Friday, July 31, 2015

Basic intro to T3, T4, FT3, FT4, rT3 after thyroidectomy

T3 is the active thyroid hormone utilized in the body. T3 can be used directly essentially everywhere in the body.

T4 is a storage form of thyroid hormones. T4 cannot be used anywhere in the body at all, so it is considered inactive or storage. It can only be converted to an active hormone state (T3) before being used.

Some T3 is made by the thyroid; the rest is converted from T4 in places like the liver and kidneys before being circulated for use around the body, also in cells that convert T4 to T3 for their own use directly.

T3 is also in a prescription called cytomel or liothyronine, this is synthetic T3. Cytomel is often sold in 5 mcg (low amount) or 25 mcg (high amount) pill forms so it is difficult to titrate a long term dosage sometimes if you need to be on it. T3 is also in natural thyroid (NDT) prescriptions (from animals). There are 9 mcg of T3 in each grain of natural thyroid in USA. T3 has very rapid effects. It has a fairly short half life.

T4 is in a prescription called Levothyroxine, Synthroid, Tirosint and other names. These are the synthetic forms. It also is in natural thyroid prescriptions (from animals). In natural thyroid there are 38 mcg of T4 per grain of natural thyroid (NDT) in USA. T4 tends to change things slowly because it is converted to T3 before being used, and may take weeks to come out of the body and thus has a longer half life.


T3 is best measured by Free t3 which is a measure of how much T3 is available for use. This varies fairly widely over the day. A higher value means more is available. A low value and we generally do poorly at that point of the day where it is low.  There are other T3 measures other than the Free T3 form but they are not ideal. T3 labs don’t measure daytime levels well near time of taking medications based on experience, so Free t3 labs are fairly time sensitive. When Free t3 level is low, many of us experience severe hypo symptoms no matter what the TSH says. You can also experience too much T3 and get hyper symptoms so having an experienced physician handling prescriptions in the T3 or NDT area is ideal, unfortunately this is hard to find.

T4 is best measured using Free t4. When relatively high in some of us it excites a high level of hyper symptoms and I experience this fairly easily. I do poorly at high levels of Free t4. One can also be hypo or get hypo symptoms when the FT4 is quite low.

rT3: Reverse t3 is a primal response of our bodies sensing something wrong, and forcing a slowing of metabolic rates in an attempt to create a somewhat hidden self preservation mode of sorts. Basically your body attempts to slow metabolism when it senses you are ill, deficient in iron, minerals, vitamins, other hormones, or otherwise have something off or wrong. Having a high metabolism when ill would not be a good thing in general, so we developed an internal system to slow metabolism at these times. Symptoms sometimes may include hair loss and fatigue not resolved by raising FT3 alone. Basically rT3 blocks T3 receptors all over the body and the Free t3 can't get in. So you will feel quite poor, sometimes even presenting with a good FT3. rT3 looks similar to T3 to the body but it can't function like T3 at all. It blocks the active thyroid (T3) hormone from being used since receptors are blocked up by the rT3 molecule. We then expend less energy, but we won’t feel well. All people have rT3, one can never get rid of all of it. However when rT3 is really high, that is when our body has kicked into its mode of forcing a slowing metabolism. We can potentially correct situations of high rT3 by finding the source of the problem. 

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Two common problem areas and some symptoms often faced post TT

As thyroid cancer survivors, having no thyroid, we are fairly unique medically in that we can experience both an excess (hyper) and a deficiency (hypo) simultaneously.

HYPER (most common with a high FT4 post TT on high levels of T4, but can be from too high a FT3 too) symptoms include mood changes and swings, A mean irritability or a short temper, headaches and migraines, anxiety, palpitations, shortness of breath and/or breathlessness, too fast a GI system or changes in GI system, sleeplessness and restlessness, more of a sharp body ache or pain like joint pain or sharp shoulder pain issues, weight changes due to excess hunger with little or no satiety, lots of pre-migraine and migraine aura effects (can include thyroid ocular aura disorders -TOADs) even if you never get or have never had a migraine in your life.

HYPO (most common with low FT3 even if TSH suppressed) all the symptoms of hypothyroidism, but common are the brain fog, depression, loss of attention span (forgetting things), skin issues, hair loss, fingernail issues, feeling dog tired, Sleeping lots, slowing metabolic rate leading to inability to lose weight despite honest effort, Tired irritability, more of a dull and swollen body ache or pain like swollen joint pain, irritable/sensitive GI, inability to do things like we used to, constipation or too slow a GI system, blooming allergies, just can't focus on work or family. When very HYPO a differing kind of irritability or a "tired irritability" and a differing headache than the HYPER one. A very low Free T3 can also cause bradycardia, palpitations in some, and many types of cardiac issues are possible. Many more issues are common when HYPO and can be found on internet searches.




Tuesday, July 7, 2015

Free T Guide

This describes a method to look into for potential help ONLY for only those doing poorly after total thyroidectomy (TT). If doing completely well on current treatments, this is overkill and you need not read further.

It also is primarily geared for those who experience some aspect of HYPER and HYPO simultaneously from replacement hormones and the information is geared around that. This generally only happens for people without thyroids.

For those who experience only HYPO conditions/medication side effects or those who still have a thyroid, this information is not that much geared for you though it may overlap in many areas. Although hard, one can generally find help when only HYPO issues are the problem of replacement hormones. It is a much different story if you get mixed HYPER/HYPO symptoms where almost nobody will help. This includes sources working around Free t3 and the HYPO point of view.

Thus this is geared for thyroid cancer survivors post-thyroidectomy, doing poorly or very poorly, and who generally experience some aspects of hypothyroidism and hyperthyroidism from replacement hormones.

Modify as needed to suit your needs and situation.

Sorry if I don't always follow up, this is a purely voluntary effort.

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Should I work with a doctor on all this?

Yes absolutely, and you must do that. Using labs, data, and information about how T3 and T4 work are methods to help you work closely with a physician and not a system meant to work outside of any medical care system or healthcare system. Nothing here is medical advice. What is described in the Free T guide, FAQ, Thyroid cancer websites, and in discussion groups are information to help you work with your doctor, but they are information only and not meant as medical care or replacement for medical care.

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Is this a discussion about advocating natural thyroid?

No. This is about the kind of actual thyroid hormone levels that likely will get you back to feeling normal, and also about some of the side issues that interfere with this from happening. It is not an advocacy system for anything but getting back to normal so you can go back to the things that are important in life.

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My endocrinologist said my numbers look "good" and I feel sick, what is going on?

What an endocrinologist means when they say something like numbers are "good", means you are TSH suppressed for cancer recurrence prevention. TSH does NOT help you feel well. It has nothing to do with that. To feel well a person has to look at carefully timed Free T levels, plus vitamins, minerals, etc.

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What are the first steps?

Start a high quality vitamin and get a lot of labs.

See if a primary care or another doctor can order:
Free t3, Free t4, Reverse t3 (rT3), TSH, Ferritin, Total Vitamin D, B-12, CBC, CMP, selenium, zinc

Additional tests that may help find problems too:
Cortisol 4x a day (canary club easiest way to get but you pay), full iron panel added to just the ferritin and any/all of the sex hormones.

I would suggest a super quality vitamin that has a very good amount of active B vitamins, D with K, selenium, zinc. I would not say to take this every day the rest of your life, but see if a high end vitamin improves things and if not at least you tried one, then if it does help decide if taking it daily is actually needed or just occasional boosts every so often:

A good option that is whole food based and active B forms, but 8 daily:
http://shop.mercola.com/product/1008/1/whole-food-multivitamin-plus-tablets-240-per-bottle-30-day-supply

Dr Vita six daily some synthetic (not all active B complex):
http://www.drvita.com/products/six-daily-advanced-multivitamin

Sometimes a swap of the T4 medication is a worthwhile very first step, e.g. swap to Levoxyl from Synthroid. This helps many.

Ferritin (storage iron) has to be tested before you supplement. I would not take a multivitamin with iron for raising ferritin if you need it, but one needs to test it first anyway before supplementing.

Then learn about Free t levels. The quickest way to boost levels with significant T3 is to switch to natural thyroid, but any method you use, synthetic T3 and T4, or NDT it is wise to familiarize yourself with numbers that work for you.

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Important lab based goals and supplements to discuss with your doctors (primary care):

Total Vitamin D (25-Hydroxyvitamin D): 70 ng/mL (USA), 174 nmol/L (International)

B-12: 800 pg/mL (Best to use an active B complex only for raising B vitamins)

Optimized values for Ferritin, (ONLY for thyroid medication users):
Male around 60-90 ng/mL
Female 60-80 ng/mL
Ferritin is just storage iron or one type of iron measure. This is NOT the same as a person not taking thyroid medications, where a ferritin level about 50-60 ng/mL is fine.

