazy Thyroid patient here...

Call in for a refill as soon as you are able ( always) - that gives you a few extra pills as they typically refill a week or so prior to your running out.

You could also call and say you dropped your prescription bottle and a bunch went down the sink drain.

Are you able to order labs in your state yourself? I find self labs invaluable and plan to have some Monday as I have developed quite alot of anxiety mid day but my heart rate and BP are completely normal. Having made 1 change to my T4 hormone, I need to confirm what the cause is if any will show on the lab's. I see my doc 1/10 and need to know whats going on so he does not cut my meds.

Hard to believe I actually typed that last sentence - but as we all know - that's how we as thyroid patients need to act to protect our health


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## Scanders (Sep 9, 2015)

It looks as if I can order my own labs in MN. I see Lab corp and Quest diagnostics as options. Any idea if they are reputable? There may be more, but these two kept coming to the forefront of my searches.

If I were to adjust my dose a bit, I'm not sure how much. I'm not kidding when I say I'm very sensitive to changing hormone levels. Although I'm not so worried about titrating up--it's going down that seems to wreak the most havoc. I can recognize the signs of hyper just as well as hypo at this point.


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## Lovlkn (Dec 20, 2009)

> Lab corp and Quest diagnostics


Those are the lab draw locations.

I've used several online sites for lab sheet request - the one below is the most recent I've used. They charge $60 for FT-4 and FT-3 which is most important for dosing. I have used Healthcheckusa.com for more extensive testing to include TSI and the Free's.

https://www.walkinlab.com/labcorp-free-t3-free-t4-blood-test-panel.html

This one is TSH, FT-4 and FT-3 for $80

http://www.healthcheckusa.com/thyroid-tests/panels/thyroid-panel-ii-t4-free-t3-free-with-tsh.aspx


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## creepingdeath (Apr 6, 2014)

My insurance has me use Quest diagnostics.

I have my blood drawn at the out patient part of the local hospital and they send it to Quest.

I've had no problems......


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## Scanders (Sep 9, 2015)

Update:
Since I was feeling so cruddy back in December, I did add 25 mcg every other day to my daily 75mcg, for what I thought would be an average of 88mcg daily. I mean, I really was feeling cruddy! I will be seeing the new endo on Tuesday and had my new labs run today. Since I was in between endos, they would only order TSH with reflexive FT4. I have to say that I'm feeling the best I've felt in a while, so I hoped I had this dose dialed in. (I'd also planned to have my own labs run early in February so I could adjust the dose if necessary, but I didn't get around to it, and, I noted that I was feeling better--not hyper, just better.) TSH was low at .10 (.3-4.5) so FT4 did get run, and was 1.1 (.7-1.5) So, when I meet with the new endo on Tuesday, I may need some talking points. I'll have to tell her I increased the dose, but I'm concerned she'll ignore that I'm feeling well, and focus on that TSH. Should I be concerned that TSH is a little low if FT4 is mid-range? I remain terrified of going back into the hypo-pit. I think I might be looking for some studies, or something "official" that might say a low TSH is OK if FT4 is normal? Or will I not find that. I have not been successful finding something like that now that I might need it, but I thought I'd seen something in the past. Thanks!


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## Lovlkn (Dec 20, 2009)

> So, when I meet with the new endo on Tuesday, I may need some talking points. I'll have to tell her I increased the dose, but I'm concerned she'll ignore that I'm feeling well, and focus on that TSH. Should I be concerned that TSH is a little low if FT4 is mid-range?


No concern of a mid level FT-4 and your low TSH. It's the Free's that really matter - not TSH as it does lag up to 6 weeks and is not a true indication of free and unbound thyroid hormone in your system.

I have had 0 luck with endo's. All they want to focus on is TSH and since yours runs low - you will have battle trying to keep yourself properly medicated.

I have had the TBII test run - I insisted when a GP I was seeing 10 years ago flipped out about my low TSH yet low to mid range Free's. It was positive - I passed that off to the doc as having positive "stimulating antibodies". My doc I see now ignores TSH and focuses on my Frees. Been seeing him since 2009 and he's never changed my doses - despite flares up or down which I attribute to either drug strength variations or diet. I have run mid to 3/4 Frees for years and usually run a TSH of around .011 if in a good place, .008 is a tad on the hyper end or ranges and if I run a .25 I am actually in hypo ranges. Start researching TBII or TSH-binding inhibitor immunoglobulin (TBII)

