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Suggest treatment for hypothyroidism and fluctuations in TSH levels

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Posted on Mon, 25 May 2015
Question: Hello. Please help – I am so frustrated with my Thyroid condition. I was diagnosed 8 years ago with Hypothyroidism (testing for Hashimoto's was "inconclusive"). My TSH was a 12, and I was started on Synthroid. TSH came down, and for many years I felt pretty good at a dose of 125mcgs. I'm a 29 year old male. My mother also has thyroid issues.

About a year ago my health began to decline. My TSH went up, so my doctors increased my Synthroid dose to 137, and then 150. I tried Cytomel on and off, but would always GAIN weight while taking it. Weight slowly climbed over the year, despite dose increases, and I've now gained over 20lbs. Very unusual for me.

My doctor switched me to Tirosint 137mcgs, and asked me to skip one dose a week since the medication is typically more easily absorbed. So the Tirosint dose was around 117mcgs when these labs were taken:

TSH 3.6 (0.450 – 4.500)
FT4 1.59 (0.82 – 1.77)
FT3 2.9 (2.0 – 4.4)

The labs look Hypo, but the FT4 is also pretty high? Now I'm taking Tirosint 137mcgs and NOT skipping a day. I'm puffy, agitated, and still gaining weight / unable to lose. I'm so frustrated. Any insight to the above would be greatly appreciated.

Thanks!
doctor
Answered by Dr. Binu Parameswaran Pillai (1 hour later)
Brief Answer:
Previous dose of 117mcg was adequate

Detailed Answer:
Good day.
noted your concern. Sorry to hear about your symptoms. Your last Thyroid blood works shows a decent TSH of 3.6 which is still in normal range. It is not hypo. The free T4 was superb. It is a good result. . There was no need to increase the dose. If at all, I would advice to take 117 mcg everyday. I don't think there is any reason to increase dose to 137 mcg.
Not to worry. Keep the dose at 117 mcg daily and recheck TSH after 6 weeks.
Regards
Binu
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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Follow up: Dr. Binu Parameswaran Pillai (1 hour later)
Thank you for your answer. With all due respect, a TSH of 3.6 is high for me, and outside of the updated ranges. It's also odd that I have a significant amount of FT4, but my TSH isn't lower. Also, my FT3 should be higher and more in-line with the FT4. So I'm either not converting well, or my body isn't utilizing the synthetic T4 as well as it should. Regardless of the above, my symptoms are terrible, and I'm still gaining weight despite clean eating and exercise. So the symptoms point to something else going on, or that my replacement dose or strategy isn't working.
doctor
Answered by Dr. Binu Parameswaran Pillai (9 hours later)
Brief Answer:
Clarification on TSH

Detailed Answer:
Thank you for the reply.

Your Free T4 is in the upper range of normal. Ft3 is mid normal.

TSH of 3.6 is okay, but i agree that some people dont feel all that well when TSH is above 3.

In pregnancy, a most demanding state, we try to keep TSH below 2.5. So it may be good to keep TSH between 2 to 3 your case . If your TSH was 3.6 while taking 117 mcg of levothyroxine, it may be better to take 117 mcg x 6 days a week and 137mcg on sundays. Once you change the dose, recheck TSH after 6 weeks.

Please be aware that TSH IS A DYNAMIC HORMONE WHICH IS SECRETED FROM PITUITARY GLAND ON A PULSATILE FASHION. So the levels can vary multiple times in a single day. It is best to do the thyroid blood profile in the mornings in fasting state.

It is now recognized that, some people have tissue level defect in converting T4 to T3. They continue to feel unwell despite a good level of T4. Tirosint/Synthroid etc are pure T4 preperations and Cytomel is pure T3 preperation.

Endocrine society doesnt favour adding T3 in the routine management of hypothyroidism. However, it is reasonable to add Cytomel ( T3) to Tirosint ( T4) in patients who continue to experience hypothyroidism symptoms despite being on good dose of Tirosint/Synthroid. Armour thyroid ( natural animal extract) is a combination of T3 and T4, but all endocrine guidelines are against using an animal based preperation because it is difficult to titrate dose

It is good to take sufficient Iodine in diet.

Besides, may i suggest to do an 8 AM Serum cortisol . What about your libido and sexual function. If it is low, then it is better to check a fasting ( 7-9 AM) serum testosterone. A low testosterone levels also can cause weight gain. You may discuss this with your PCP

Kind regards
Binu
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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Follow up: Dr. Binu Parameswaran Pillai (2 hours later)
Thank you for the follow-up. I definitely am feeling overmedicated on the 137mcgs Tirosint. I'm anxious and jittery. It's been two weeks, and I've gained 5lbs with no change in diet or routine. Is it common to gain weight and retain fluids like that during a dose increase? If so, does it settle back down? I'm at a lose here.
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Answered by Dr. Binu Parameswaran Pillai (11 hours later)
Brief Answer:
Increase i thyroxine dose doesnt cause weight gain

Detailed Answer:
No. You dont gain weight with increase in dose. Usually dose reduction cause weight gain. You may need investigations for additional causes of weight gain ( which i mentioned earlier)
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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Answered by
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Dr. Binu Parameswaran Pillai

Endocrinologist

Practicing since :2003

Answered : 1435 Questions

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Suggest treatment for hypothyroidism and fluctuations in TSH levels

Brief Answer: Previous dose of 117mcg was adequate Detailed Answer: Good day. noted your concern. Sorry to hear about your symptoms. Your last Thyroid blood works shows a decent TSH of 3.6 which is still in normal range. It is not hypo. The free T4 was superb. It is a good result. . There was no need to increase the dose. If at all, I would advice to take 117 mcg everyday. I don't think there is any reason to increase dose to 137 mcg. Not to worry. Keep the dose at 117 mcg daily and recheck TSH after 6 weeks. Regards Binu