Zinc 60-120 ug/dL

Selenium 75-190 ug/L

One can take Selenium and Zinc to help the T4 convert to T3. Check all your vitamins before adding as you do not want to go too high, or have the selenium level checked via lab first to see if you are low. Suggested dose if low/light:

Selenium (selenium yeast or selenomethionine) up to 200 mcg but suggest testing levels if possible as not all are deficient, OR several Brazil nuts that were actually grown in Brazil though this can be difficult to determine.
Zinc 30 mg

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Quick explanation of goals on Free T labs

For proper levels of FT3 and FT4 you should be on same medication for at least a month, and not taken your medication recently.

What counts the most is the FT3 at a reasonable or moderate FT4. A good FT3 at high FT4 such as can happen post TT on high levels of T4 only, even very high in range FT4, can leave a person quite sick sometimes still. The basic goal is to convert to a good or a very good FT3, at moderate to mid-level FT4.

There is variation in all individuals so learn what works for you, and change this model to your liking. Note that some do well at the lower numbers and some do well at the upper numbers, particularly on Free t4. Only by trying will you find out what works for you.

Natural thyroid has significant T3 and can be a quick way to get significant T3, but even so knowing the levels that are good is important.

Once you get levels to something like the below best you can, and if you still don't feel the effects of better T3 at moderate T4 levels that are an indicator to examine side issues such as reverse t3, iron, anemia, etc.

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USA based lab goals - For those who get both hyper and hypo issues.

For your Free T labs, you would want the Free t3 to test well over 3.25 pg/mL (ideally around 3.5 to 4.4) when the Free t4 is between 0.9 and 1.4 ng/dL. If the Free t4 is over 1.4 that is generally about the start of problems and crowds the Free t3 making it less valid. Basically the higher Free t4 actually sometimes prevents the FT3 from going up in some of us above these numbers (say FT4 of 1.4).

A Free t3 less than 3.25 can present issues for many. However if you have a cardiac risk, palpitations, or continue to have issues such as migraines from the higher FT4 consider trying the FT4 from 0.8 to 1.2 ng/dL bringing it down slowly to find optimal values where issues go away while at same time keeping the FT3 up with T3 increases as best as possible.

Better looking labs done with a T4/T3 combo with the intent of feeling more normal but keeping TSH suppressed, this is a person coming in having too many HYPER symptoms and also having HYPO symptoms at the same time. The goal they took was to reduce the T4 level and boost the T3 level:

Example1: A person who lost the HYPER issues after reducing T4 and adding T3 (everyone is individual so only you know if you still have HYPER issues).
Free t4: USA: 1.2 ng/dL
Free t3: USA: 4.0 pg/mL

Example2: A person still having moderate HYPER issues at above numbers(example 1) and still had to reduce the T4 level
Free t4: USA: 1.0 ng/dL
Free t3: USA: 3.5 pg/mL

Example3: A person still having moderate HYPER issues at above numbers (example 2) and still had to reduce the T4 level
Free t4: USA: 0.9 ng/dL
Free t3: USA: 3.25 pg/mL

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International units (SI) based explanations - For those who get both hyper and hypo issues.

For your Free t labs you would want the Free t3 to test well 5.0 pmol/L (ideally around 5.3 to 6.75) when the Free t4 is between 11.58 and 18 pmol/L. If the Free t4 is over 18 pmol/L that is generally about the start of problems and crowds the Free t3 making it less valid. Basically the higher Free t4 actually sometimes prevents the FT3 from going up in some of us above these numbers (say FT4 of 18).

A Free t3 less than 5 can present issues for many. However if you have a cardiac risk, palpitations, or continue to have issues such as migraines from the higher FT4 consider trying the FT4 from 10.3 to 12.87 pmol/L bringing it down slowly to find optimal values where issues go away while at same time keeping the FT3 up with T3 increases as best as possible.

Better looking labs done with a T4/T3 combo with the intent of feeling more normal but keeping TSH suppressed, this is a person coming in having too many HYPER symptoms and also having HYPO symptoms at the same time. The goal they took was to reduce the T4 level and boost the T3 level:

Example1: A person who lost the HYPER issues after reducing T4 and adding T3 (everyone is individual so only you know if you still have HYPER issues)
Free t4: Outside USA: 15.44 pmol/L
Free t3: Outside USA: 6.14 pmol/L

Example2: A person still having moderate HYPER issues at above numbers (example 1) and still had to reduce the T4 level
Free t4: Outside USA: 12.87 pmol/L
Free t3: Outside USA: 5.38 pmol/L

Example3: A person still having moderate HYPER issues at above numbers (example 2) and still had to reduce the T4 level
Free t4: Outside USA: 11.58 pmol/L
Free t3: Outside USA: 5.00 pmol/L

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When to get Free t labs:

Try to determine your symptoms as to HYPER/HYPO, or only HYPO, as a guide.

Labs tell you what your measurements are at that time. No time is right or wrong for the most part, however never take all your daily cytomel/T3 or NDT at once and test soon after as this will be the only way to really get data that does not work well or be comparable. If you take all NDT at once perhaps morning readings might be the only thing you can get to work as it will be hard to find the middle ground.

The time you chose may depend on your symptoms (see some of symptoms of hyper and hypo above). Those in process of converting over to a T4/T3 combo from very high doses of T4 sometimes like middle of the day or right before a second half of any cytomel because they want to know how high things get. Their challenge is currently more of the HYPER symptoms and the impaired T3 conversion from high FT4.

Those who have moderated values and are far away from the very high FT4 levels may choose to move over to AM readings before taking medications.


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Is there a simple way to help myself over time?

Create a written table or a spreadsheet to use at each lab. Over time include these columns or rows:

1 Date & Time of day of blood draw
2 Thyroid medications (T4 and T3 in mcg) and time taken
3 Free T3
4 Free T4
5 Reverse t3
6 TSH
7 Notes

Other labs to make a separate spreadsheet on

1 Ferritin level and other iron levels at last lab (no iron for one week prior), amount now taking if any
2 Vitamin D at last lab, amount now taking if any
3 Vitamin B-12 at last lab, amount now taking if any
4 Other vitamins and minerals taking: selenium, zinc, iodine, etc
5 Symptoms I am having at this date, and/or rating of how feeling & issues.

Make a cancer lab spreadsheet too
1 Date
2 TSH
3 TgAB
4 Tg
5 Assay used for Tg lab, call lab if not listed so you know

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Example Spreadsheet with goals, history

POTENTIAL GOALS:
FT4 1.1, FT3 3.7, TSH Suppressed, no HYPO or HYPER issues.

HISTORY:
1/1/15 3 PM, 150 mcg T4, 0 mcg T3, FT4 1.95, FT3 2.75, TSH 0.35 - on synthroid
Notes: Weight gain, irritability, brain fog. Hyper/Hypo both. Next I plan to get docs to replace 25 mcg T4 with 5 mcg T3

3/15/15 3 PM, 125 mcg T4, 5 mcg T3, FT4 1.5, FT3 2.65, TSH 0.6
Take 125 mcg synthroid AM, half of cytomel in AM, half at 3 PM labs and were before this second half.
Notes: Still having weight gain, doing worse. 5 mcg T3 was not enough as T3 falling behind, TSH also going wrong way. Still Hypo/hyper. Will try 2.5 grains NDT

5/1/15 3 PM, 95 mcg T4, 22.5 mcg T3, FT4 1.1, FT3 3.7, TSH 0.1 –
Take 2.5 grains Nature-throid, 40% in AM, 60% at 3 PM and labs were before this second half.
At goals, feeling better.

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General info on Free T’s (laboratory test):

One learns that Free T levels, not TSH, is the most critical thing to feeling well. It's not that we ignore TSH, because that is important for cancer prevention but TSH does not help you feel well. Free t's should be your guide to feeling well. Most doctors don't bother checking Free T labs carefully, they just look at TSH and assume you are ok even though the Free t's may be super out of whack and unfortunately you will be too.

One also has to look at vitamins, minerals, cortisol, iron, B-12, and others. Importantly, if T3 levels are good and Free t4 not too high, yet problems persist, that is a very important signal to look at reverse T3 and related issues such as iron.