For people who run a higher TSH those numbers probably sound insane but I have hashitoxicosis and had my thyroid removed 15 years ago and when my Free's are in a good place my TSH suppresses. I read somewhere ( don't have a reference) if one is properly medicated than it's only natural for the TSH to be close to 0 - because the body isn't calling for thyroid hormone. Makes alot of sense - too bad more doctors don't go with that thinking.

http://www.questdiagnostics.com/hcp/intguide/EndoMetab/EndoManual_AtoZ_PDFs/TBII.pdf Read bottom of paragraph on right - TBII can inhibit TSH binding to its receptor


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## GOLGO13 (Jun 13, 2018)

While I think this is a tricky topic and probably depends on the person, you may find this video interesting: 



Skip to 9:10 of the video and this is what an endocrinologist would feel about suppressed TSH...and why you may feel better with it.

Now, I will say this appears to be the best endocrinologist I've heard speak...as Lovlkn says they can be pretty difficult. Especially if you are not reacting well to the normal protocol. the 4 endo's I've been to have been mixed in quality and mostly not great.

This guy at least appears to be open to giving people some synthetic T3...so he seems to be a bit more progressive.

Since he's a teacher, and if you watch the whole video, you may realize why they go by TSH only most of the time.

I do think he brings up a good point though...and this could be related to your drop in FT3. There could be some sort of other issue causing you problems and increasing your dosage could be compensating. It's worth checking all the normal things that could make you feel bad. Iron/ferritin, B12, Zinc, etc....and have you had any big stress events lately?

Maybe that could be your strategy if they are worried about the suppressed TSH. You could ask them to test all the types of things that could make you need more thyroid hormone to feel good. That way, if they do find something out of wack, it could fix things. Do you have more historical test results? It could be interesting to see how things have changed over time.

Either way...good luck!!


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## GOLGO13 (Jun 13, 2018)

My current endocrinologist completely dismissed that I have a conversion issue. I don't think she tested to see if I do, she just said you would have had to be born with a conversion problem. I should have said, OK...let's test for that.

So I am going to a new endo in a month to see if I can get better help. Of course you can keep searching until you find a good doctor...and that can be tough.

I think for people with complex situations it's even harder. Like our members who had their thyroid removed. The guy in that video even mentioned about people who had their thyroid removed. So I'm sure that's a thing.

I just get disappointed when right off the bat they are dismissive. I hope your new endo is more open minded.


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## GOLGO13 (Jun 13, 2018)

I had another thought. How do you prepare for your blood testing? Do you take it first thing in morning before taking your dose? That is often advised.

Also, some supplements can affect the test. Biotin is one of the big ones. But only if you are taking a large amount of it. Some people with this issue do since it affects nails and skin. From what I understand, you'd want to stop using biotin 3-4 days before the test.

Something to consider.

Looking at your past labs from the first post, they look pretty similar to mine and I am also very sensitive to minor changes. Personally it appears to be a conversion issue which I believe I also have. If you can find someone to test RT3 that could be interesting. Endo's tend to not believe in that test...but to me it seems like a logical indicator of an issue. If your body is converting T4 to RT3 rather than T3, that's the sign of an issue. Usually low calorie diets or high amounts of stress.


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## Scanders (Sep 9, 2015)

Thanks for the replies! Golgo, unfortunately they didn't order FT3 this time, but in retrospect, I'm wondering if that drop in December might have been from stress, and I recall now some GI symptoms that may have been a bug, or also stress related. At any rate, I'm grateful that at least a reflexive FT4 was run, so we can see that in spite of a low TSH, my thyroid hormone levels are fine. Lovkin, what you said about the low TSH and mid-range FT4 indicating that perhaps I've got it right, since I'm feeling all right. So in talking with the new endo, I guess maybe my best defense is to not appear to be a "crazy thyroid person" demanding unreasonable amounts of replacement hormone. (I've read that happens.) I just want to continue with what helps me feel well. Doesn't sound crazy to me. (I'm still with endocrinology because my PCP doesn't want to deal with me until I've been on a stable dose for...I don't know how long, actually.) But we'll have to hope that I can get this new endo trained. It took a bit with the last one, but we got there. And I'm still hoping my old one will return to practice somewhere, even if not at my clinic.


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## Lovlkn (Dec 20, 2009)

> While I think this is a tricky topic and probably depends on the person, you may find this video interesting:
> 
> 
> 
> Skip to 9:10 of the video and this is what an endocrinologist would feel about suppressed TSH...and why you may feel better with it.