Free t ranges are in a state of change. Free t4 ranges coming down, Free T3 ranges coming up over last 5-10 years. Ranges were designed around people with a thyroid, we need higher Free T3 post TT because we no longer have an on demand system and generally speaking the pituitary makes its own T3 from T4 so we want to be sure the rest of the body has an adequate supply in the post TT world where T3 issues cause most of the problems that happen because doctors take the T4 high making the pituitary supplied but the rest of the body not.

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FREE T3 – Active hormone

A better Free t3 range in US (traditional units) post TT would be something like 3.0 to 4.4 pg/mL (roughly 20% added to bottom of the range). One can get Free T3 related hypo symptoms well into the mid 3's particularly with no thyroid. If you are generally above 3.25 pg/mL and have no other issues such as vitamin, mineral, adrenal/cortisol and sex hormone related it is possible to feel ok. Official ranges vary but often much lower, an example range semi-updated would look like 2.4 to 4.4 pg/mL, but I would love to see the bottom raised. Definitely aim for above 3.25 pg/mL, and if you can get to 4.0 pg/mL that is better. Generally speaking if one optimizes all issues such as vitamin and mineral and other mentioned above, and the FT3 is low the only way to raise it is a long term cytomel prescription or natural thyroid containing T3.

For system international (SI) including Canada, or mostly non-US based labs: Conversion factor pg/mL to pmol/L is 1.5362.

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FREE T4 – storage hormone only no merit to making it high if doing poorly since T3 compensates.

Older Free t4 ranges in US often went as high as 2.0 ng/dL but some places have taken the top down to 1.5 ng/dL now, and if not that then maybe 1.7 or 1.8 ng/dL. I don't like my Free t4 over 1.4 so I can let T3 do its job. I am fine at moderate Free t4 but people vary where they feel well and some like it a bit higher, some like it lower. An example range reasonably updated would look like 0.75 to 1.5 ng/dL. If you test above 1.4 the only way to reduce this number is to reduce your T4 medications, and if your TSH is not where needed you need a long term cytomel prescription or switch to natural thyroid.

For system international (SI) or non-US ranges: Conversion factor ng/dL to pmol/L is 12.87.

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My doc doesn't want any of this, what should I do, and why is such BAD research on T4/T3 combination and NDT the only thing out there?

Many endocrinologists today oppose the use of combo T4/T3 as well as NDT for thyroid cancer patients. A few endocrinologists are fine with it but they are hard doctors to find as the current state of training in endocrinology doesn't teach how to prescribe, dose, and manage patients on combo T4 and T3, or DTE/NDT. The main problem is one can't use TSH alone when dosing patients, but must switch to a model of FT4 and FT3 with rT3 helping gauge if something is going on.

You can always look for another doctor, in the mean time all the issues mentioned under supplements and lab based goals section can be worked on with a primary care.

You can also switch around the T4's as a very first step, sometimes it can help quite a bit. Even conservative endocrinologists will usually be open to changing to alternate T4’s.

We can see that research in T3 and NDT has not been well done when the conversion charts of T4 only to NDT are so far off. Much of the real attempts at researching these replacement hormone therapies was done ahead of labs like FT4 and FT3, some as far back as the early 20th century. Every once in awhile we find recent research papers where they try to "force fit" T3/NDT into the model of T4 only. They primarily still gauge on TSH instead of FT4 and FT3, they give T3 or NDT once a day, they convert from T4 only to NDT in a single day even if the FT4 is too high to switch, they use completely inaccurate dosing based on charts made over 100 years ago, they never take the goal we have of aiming for good or very good FT3 at moderate to middle of the road FT4. The research today is quite poor in my opinion, very biased, and not properly setup. Not to mention the use of TSH to determine everything, and for many who do poorly like I do, TSH just is not a good measure as we become completely suppressed on NDT.

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Links to doctor lists

When you get to the actual physician list click on a heading like "state" to sort by state or province, etc. Scroll down to your state. Kind of not the best web interface to a list, as some have trouble getting to doctors in a specific state, but work with it a bit and you will get the doctors in your state:
http://www.thyroidchange.org/list-of-doctors.html

RLC labs links
http://getrealthyroid.com/get-real-now/find-a-doctor/

Posted by emmaleah, finding docs by prescribers:
http://projects.propublica.org/checkup/
One way to make it work is go to say "Armour" or "Liothyronine" in the "Top Drugs" list, then go into that by clicking into it, then click on your state on the left and it shows the most to least prescribing doctors of that exact thing. So if you want Armour in your state you have a list of docs that do it. But they have to do at least 50 prescriptions of it I guess.

Slightly older and no longer updated, but still valuable:
https://www.verywell.com/thyroid-disease-top-doctors-directory-3231612

Functional Medicine, Select MD/DO, enter zipcode. Posted by snova68
https://www.functionalmedicine.org/practitioner_search.aspx?id=117

Some osteopathic physicians will look more into T3 and T4, some but not all
http://www.osteopathic.org/osteopathic-health/Pages/find-a-do-search.aspx

Naturopaths in some states can give prescriptions, select Adrenal/endocrinology disorders and enter zip code
http://www.naturopathic.org/AF_MemberDirectory.asp?version=2

Hypothyroid mom lists
http://hypothyroidmom.com/30-online-resources-to-find-a-good-thyroid-doctor/

Thyroid Nation list
http://thyroidnation.com/thyroid-friendly-doctors/

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How do I give this information to MY doctor?
The National Association of Hypothyroidism (NAH) website is geared exactly around giving a physician the clinical information they need to help those who do not do well on T4 only. I would give these two links to your doctor:

NAH – National Association of Hypothyroidism. The best clinical resource found:
http://nahypothyroidism.org/

Hope for the future, BiancoLab
http://deiodinase.org/


FAQ to Free T guide

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For my Free T labs, what are the conversion factors for US to international on FT4 and FT3?

Free t3 Conversion factor pg/mL to pmol/L is 1.5362
(multiply US value by 1.5362, or divide international value by 1.5362, to change one to other)

Free t4 Conversion factor ng/dL to pmol/L is 12.87
(multiply US value by 12.87, or divide International value by 12.87, to change one to other)

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What are the most common mistakes on switching from pure T4 to NDT after TT?

You should understand various things before starting NDT, and work with your doctors on these issues.

1) If switching from pure T4 (synthroid for example) moderate the Free t4 before starting NDT.
2) Getting a sufficient dose to your T4 dose so the TSH does not go up eventually. Really bad, or far from true, charts of equivalents of T4 to NDT are out there.
3) Taking the daily dose of NDT all at once in a day like first thing AM as that is the pattern for synthroid and not NDT - very rare to make once a day work after TT with NDT. There are variation of splitting in two, like splitting in three but once a day is not recommended.
4) Checking Tg before and after going on to see if NDT gives you a positive Tg.
5) Making sure you don't do labs (blood draw) right after, or anywhere close to soon after taking medications. People do it several ways but all labs shouldn't be done anywhere soon after taking a portion of the NDT.

1 Most people will need to moderate the Free T4 down quite a bit before starting if on pure T4. They just can’t go from one day on a high dose of pure T4 then switch to NDT the next day. Because of the higher levels of Free t4 they may get various hyper symptoms or many hyper symptoms on first days or weeks of taking NDT if they switch immediately.

2 Many people are not given a sufficient dose due to incorrect charts on equivalents. You want a sufficient dose such that eventually you don't go hypo and you keep the TSH suppressed for thyroid cancer recurrence issues. Basically in 2 weeks to months out from now they will go hypo or nearly hypo on the equivalents found in charts often referenced. What that means is the TSH will go from hypothetical say 0.15, to again hypothetical TSH of 2.75 because they are under-dosed. But this won't show up again anywhere from 2 weeks to many months.

3 Many people will need to take the daily dose of NDT divided in half, taking half in morning first thing, and half in afternoon. A recommended alternative is 40% NDT in AM and 60% in afternoon.

4 Also be aware that all NDT contains thyroglobulin and while it doesn't change the Tg for most people it does for some, myself included. One can swap to exact same amounts of synthetic T4/T3 for 14 to 20 days ahead of Tg labs. You can test Tg before and after going on to see if you get a positive Tg from NDT.

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How do I add cytomel (T3) to my T4 prescription?

Note that people needing larger amount of T3 because their FT3 tests very low, often need to bring the amounts up slowly over time.

Depends on where your TSH and Free t4 currently are.

a) Condition: Goal is to keep things roughly the same TSH.
In this case reduce t4 by 4 mcg for each 1 mcg of T3 added. That is rough, and people vary all over but it is always easy to add T4 back so I would reduce the T4 prescription by 4 mcg for each 1 mcg T3 added first. For safety sake, if the TSH is already highly suppressed on T4 meds you should remove the T4 well ahead, such as a week or more before adding the T3 you plan on trying.

b) Condition: Goal is to bring TSH down.
If your FT4 is moderate/mid level and TSH not suppressed you likely won’t need to reduce the amount of T4 you take or not as much.

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Do I switch immediately from pure T4 (like synthroid) to NDT the next day?

When you switch from pure T4, most people start with a Free t4 level somewhere of FT4 1.4 to 2.0. Generally all these people must go off T4 medication for up to one full week before starting anything like Armour or Nature-throid that has T3 in it.

T3 is super powerful and has an immediate effect basically within an hour of taking it. So if you add it to a higher level of FT4 you get hyper symptoms immediately after taking on a switch. This is why you must wait up to a whole week for some people to start, but it depends on what the FT4 is.

You want a very moderate FT4 to start the NDT, so you generally have to wait some days to a week to drop the FT4 down before starting as pure T4 usually leaves the FT4 too high to start NDT.

Roughly speaking you want a FT4 of about 1.2 to start NDT. 1.4 is ok for some, for cardiac risk 1.0 is suggested. There is wide variation in people, but for best experience it is suggested to bring it down first, then start the NDT.

Gauge where you are based on a FT4 before starting NDT. If your FT4 1.8 you can't switch the next day. The higher it is the more you need to wait before you start basically.

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Does T3 change TSH?

Yes. T3 is also much more powerful than T4 per mcg taken. However, the TSH effect of T3 varies widely by person and is specific to you, but no matter what the case is for you, the T3 will be vastly more powerful at suppressing TSH than T4.

The majority of people will be somewhere in the area of 1 mcg T3 has the same effect as 2 to 4 mcg T4. A tighter view would say many are around 2.5 to 3.5, in T3 being that times more powerful than T4 at suppressing TSH. Official statements usually say T3 is 4 times more powerful but this is very conservative view to accommodate the high possible side effects and most people probably run in the 2.5 to 3.5 effect area.

You won't know till you try for yourself where you are.

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How do I take natural desiccated thyroid (NDT) or long term cytomel?

Almost everyone divides the daily dose in two and takes half of the daily dose first thing in AM and half in afternoon, or a wide set of variations of this. That is to help with T3 run-out. If you take it once a day your alertness levels may swing too much, and at same time the T3 gets too high early and runs out later in afternoon. This can cause side effects of too high a T3 early in the day (HYPER), and T3 run out feel late in the day (HYPO). There are a few who have a cortisol cycle such that they can't take it later in day and end up once a day, but almost everyone else from the start takes it at least two times a day.

Generally once a day DTE/NDT is associated with light or very light doses.

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What are the equivalent amounts to switch from T4 only to NDT (middle of a bell curve)?

With NDT we use the word "grain". 1 grain of NDT has 38 mcg T4 and 9 mcg T3 in the USA. The listed mg of a grain depends on brand such as Armour or Nature-Throid. A grain can be 60mg or 65 mg (which is not an amount of T4 or T3) and again depends on the brand as to the mg but not the amount of T4 and T3.

This chart is aimed at the kind of middle of the curve group where 1 mcg of T3 is about like 2.5 to 3.5 mcg of T4. It does not represent all people, just kind of the middle of the bell curve. Amounts to swap are dependent upon each individual and how T3 works on you. With that in mind, the middle of the bell curve group suggests swaps having 1 grain equal about 60 to 70 mcg T4. You very well may need more or less if you take very large amounts, or very low amounts, of T4 to work for you and you are of normal weight:

100 mcg pure T4 swap to 1.4 to 1.7 grains, available pills are: 1.5 or 1.75
125 mcg pure T4 swap to 1.75 to 2.1 grains, available pills are: 1.75 or 2.0
150 mcg pure T4 swap to 2.1 to 2.5 grains, available pills are: 2.0, 2.25 and 2.5
175 mcg pure T4 swap to 2.5 to 3 grains, available pills are: 2.5 or 3.0
200 mcg pure T4 swap to 2.85 to 3.3 grains, available pills are: 3.0

Once again, you split this in two, taking half first thing AM and half in the afternoon or some variation like in thirds, etc.

Those who do not absorb synthroid that well and thus take larger amounts are further out on a bell curve and would have differing numbers than above. For them 1 mcg of T3 might have the effect closer to 5 or 6 mcg of T4. This would be very possible but is less likely. So keep in mind the chart above is middle of the curve and if you are taking very large amounts of synthroid with a normal weight the chart above may not apply to you but it may be possible to adapt it knowing you take double the amount of synthroid than others your weight for example.

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But the charts give a different equivalent for NDT, why is that?

Equivalency charts are designed around a highly conservative view that the highest possible effect should be listed in equivalents in case of side effects, trouble is that can raise TSH and leave you feeling lousy. Because of that basically there are charts out there giving incorrect amount of NDT to replace pure T4 even by conservative measures. These charts say 1 grain has the same effect as 100 mcg T4. This is just not the case. 1 grain of natural thyroid has only 38 mcg T4 and 9 mcg T3. This cannot have the same effect as pure 100 mcg T4.

From the calculations below you can see that for most people 1 grain of natural thyroid (USA only) has the effect of somewhere in the 60 to 70 mcg area of straight T4 only.

38 + [9x (varies by person but try 2.5)] = 38 + 22.5 = 60.5 T4 equivalent in my case because 1 mcg T3 has the same effect for me as 2.5 mcg T4.

38 + [9x (varies by person but try 3.5)] = 38 + 31.5 = 69.5 T4 equivalent in a person where 1 mcg T3 has the same effect as 3.5 mcg T4.

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How about ERFA (Canadian NDT)?

60 mg ERFA might have the effect of roughly only 55 to 63 mcg of straight T4. Varies widely by person, best ballpark is to use 2.5 to 3.5 maybe as much as 4 as multiplier on each mcg of T3 but it can vary from that and is individual.

In each Erfa 60 mg, there is 35 mcg. of T4 and 8 mcg of T3. If T3 for you specifically has the effect of 3 times T4, then use simple math:

 35 + 8x3 = 59 mcg straight T4

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Does T3 or NDT use swing TSH around with lots of daily variation as I was told it will and I need my TSH suppressed due to thyroid cancer?

No. You can get what is called T3 run-out where the T3 gives a high alertness level after you take it and this often will fade as one gets to the afternoon, but the TSH does not change that quickly. Most people take T3 or NDT two times a day and it is not uncommon to forget, missing multiple or even a single T3 dose. This can cause the TSH to change a very small amount. If you are the kind of person that will forget taking afternoon T3 or NDT often you may get some small variations.

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I have high risk thyroid cancer and want to switch over to pure NDT but not let TSH rise, any way to be sure since charts are not the best conversion?

Monitor your Free t4 during switchover weekly and never let the Free t4 fall below say 1.0 US (which is 12.87 in international units) maybe even 1.1. If it is falling and looks like it is about to go under, increase the dose.

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I switched to NDT for my T3, can this change my Thyrogobulin (cancer marker)?

It is a good idea to test Tg right before and some time after going on NDT.

Animal based thyroid hormones do contain thyroglobulin (Tg). This can make it past the digestive system to the bloodstream. Tg is the lab based cancer marker used for checking for cancer recurrence after TT, and a rising Tg (at similar TSH) is indicative of cancer recurrence. Probably less than 5 or 10% of people get a rise in Tg from natural thyroid, I am one of those. There are no studies that I know of on this.

Most people the stomach digests the Tg and breaks it down to proteins. Unfortunately stomach digestion varies all the time by other things we eat or our gut bacteria. For those who get a change in Tg from natural thyroid when getting a Tg lab one can swap in exact same amount of synthetic (T4 and T3) for 2-4 weeks ahead of Tg labs if considering a natural thyroid replacement for long term. Basically 2 weeks is ok, 4 weeks if extra worried about the Tg level accuracy. It isn't hard to overcome the positive Tg caused by natural thyroid using this swapping method.

The mean half life of Thyroglobulin in the bloodstream is 65 hours. Taking away 5 half lives comes out around 13 to 14 days actually. Five half lives is sufficient to get it all the Tg out of the system from a technical perspective but give it a bit more to be sure.

The alternative method to swapping synthetic T4/T3 for those who can't handle synthetic thyroid at all is to use the Tg on NDT as a base, and see if it rises significantly from the base. It may vary some due to digestion changes, but a larger change might indicate cancer recurrence.