Golo - one point he makes is low TSH = Bone loss. I have to disagree with this statement as I have had bi annual dexa scans and having little to no TSH - I have maintained the Osteopenia I developed while full blown graves. Family history also impacts my bones. I do know that I am "stable" age is helping keep me in a good place. haha.

I feel that any endo you go to will hold firm on the importance of TSH testing and dosing. Don't give up and consider going to a different GP.


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## Scanders (Sep 9, 2015)

I had a bone scan last year since I had "undetectable" TSH for so long. Bone scan was excellent! But I am concerned that the endo will focus on TSH, and my GP, who I've seen forever, has already indicated she defers to endocrinology, since as I said, she doesn't want to manage this just yet. So, wish me luck! No use borrowing trouble unless I have to. I just wanted to be prepared with a plausible argument why allowing me to continue feeling well, as I do now, should be considered, even if TSH is low. Perhaps I'll be pleasantly surprised.


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## GOLGO13 (Jun 13, 2018)

Maybe just indicate that TSH doesn't seem to be correlating with how you are feeling. Maybe even trying to find out why that can happen. Usually that sort of thing is more common when on NDT or if taking biotin supplements.


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## Lovlkn (Dec 20, 2009)

http://jcem.endojournals.org/cgi/content/full/86/10/4814



> The Journal of Clinical Endocrinology & Metabolism Vol. 86, No. 10 4814-4817
> 
> Copyright © 2001 by The Endocrine Society
> 
> ...


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## Lovlkn (Dec 20, 2009)

Blocking TSH-R antibodies (blocking TRAb) block the receptor, preventing TSH from stimulating these receptors which can result in both low thyroid hormone levels as well as low TSH (in the latter case because the receptor is occupied by antibody). Some patients have both autoantibody types, that is, both stimulating and blocking TSH-R Ab. Depending on the "profile" of these autoantibodies at any point in the disease, the patient can experience either hyperthyroidism (more stimulating TRAb than blocking TRAb) or hypothyroidism (more blocking TRAb).What's important here is that the cause is autoimmune in nature, whatever the autoantibody type or metabolic consequences.

Here's the link to that last paragraph:
http://graves.medshelf.org/New_Antibody_Discovered


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## Lovlkn (Dec 20, 2009)

http://www.thyroid.org/patients/notes/march02/02_03_5.html

Thyrotropin-receptor antibodies in patients with hyperthyroidism caused by Graves' disease inhibit thyrotropin secretion 

The background of the study. Patients who have hyperthyroidism have low serum thyrotropin (TSH) concentrations. When the patients are treated, serum TSH concentrations rise to normal or above. In some patients the recovery of TSH secretion is delayed. This study was done to determine if the TSH receptor-stimulating antibodies present in the serum of patients with hyperthyroidism caused by Graves' disease inhibit TSH secretion.

How the study was done. The effect of TSH receptor-stimulating antibodies on TSH secretion was studied in rats. The rats were given immunoglobulins (IgG) purified from the serum of a normal subject and patients with hyperthyroidism caused by Graves' disease; the latter had high serum concentrations of TSH receptor-stimulating antibodies. Blood samples were collected for measurement of plasma TSH 1, 2, 4, 8, 24, and 48 hours after the injections.

The results of the study. After the injections of IgG, the 48-hour mean plasma TSH concentration in the rats that received the IgG prepared from the serum of patients with hyperthyroidism was lower than in the rats that received the normal IgG.

The conclusions of the study. In patients with hyperthyroidism caused by Graves' disease, TSH secretion may be inhibited not only by the high serum T4 concentrations, but also by TSH receptor-stimulating antibodies.

The original article. Brokken LJS, Scheenhart JWC, Wiersinga WM, Prummel MF. Suppression of serum TSH by Graves' Ig: evidence for a functional pituitary receptor. J Clin Endocrinol Metab 2001;86:4814-7.


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## Lovlkn (Dec 20, 2009)

http://www.hormonerestoration.com/Thyroid.html

Here is the paragraph that mentions a bit about it with an author cited in brackets:

"Even when doctors do prescribe thyroid hormone, they usually prescribe only
T4 (Synthroid®, Levoxyl®). It must be converted to T3 to become active. They give T4 in low doses that just "normalize" the TSH to any value within the reference range. The result is an almost universal undertreatment of thyroid insufficiency because the hypothalamic-pituitary axis is more easily suppressed by oral thyroid hormones than it is by the normal continuous T4 and T3 secretion by the normal thyroid gland. Once-daily oral thyroid replacement produces a large spike in serum levels and this over-suppresses the TSH for more than 24 hours. With the usual TSH-normalizing T4 therapy, free T3 levels remain relatively low (Escobar-Morreale 1996).
Often they are lower than before the T4 therapy was started leaving a patient more hypothyroid than before therapy!
{Also, when the TSH is reduced by thyroid replacement, so is T4-to-T3 conversion reduced throughout the body. (Kabadi 2006)}
Some conventional thyroid specialists are aware of this and do recommend giving enough T4 to push the TSH to the bottom of the reference range or a bit lower and to push the FT4 to at or above the top of its reference range, but most doctors are unaware of this, causing them to undertreat most of their patients."