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I plan on starting NDT or cytomel and want to know if there are side effects from too high a FT3?

It depends on where the TSH and FT4 are as to the symptoms you may get.

If you take NDT or cytomel and your FT4 is toward the top of range (or over range) and you push the FT3 up till it is over range people often get too fast a GI, stomach irritability, anxiety, and other various hyper symptoms.

This is why you want to moderate the FT4 to take T3 and be sure you don’t take all your daily dose of NDT or T3 all at once.

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Any tips for taking NDT?

A kind of default is to split and take half early AM and half in the afternoon. There are some who need less in AM and some who need less in PM, so find what works for you.

Avoid calcium, iron, and fiber even more so than synthroid or cytomel.

Avoid food if you can for an hour before and after.

Optional: Chew if FT levels vary on same dose over time. Basically only do this if you do not absorb it well, or you want it to absorb better, faster or more evenly: Chew it as completely as you can. Completely pulverize it so it is down to something that absorbs readily. Then swallow with lots of water. The manufacturers don't say to do this, but it most definitely absorbs faster this way. But only chew if you seem to have trouble with absorption or absorption issues. Many will not need to do this, and a few will prefer it.

If you get a positive Thyrogobulin (positive Tg or cancer marker) from it, just swap in the synthetic T4 and T3 for 2-4 weeks ahead of Tg labs.

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Can I take cytomel/NDT with food?

Sometimes cytomel or NDT is taken with food by some people. So the food issue is complex. Basically yes you can take it with light food in some circumstances.... That varies all over and is person specific.

A few people can't take it with food at all or it does not absorb.

Other people do take T3 with light food to slow down the absorption and T3 usage. This is hard to understand until you understand what T3 run-out is, but taking it with food slows that down sometimes for some people. Taking it on an empty stomach and sometimes it gets "used up" too quickly or you are subject to T3 run-out, get tired, etc. Taking it all at once or too much at once in the day and it can sometimes spike the T3 levels up too high, basically taking it with light food can slow this down for some people.

So the answer is all over.

Just keep in mind once on any T3 for the long term, that Free t testing has to be done much more carefully timed than before being on anything with T3.

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Does T3 help me lose weight?

Some causes of weight gain after thyroidectomy:

* Higher FT4 causes excess hunger with low satiety for many people, thus we gain weight.

* Low FT3. This is metabolic shut down territory. Body stops expending and goes into a kind of conservation mode, thus we gain weight.

Also but much rarer would be very low FT4, or very high FT3. Make sure you get all your lab reports so you know your numbers.

The way I describe T3 use and weight is, if you do a super hard diet and your T3 levels are poor (and/or in some of us FT4 levels are too high) you likely will fail. If you do a super hard diet and T3 levels are good you have a chance. But the super hard diet makes you lose weight; the T3 level if poor prevents it from working but does not cause weight loss as that is the role of the diet.

Diet plan
Intermittent fast

For cravings - once a day chocolate
Chocolate without sweetener tastes great


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When I add NDT/T3 to my regimen the TSH is so suppressed, why is this?

Human evolution never involved adaptation to significant exogenous T3 or T4. There is no guarantee the pituitary gland works exactly linearly correct at high doses of thyroid medication associated with post thyroidectomy patients, and particularly so for those that include T3.

Further reading about TSH error sources are discussed on the National Association of Hypothyroidism website.

http://nahypothyroidism.org/

The pituitary is a feedback control system that wasn’t really designed around people doing thyroid cancer recurrence prevention and may not normally operate under these conditions.

The pituitary makes its own T3 supply from T4 via direct conversion for its own use though it measures the total thyroid hormone levels in the bloodstream it does not depend on the blood T3 levels apparently since it can convert its own supply. This often results in peripheral signs of hypothyroidism such as skin or hair issue even though TSH is suppressed.

Reverse T3 (rT3) counts against TSH yet supplies no benefit since even rT3 is a hormone that is measured as part of the total hormone level by the pituitary

Benign pituitary adenomas are not uncommon and make the TSH a poor indicator.

In general the worse a T4 to T3 converter you are the less reliable your TSH reading may actually be.

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My doctor uses Total T3, what about that?

The reason your doctor uses Total T3 is to take the daily variability out of the picture to some degree. Using Free t3 one has to time things well or the results get easily skewed, total T3 is less susceptible to this happening.

The trouble with Total T3 is it includes bound, free, and reverse all combined to a grand total. Yet some of those are bad and some are good. So a total T3 can include bad things.

I really don't see why it is so hard for a doctor to say they like seeing what results are at (you and doctors choice say:) 7, 9, 24 hours, or whatever X hours after taking meds such that they would rather order a test that gives not as useful information. It is pretty easy to tell a patient take your meds like you always do but I am used to Free t levels at X hours so I want you to do a lab at that time. Not so hard really, but many doctors don't trust patients to time it right and would like to take that out of the picture.

Free t3 gives a clear picture of where you are, it is really the thing to work off over time. When it is low you do badly.

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I took T3 (or natural thyroid) and got no reaction, what are the possibilities of what is going on?

Depending on your Free t3 level when you started, you might not be on enough T3. However, If you do not get much of any response from T3 at all and your symptoms persist this is a classic indication of a reverse T3 issue. Reverse t3 blocks T3 receptors in the body, thus making it hard to feel the effects of T3 initially. Reverse t3 can be caused by low ferritin (storage iron) as most frequent cause, cortisol, stress, and other factors. Make sure if you order iron tests that ferritin is tested and not just serum iron. Unless cortisol is well tested you don't know if high or low, so a must that you not treat either way unless certain cortisol is running high or low.

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I took T3 and got too much a reaction, what are the possibilities?

a) your cortisol is off, high, low. Unless cortisol is well tested you don't know which so a must that you not treat either way unless certain. Advise canary club 4x a day salivary cortisol.
http://www.canaryclub.org/

b) You added T3 at way too high a FT4 for you. Everyone varies, but if you are a reaction kind of person you need to take FT4 down to like 1.2 or 1.1 then try adding T3.

c) a side condition like PCOS, or any other sex hormone issue can dramatically change the thyroid medications effect. There is nothing worse for a woman than wrong testosterone levels, these can cause many issues. For a man there is nothing worse than wrong estrogen levels, these can cause many issues not the least or which is a rising PSA.

d) You started with too much T3, such as day one 25 mcg.

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Does T3 cause a-fib, irregular rhythm and heart rate problems?

Generally to add T3 if you are a person subject to cardiac issues you should bring your Free t4 to 1.2 or less (US labs). Some people may need to bring this level down even more. Adding T3 or NDT at higher FT4 is often the problem.

Too much medication indicated by a high Free t4 (common) or way high Free t3 (very rare) might cause you to get a-fib, irregular rhythm and heart rate increases.

T3 has a fairly immediate effect and should be done with a fair amount of care. T4 is fairly slow to act, T3 changes things almost immediately. But either can be in excess. Always check your Free t4 first and look at that as a potential cause.

Some people find a balanced Free t scenario less likely to cause any of these issues than the typical high Free t4 scenario many are directed to post TT. Moderate FT4 and good FT3 are both in range, Unfortunately high Free t4 is often ignored by physicians.

Another major factor on these issues is cortisol levels (adrenal hormone). People with low or high cortisol levels, even if only subclinically low or high, are more subject to irregular rhythm and heart rate problems. Correcting cortisol levels can often help for those with these issues.

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I got a prescription for 50 mcg T3, I want to start this right away with my full course of T4, should I just jump right into taking the 50 mcg cytomel?

It is VERY uncommon to be prescribed 50 mcg cytomel. If you were prescribed 50 mcg cytomel just be sure you have carefully gone over all your physicians reasons for prescribing such a large quantity and that you fully understand what the plan is in detail. Taking large quantities of cytomel is VERY rare outside of certain special circumstances, so be sure there is full communication about why you need this large quantity, how you should proceed in taking this kind of large quantity of T3, what the potential side effects might be because they can be severe or even potentially deadly at this high a dose. Experience says those who must take larger amounts know and can describe to others the reasons they are prescribed a very large dose of T3.

There have been cases of prescription error, mistakes, miscommunications, insurance issues where only high doses are in approvals for RAI uses and high doses are prescribed accidently because of the insurance approval system listing the RAI dose, and numerous other problems involving large prescriptions of cytomel.

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Are there really any differences with people who have a thyroid and also take replacement hormones?

Summary in comparison to those who have thyroids but also take replacement hormones:

1) Thyroglobulin as most important issue, we must always concern ourselves with it.
2) Observational: Need for lower Free t4 generally speaking than those who have thyroid even if they are taking lots of replacement hormones as well. E.G potential lower range on Free t4 needed post TT.
3) Observational: We seem to magnify and get hyperthyroid symptoms more so than those with thyroids. Our testing and symptom observations have to center just as equally on hyperthyroid symptoms and levels, as they do on hypothyroid symptoms such as connected to low Free t3. We need to check both sides, hyper and hypo to do really well.

We have all read there are no differences but there are some. Many people try to act like one size fits all but it tends not to work too well. We have cancer and this is really different. We have to worry about Thyroglobulin (the cancer marker) and this can be a large issue if we have almost any risk for cancer recurrence. This is really important, and there are answers about Tg even if you take NDT. But Tg levels and what they mean should be understood and does differ from a person without thyroid cancer who is taking replacement hormones.

Unfortunately those of us without a thyroid almost always tolerate lower Free t4 than somebody with a thyroid. This is purely observational but seems very valid. Somehow the body is able to tolerate higher Free t4 levels when you have a thyroid even though that person's thyroid isn't really doing much if they are taking a fair amount of replacement hormone. The body gives some additional accommodation somehow if you have a thyroid. While there is large variation in people almost universally the recommendations and comfort levels without symptoms people have on levels of Free t4 will be lower without a thyroid. Large numbers of us have found this as a significant difference to those who have thyroids but are taking replacement hormones. This is kind of like saying the Free t4 range probably is lower for those after a thyroidectomy. Many of us think it should end at 1.5 (US level) after a thyroidectomy. Many still having a thyroid but taking replacement hormones find comfort and no issues at levels much higher than this.

Another observation is we are much more susceptible to hyperthyroidism symptoms without a thyroid. We can get a wide array of hyperthyroid symptoms that are just as bad as the hypothyroid symptoms, but we feel them quicker. Generally speaking we magnify the hyperthyroid symptoms without a thyroid. Common symptoms of hyperthyroidism include: anxiety, GI irritability and moving too fast, mood changes and swings, irritability or a short temper, headache and migraine, excess hunger and more. Those with thyroids but taking replacement hormones can often get away with little hyperthyroid symptoms and almost no concern for them in their lab testing. We generally must concern ourselves with levels that get too high on Free t4 and Free t3. Our measurements must focus hyperthyroid symptoms too.

So concern yourself and familiarize yourself with hyperthyroid symptoms way more than a person with identical numbers but who has a thyroid and is taking replacement hormones. This is why we pay attention to the hyper side just as much as the hypo side (like low free t3) and our testing and labs reflect that concern. There will be a few who never experience hyperthyroid symptoms at any number, just don't count on you being in that group if you have thyroid cancer and no longer have a thyroid. Too often the story surfaces of years of hyperthyroid symptoms disappearing after a dose reduction. That story is heard often. We do seem to differ from regular hypothyroid patients taking replacement hormones.

Thyroid Cancer Basics of influence from Iron, Cortisol, D, K, B-12, others. Bone and Joint

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Intro to Ferritin/iron

Ferritin is stored iron in the body that is released over time. Ferritin can be high or low, and both can be bad. Be sure to have your ferritin tested before supplementing with iron. Do NOT take any iron supplements for one week before any type of iron lab work if just starting, later on you can look at ferritin rises differently but to get a baseline start without taking iron.

Ideally ask for the full iron panel PLUS ferritin. Labs have differing groupings but usually put ferritin as a separate lab that is outside the iron panel. Hopefully your physician will order all to work with you on this area.

Optimized values for Ferritin, (ONLY for thyroid medication users):
Male around 60-90 ng/mL
Female 60-80 ng/mL
Ferritin is just storage iron or one type of iron measure. This is NOT the same as a person not taking thyroid medications, where a ferritin level about 50-60 ng/mL is fine.

Although ferritin issues are the most common thyroid medication connected to iron levels issue, you should also consider getting your doctor to run a full iron panel. This has additional checks for anemia, iron deficiency and more. A percent saturation of less than 33% or elevated TIBC or UIBC are iron deficiency indicators. But again do NOT take any iron supplements for one week before any type of iron lab work. Other things that change the iron panel results making them invalid can include birth control pills, consuming lots of meat before the lab, and various inflammatory conditions. Iron testing has to be done very carefully with some considerable preparation, it is not uncommon to not be informed on how to prepare properly for an iron panel. The other iron labs can have error fairly often and can need repeating.

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LOW Ferritin

Aside from low Free t3, low ferritin or storage iron often connects to hair loss, low energy, poor thyroid medication utilization and many other issues. When storage iron is low, such as a ferritin level of 10 or 18 or other low value, the body creates reverse t3 out of T4 and it goes straight to T3 receptors. This is particularly true in places like hair follicles, but generally everywhere in the body. The reverse t3 blocks up t3 receptors and you feel off. This is because the body is thrown into a kind of preservation mode from low iron stores. This is most linked to ferritin, even if the other iron tests are better or more normal values. Importantly this happens even at the so called "low normal" of the ferritin range, though I don't think there is an exact value it is known to start happening.

If the ferritin is quite low, IV iron infusion is the easiest way to boost.

Real easy to buy iron and works super well:

http://www.vitaminshoppe.com/store/en/browse/sku_detail.jsp?id=VS-2606

Also to buy: cast iron pans or cookware, use them.

Iron to avoid: ferrous fumerate, ALL multivitamins with iron.

Note that long term taking of multivitamins with iron is associated with colon and GI cancers. The idea of boosting iron is boost awhile and go off awhile, thus supplement with something other than a multivitamin. Decades of taking multivitamins with iron increases colon and GI cancer risk.

If you are iron deficient you should have a complete blood count (CBC) with Hemoglobin and Hematocrit to check for anemia:

http://www.nytimes.com/health/guides/disease/anemia/diagnosis.html

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HIGH Ferritn

If ferritin is too high donate blood, this can bring the levels to those mentioned above. If it is extremely high that is a condition called hemochromatosis.

Here is a link to Uptodate (used by many docs as a reference) info on hemochromatosis:

http://www.uptodate.com/contents/hemochromatosis-hereditary-iron-overload-b eyond-the-basics

It is common amongst southern European/ Mediterranean descent individuals. Here is the key statement from UptoDate:

"Ferritin levels greater than 300 ng/mL in men and 200 ng/mL in women support a diagnosis of hemochromatosis. However, ferritin levels can also be increased by many common disorders other than hemochromatosis"

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What is rT3?

Reverse t3 (rT3) is a primal response of our bodies sensing something wrong, and forcing a slowing of metabolic rates in an attempt to create a somewhat hidden self preservation mode of sorts. Basically your body attempts to slow metabolism when it senses you are ill, deficient in iron, minerals, vitamins, other hormones, or otherwise have something off or wrong. Having a high metabolism when ill would not be a good thing in general, so we developed an internal system to slow metabolism at these times. Symptoms sometimes may include hair loss and fatigue not resolved by raising FT3 alone.

Basically rT3 blocks T3 receptors all over the body and the Free t3 can't get in. So you will feel quite poor, sometimes even presenting with a good FT3. rT3 looks similar to T3 to the body but it can't function like T3 at all. It blocks the active thyroid (T3) hormone from being used since receptors are blocked up by the rT3 molecule. We then expend less energy, but we won’t feel well. All people have rT3, one can never get rid of all of it. However when rT3 is really high, that is when our body has kicked into its mode of forcing a slowing metabolism. We can potentially correct situations of high rT3 by finding the source of the problem.

The most common source of the rT3 issue is iron deficiency or storage iron deficiency (ferritin) and any related anemia's even if mild. Storage iron (ferritin) when deficient or even just low can cause the body to go directly into preventing thyroid hormone utilization, or the metabolic preservation mode. Add to that decreases in hematocrit, hemoglobin, RBC counts, and we might end up with anemia as well. The body starts with sensing that something is wrong with low ferritin, and then rT3 spikes up till iron stores go back up (better diet that includes iron). But in the mean time we feel off sometimes even with a good FT3 because our body is in a hidden self preservation mode.