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## Lovlkn (Dec 20, 2009)

Last 4 posts were from my Notes file. Hope this helps. Brokken would be a good "search". He's done a ton of research,.


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## GOLGO13 (Jun 13, 2018)

Another thought I had is they should test you more often in case the autoimmune attack is suppressing TSH by spilling hormone temporarily. But then it goes back to hypo afterwards.


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## Scanders (Sep 9, 2015)

Thank you! Very helpful!


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## Scanders (Sep 9, 2015)

Happy surprise! New endo left things alone, even with the low TSH, and ordered 88mcg tabs to make dosing easier than my patched together dosing. She did go on to talk a fair amount about the correlation between low TSH and atrial fibrillation (she's married to a cardiologist.) But for now she's willing to wait and watch.


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## Lovlkn (Dec 20, 2009)

YEA!!!



> She did go on to talk a fair amount about the correlation between low TSH and atrial fibrillation (she's married to a cardiologist.) But for now she's willing to wait and watch.


Now it's your job to "educate" her on "normal or in range" FT-4 and FT-3 and low TSH. I have been low TSH for over 15 years - have had no increase in my osteopenia nor any heart issues. What the medical community fails to SEE is that low TSH with mid range FT-4 and FT-3 is completely normal. Did you ask for the TBII test? Keep that one in your back pocket if not as Im sure in your case it will be positive since your TSH falls once your Frees rise


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## GOLGO13 (Jun 13, 2018)

My guess is you fall into a situation where TSH is not a good indicator. Maybe it has to do with your historical procedures.


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## Lovlkn (Dec 20, 2009)

It's a blocking antibody thing -


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## Scanders (Sep 9, 2015)

I, too, think I have a blocking antibody thing going on, especially given how challenging it's been to get FT4 up to mid-range and keep it there. Now, given her "talk" about how sensitive TSH is and the a-fib connection, etc, I expect that at some point she will want to see TSH higher. And of course there's the possibility that she's taking the watch and see attitude for this round so as not to get me riled up right out of the gate with the first visit. But I'll try to assume the best intentions, and also keep that TBII suggestion tucked away should I need it. Thank you so much for your support! (I was really worried about a new endo.)


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## Lovlkn (Dec 20, 2009)

I'm telling you.... you will never get a Endo to work with a low TSH - you need to find a GP.

Easiest way to work around all of this is to go to a integrative type doc - get your med's straightened out and then transition to a GP so insurance covers your visits. However, with the new healthcare - none of my semi annual visits are covered anyway and I pay out of pocket. Lab;s are always covered at an integrative doc and they tend to straighten out any other imbalances you have


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## Scanders (Sep 9, 2015)

Yes, I believe you, and I expect this is just the honeymoon phase, but I'll go with it while I can. I'm not sure my GP would treat low TSH any differently than the endo, so I'll have to keep in mind that I might need a new GP, too. Such a journey...


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## Lovlkn (Dec 20, 2009)

I saw 2 different GP's at the same time - alternated who I saw for prescription refills - this was over 10 years ago but it gave me the med's I needed to dial in my set dose. When they both freaked about TSH I had 1 of them run the TBII test. That worked for awhile then it was like she had amnesia and freaked again about the low TSH. That's when I found my current DO who treated a friend for Graves disease. He wasn't concerned about my TSH and told me as long as my FT-4 and FT-3 were within the ranges he didn't have any issue with it.

Taking it one step further - he started running semi annual DEXA scans ( which I now postpone to 3-4 years) and am living proof that having little to no TSH has not impacted my bones. I started with osteopenia ( family history and also years of not being diagnosed with Graves, and the fact I never drank milk after my teens and was low on D forever) anyway - my osteopenia is stable. I now take proper calcium, D and Magnesium and so far it seems to be working despite my lack of TSH.

If I was dosed using TSH I would be completely hypo.

Keep the faith - keep trying - eventually you will find a doc to treat your hormone replacement properly


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