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Introduction to Cortisol from a naturopathic through medical point of view

Cortisol is at its peak 30 minutes after you awake and declines all day so to see an issue you need multiple samples. Many of us try the salivary cortisol test which is done 4x a day from Canary Club (mail order). There is natural variation and one can see that in a graph where normal has upper and lower for any time point on the graph.

http://www.canaryclub.org/specialized-panel-hormone-tests-pm/diurnal-cortis ol-4x-zrt-stress-hormone-test-kit-c1-c2-c3-c4.html

Just be aware many naturopaths and even a few doctors will try to treat cortisol without good testing. I would never advise that. If you go to a doctor or a naturopath and they try to treat cortisol levels without a real substantial set of testing that was carefully done you should not take their advice. Cortisol can be high or low, so the wrong treatment will make a bad situation much worse. Nor should you just buy any kind of adrenal booster or adrenal support product without being certain what the problem is, how much of a problem there is, and which items in the product are known to help. There are hundreds of these products out there and many people take them without this information, this is not generally a good thing to do.

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LOW Cortisol

a.
If cortisol is modestly low at points of the day one can take licorice as a tea or supplement for awhile , please note that is not long term.. The licorice must have glycyrrhizic acid as some sold that is removed. This will stimulate a re-start of the adrenal system. Licorice can raise BP for some people. The length of time people take licorice varies by various sources of recommendation, but one should not take it indefinitely. See more on licorice below.

If cortisol is really low you have to see a doctor to check for Addison’s disease or adrenal insufficiency:

Adrenal insufficiency test (very low cortisol)
http://en.wikipedia.org/wiki/ACTH_stimulation_test

b. How does licorice work?

Licorice/glycyrrhizin is used to raise cortisol. Lots of articles about it, they all differ in amounts, how long to take, etc. Licorice mimics desoxycorticosterone or ACTH, thus one gets a cortisol boost from it. The theory is when a person has low cortisol you stimulate with an ACTH like effect for several weeks/ or month with licorice and the body kicks back in and resumes its more normal cortisol cycle and you discontinue licorice. It is a kick to the system basically. One should never take licorice for long periods, this is why candy can't be sold with real licorice because long term use is dangerous.

This does not cover it all but covers how it mimics ACTH or the theory of what is used and described in many articles and books for using licorice to raise cortisol. This is a published article so it does not cover an implementation but essentially the method of action, mimic ACTH:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2136773/

Reader12 posted this on a general intro to licorice:
http://www.livestrong.com/article/522282-licorice-cortisol/

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HIGH Cortisol

Oppositely if cortisol modestly high you can take Holy Basil which is a supplement to lower modestly high cortisol levels. Holy Basil got is name because monks in India wanted to de-stress or remove cortisol.

If cortisol is very high you have to see a doctor to check for Cushings syndrome:

Cushings syndrome test (very high cortisol)
http://en.wikipedia.org/wiki/Dexamethasone_suppression_test

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Vitamin D Basics

Goals
Total Vitamin D (25-Hydroxyvitamin D): 70 ng/mL (USA), 174 nmol/L (International)

Vitamin D conversion reference:

Total vitamin D: ng/ml to nmol/L multiply USA gravimetric unit by 2.496

So in USA a good/solid Vitamin D of 70 ng/ml is the same internationally as 174 nmol/L

http://www.questdiagnostics.com/dms/Documents/test-center/si_units.pdf

When Vitamin D is high in the range, T3 levels seem to stay more steady over the whole of the day. One generally feels lively or overall much better with a very good normal vitamin D. However, never go too high on Vitamin D as this is dangerous.

There is no standard dose that I know of for Vitamin D as it depends upon sun exposure and weight. A total Vitamin D at levels like 25 to 35 is hugely low. These days the newer type guidelines recommend something like 50, and for cancer patients 70. Some people may need for long term 1000 IU, some need 2000 IU, some need 5000 IU, some need 10000 IU as it depends on you as an individual. Sublingual Vitamin D is good.

Many people need large dose of Vitamin D to get levels up but again it varies not only on weight like other medications but sun exposure. Many people during low sun exposures need lots of Vitamin D supplement as routine, but far less or no supplemental Vitamin D during periods of larger sun exposure.

Do get sun exposure or tans. Get small amounts with small incremental build up. Never get too much. I am a person who believes sun tan lotions are the cause of skin cancer against most people in the world who think it saves them, so I think I would not use them for myself instead use my brain to say I should limit excess sun. Sun and tans are super great, burns and too much sun are super bad. There is a sort of bell curve. Too little sun/tan is the left of the bell curve and bad, too much is the far right and bad. Find your just right, depends on your skin and if you have red hair and so on where the bell curve is.

Good D info, lots of reading:

http://vitamind.mercola.com/

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Mercola on Vitamin K

Be sure to tell your doctors such as cardiologists if adding a new vitamin K supplement, or D3 with K2 supplement. Particularly if getting, or about to get, a blood thinner/anticoagulant prescription.

Source:
http://articles.mercola.com/sites/articles/archive/2012/12/16/vitamin-k2.as px

See on right the summary: Story at-a-glance

Vitamin K2 is an important fat-soluble vitamin that plays critical roles in protecting your heart and brain, and building strong bones. It also plays an important role in cancer protection

The biological role of vitamin K2 is to help move calcium into the proper areas in your body, such as your bones and teeth. It also helps remove calcium from areas where it shouldn’t be, such as in your arteries and soft tissues

The optimal amounts of vitamin K2 are still under investigation, but it seems likely that 180 to 200 micrograms of vitamin K2 might be enough to activate your body’s K2-dependent proteins to shuttle calcium to the proper areas

If you take oral vitamin D, you also need to take vitamin K2. Vitamin K2 deficiency is actually what produces the symptoms of vitamin D toxicity, which includes inappropriate calcification that can lead to hardening of your arteries

If you take a calcium supplement, it’s important to maintain the proper balance between calcium, vitamin K2, vitamin D, and magnesium. Lack of balance between these nutrients is why calcium supplements have become associated with increased risk of heart attack and stroke

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Vitamin B-12 Basics

Goals
B-12: 800 pg/mL

Vitamin B-12 is the energy vitamin, when it runs low or low in range you may feel off. Low values can lead to fatigue and anemia. Similar to Vitamin D when Vitamin B-12 is high in the range one seems to feel more steady over the whole of the day. One generally feels much better with a very good normal vitamin B-12. Methylcobalamin is the active form and is more absorbable, sprays and sublingual’s are recommended. As with all B vitamins suggest the active B forms. Mary Shomon covers it well:

http://thyroid.about.com/cs/newsinfo/l/blb12anemia.htm

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What about Selenium?

Selenium and Zinc are supplements helpful in converting T4 to T3. At the start of the process be sure to have someor test normally before supplementing. Be sure you do not have a multivitamin with sodium selenite or selenium selenate as these are not just bad but harmful to the process. Be sure if your vitamin has it that it is selenomethionine or selenium yeast (and a few newer ones), or buy as a separate supplement. I would not overdo selenium or selenium supplements, as excess is bad.

Much variance in amounts to take in articles. One brazil nut has roughly about 90 mcg IF it was actually grown in Brazil and is unprocessed (raw), but if it was grown somewhere else it might not have that much. Many articles mention 200 mcg a day as a supplement, but this may actually be too much if you get plenty with food already. I would say 25 to 50 mcg is fine, unless you test low.

Post TT there is no consensus on amounts to take, or if it truly helps. As is so often the case in thyroid related issues, more a lack of good articles if you want scientific ones following clinical needs and goals such as for a thyroid patient or thyroid cancer patient who just needs to know what to do.

Selenium is the first thing I ever tried when I was super high Free t4 and just not feeling well after TT. It might have helped a bit, I don't think it really pushed my T3 way up. At most I got a minor bump on T3 levels. So I don't think it was my issue but it is just one thing we can do amongst many. Selenium deficiency is more connected to Hashimoto's as far as I can tell, and I never had that. But there are many general links one can read.

Chris Kresser (type of integrative medicine practitioner) info in link below. He is positive somewhat on selenium overall, has some references, but also some warnings on selenium:

http://chriskresser.com/selenium-the-missing-link-for-treating-hypothyroidi sm

A solid NIH reference
http://ods.od.nih.gov/factsheets/Selenium-HealthProfessional/

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Iodine (optional)

You probably got thyroid nodules because you had a low iodine condition at points in your life. Nodules or goiters are associated with low iodine and this has been known for over 100 years. People get low iodine, not only because our diet is low in iodine in the US but because fluoride and bromines block it in our body.

Iodine isn't just used by the thyroid but it isn't used in a process like a vitamin or glucose. Outside the thyroid it is most commonly linked to mammary gland and clearing calcifications, thus a removal type process. Deficiency is often linked to fibrocystic breast tissue. Iodine reading and discussions are unfortunately in two camps, the ultra mega-dosing though it can benefit a few, and those who say only the thyroid needs it. Try to avoid those camps at first reading if wanting to read where you fit in.

If you take iodine, you should also take adequate selenium, or try to be sure you are not selenium deficient. Iodine without sufficient selenium levels is associated with autoimmune thyroid disorders.

People who will most benefit from looking into iodine are those with breast tissue issues and those with prostate issues.

Good references on iodine:

http://www.wheatbellyblog.com/2012/07/an-iodine-primer/

Good discussion on iodine interference and endocrine system disruptors:
http://articles.mercola.com/sites/articles/archive/2009/09/05/another-poiso n-hiding-in-your-environment.aspx

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I get joint/bone pain issues what can I do?
What about issues of bone density?

If you get joint/bone issues after a TT I would look into several things.

1)  Thyroid meds.

a) Fillers in thyroid meds can sometimes cause these issues. Try changing to a differing thyroid medication.

b) Look into where your Free t4 tests, when too high it will exacerbate a simple joint issue into a much more painful issue when it comes to these joint and bone issues. I like my FT4 below 1.4 ng/dL (US labs) to avoid issues (same as 18 pmol/L in international units). This is person specific, and level specific to an individual. I have found minor rotator cuff issues become much larger issues when my FT4 is higher. When you take away T4 to reduce your Free t4 level, you can always add T3 (cytomel) or switch to natural thyroid as a combination T4/T3.

2) Calcium, PTH

a) know your calcium level (have tested) and if it tests over 10, get a parathyroid check (PTH). See http://www.parathyroid.com/

b) if calcium is rising from the past, but is normal and PTH normal, look into D, magnesium and trace minerals

c) If calcium is normal or low normal, and PTH pushes high or over range, try taking calcium as your PTH pushing high by itself might indicate poor dietary calcium

d) If calcium isn't rising and is normal look at rheumatoid arthritis and osteoarthritis, comparison at:
https://www.ra.com/what-is-rheumatoid-arthritis/ra-vs-oa

3) Probiotics Take these fairly often if we have or get occasional GI changes from thyroid medications as these GI changes influence our absorption of minerals.

4)  Vit D + Vit K, Magnesium + Potassium. Many of us have to look at boosting vitamins and minerals, being sure the osteoblasts get plenty of what we need to deposit new bone. That means: aside from knowing calcium know the Total D level (have tested). Get good Magnesium too. However, taking magnesium can lead to a feeling of HYPO if you don't have good Potassium levels. If you take magnesium think about also taking potassium or eat bananas and spinach.

Best D supplements are a vitamin K2 with D3.

For Vitamins D+K here is one that seems to work well
http://www.michaelshealth.com/retail/products/vitamin-d3-5000-iu-90ct.html

5) Trace Minerals for bone. Potentially get additional trace minerals in your diet that include: Zinc, Silica, Strontium, Boron, Manganese, Chromium as these will help your body do its job and make new bone. Opt for testing of levels if possible, and I would never recommend over-doing supplements personally.

6) Additional help. I also suggest collagen to try for anyone with these issues, often taken for skin it helps a lot with joint and bones as well. Some brands:

 Reservage Collagen

Great Lakes Gelatin

Discussion

Some of the issue lies in that replacement thyroid hormones can change our GI system + absorption of nutrients and trace minerals. Secondly, some after TT have parathyroid issues to deal with. Finally,  anyone on complete replacement thyroid hormones tends to sweat more than others do, this also changes our body chemistry particularly Potassium and Magnesium.

Post TT we all need to worry about our gut (probiotics from time to time) since that gets changed at times, plus worry about trace minerals for bone. Here is a good breakdown on trace minerals that get harder to absorb, or the gut changes we get influence negatively on these and we have to be sure we get them more so than others since we are on replacement hormones:

Better bones guide

It is not hard to find vitamins or bone density boosters that include:
Calcium (but only if you test low do you need it)
D3 and K2 - often sold as a combination these days
Phosphorus
Potassium

Mildly difficult to get a sufficient amount include
Adequate Zinc and adequate Chromium, good quality and enough magnesium

Particularly difficult to get good supplementation from either vitamins, or even formula's sold for bone density include:
Silica, Strontium, Boron, Manganese

Some examples of the harder to get items

and find a chromium, manganese and any others you may want.

This is a single supplement that does have the trace minerals, but also provides a lot of calcium, K, etc. It is almost a multi-vitamin that is oriented around bone/joint. I would not take this with a multivitamin as you may get too much of some things, as this has quite a lot of things added. It does not provide as much of any of the trace minerals in the betterbones guide above suggests, but it is a single source that includes at least some of all the trace minerals:

http://www.vitacost.com/solaray-bone-tone-240-capsules


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Where to get Free t labs:

If docs won’t order, first look for a doc that does, but you can order your own:

Posted on Inspire by reneeh63
http://www.healthonelabs.com/pub/tests/test/pid/167

There is also mymedlab.com :
https://www.mymedlab.com/thyroid/thyroid-basic-panel

Canary Club which is great for cortisol and others, but their thyroid labs are too differing to compare to LabCorp for example:
http://www.canaryclub.org/

posted on Inspire by Nature_throid:
https://www.directlabs.com/

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How do I give this information to MY doctor?
The NAH website is geared exactly around giving a physician the clinical information they need to help those who do not do well on T4 only. I would give these two links to your doctor:

NAH – National Association of Hypothyroidism. The best clinical resource found:
http://nahypothyroidism.org/

Hope for the future, BiancoLab
http://deiodinase.org/

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Links to doctor lists

When you get to the actual physician list click on a heading like "state" to sort by state or province, etc. Scroll down to your state. Kind of not the best web interface to a list, as some have trouble getting to doctors in a specific state, but work with it a bit and you will get the doctors in your state:
http://www.thyroidchange.org/list-of-doctors.html

RLC labs links
https://getrealthyroid.com/find-a-thyroid-doctor.html

Posted by emmaleah, finding docs by prescribers:
http://projects.propublica.org/checkup/
One way to make it work is go to say "Armour" or "Liothyronine" in the "Top Drugs" list, then go into that by clicking into it, then click on your state on the left and it shows the most to least prescribing doctors of that exact thing. So if you want Armour in your state you have a list of docs that do it. But they have to do at least 50 prescriptions of it I guess.

Slightly older and no longer updated, but still valuable:
 http://www.thyroid-info.com/topdrs/index.htm

Functional Medicine, Select MD/DO, enter zipcode. Posted by snova68
https://www.functionalmedicine.org/practitioner_search.aspx?id=117

Some osteopathic physicians will look more into T3 and T4, some but not all
http://www.osteopathic.org/osteopathic-health/Pages/find-a-do-search.aspx

Naturopaths in some states can give prescriptions, select Adrenal/endocrinology disorders and enter zip code
http://www.naturopathic.org/AF_MemberDirectory.asp?version=2

Hypothyroid mom lists
http://hypothyroidmom.com/30-online-resources-to-find-a-good-thyroid-doctor/

Thyroid Nation list
http://thyroidnation.com/thyroid-friendly-doctors/

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Links to more info and sources of much of info

These are all websites, some by book authors who are well known for their work/research/papers/books. Dr Shames, Dr Holtorf, Dr Bianco, Mary Shomon, etc

NAH – National Association of Hypothyroidism - great graphics. The best clinical resource found:
http://nahypothyroidism.org/

Hope for the future, BiancoLab
http://deiodinase.org/

Mary Shomon – outstanding author
https://www.verywell.com/thyroid-4014636

Dr Shames related – one of original authors on more than just T4
http://thyroidpower.com/

Dr Holtorf related links
http://www.holtorfmed.com/

http://www.hormoneandlongevitycenter.com/thyroidtreatments1/

Great reviews with many links (see under thyroid)
http://hormonerestoration.com/Evidence.html

Thyroid help - general

T4 to T3 summaries
Dr Mercola on using Free t’s instead of TSH as primary labs (Dr Mercola is not addressing thyroid cancer patients but lays out case for Free t's):
http://www.mercola.com/article/hypothyroid/diagnosis_comp.htm

posted by MtDenali:
http://www.thehealthyhomeeconomist.com/thyroid-disease-as-a-psychiatric-pre tender/

More
http://www.naturalendocrinesolutions.com/articles/do-you-have-a-t4-to-t3-co nversion-problem/

Reverse T3 links

http://thyroid.about.com/od/t3treatment/a/Reverse-T3-triiodothyronine-RT3-T hyroid.htm

https://groups.yahoo.com/neo/groups/RT3_T3/info

http://www.custommedicine.com.au/health-articles/reverse-t3-dominance/