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 (ferritin), minerals, vitamins, other hormones, or otherwise have something off or wrong, or even you react in a negative way to the fillers in your thyroid hormone pills.  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 or very 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. rT3 is made from T4, and never comes from Free t3, or from cytomel, or any source of T3 in thyroid hormone pills such as DTE/NDT.

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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 on pure T4 or large amounts of T4 versus any T3. Basic summary: too high for you as an individual Free t4 (which is NOT the listed range) ) symptoms include mood changes and swings, A mean irritability or a short temper, headaches and migraines, anxiety, palpitations & excess heart rate issues, shortness of breath and/or breathlessness, sleeplessness/insomnia and restlessness, more of a sharp body ache or pain like joint pain or sharp shoulder pain issues, too fast a GI system (initially) or changes in GI system with eventual constipation from dehydration in some cases, Pain type neuropathy, weight changes due to excess hunger with little or no satiety, lots of pre-migraine and migraine aura type effects (can include what I call thyroid ocular aura disorders -TOADs or simply visual aura) even if you never had migraines in your life.

HYPO (most common with low individual FT3 (does not mean below range) even if TSH suppressed but can also be too low for you a Free t4) all the symptoms of hypothyroidism, but common are fatigues, brain fog, depression, loss of attention span (forgetting things), skin issues, hair loss and hair issues, fingernail issues, too low a heart rate, 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, muscle cramps, 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?

If you don't have all the basic 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, Folate, CBC, CMP, Homocysteine

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):

Some generally good lab goals on those other things to look at

Total Vitamin D (25-Hydroxyvitamin D): 50 ng/mL (USA)

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

Good value on Ferritin: 50-80 ng/mL

Homocysteine: below 10

Folate around 6 or 7 ng/mL 

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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 and Reverse t3 as low as possible.

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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Good and bad looking labs example.

Here is an example of a person that likely will have fewer issues, USA lab type values
Free t4: 1.09 ng/dL
Free t3: 3.62 pg/mL
Reverse T3: 10.8 ng/dl

An example of poor looking values or more likely to have issues.
Free t4: 1.8 ng/dL
Free t3: 2.4 pg/mL
Reverse T3: 23.4 ng/dl
Reasons that is bad looking data include but not limited to
Too much T4 = HYPER issues, way too much T4 for most of us
Too little T3 = HYPO issues, way too low a T3 level for most of us
Too much rT3 = makes it so you can't feel a decent FT3, so even if you get a good FT3 you might feel poorly. rT3 being relatively high can be from fillers, to poor iron, to being sick, to many other reasons

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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). I like to keep my FT4 under 1.2 and feel best that way.

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 mild HYPER issues at above numbers (example 2) and still had to reduce the T4 level slightly, trying to keep FT3 up best as possible.
Free t4: USA: 0.95 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 mild HYPER issues at above numbers (example 2) and still had to reduce the T4 level slightly, trying to keep FT3 up best as possible.
Free t4: Outside USA: 12.22 pmol/L
Free t3: Outside USA: 5.00 pmol/L

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When to get Free t labs:

When you get labs may differ significantly from people with a thyroid and the discussion below only pertains to people without a thyroid, generally having started on T4 only who want to solve issues they are having. Endocrinologists have concern with primarily TSH and not Free T's, and TSH doesn't change quickly so if you are doing well on T4 only and only want to worry about TSH then timing labs does not matter to some extent. Probably best to test like a person with a thyroid which is first thing AM before taking medication or breakfast.

For the rest of us pick 8, 16 or 24 hours but let people know what you choose when posting labs.

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.  Basically as a general rule, one should not take medication right before the blood draw.

People who split thyroid medications up in the day sometimes do 8 hours or before the second half of a T4/T3 combo or NDT. Others who split dose do first thing AM labs, then take meds (roughly 16 hours since yesterdays second half of thyroid medications). So 8 hours, or 16 hours, are common times. There are sites who say 24 hours but that is people with thyroids usually or those on T4 only who do well on T4 only. Take your pick 8, 16, and perhaps 24 hours.

One can also try to determine the time to test based upon symptoms as to HYPER/HYPO, or only HYPO, as a guide.

The time you chose may depend on your symptoms (see some of the symptoms of hyper and hypo above in FT guide). Those in process of converting over to a T4/T3 combo from very high doses of T4 sometimes like the middle of the day or right before the second half of any NDT/cytomel (8 hour slot) 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 (16-hour slot).

If you take all NDT at once, which I don't recommend without a thyroid, perhaps morning readings might be the only thing you can get to work as it will be hard to find the middle ground.

If you are on T4 only, generally well and no issues, probably test in AM before taking your medication. If you do have issues you want to review HYPO and HYPER symptoms at the top of the blog to see which is of most concern.

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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 7 AM, 150 mcg T4, 0 mcg T3, FT4 1.95, FT3 2.75, rT3 20, TSH 0.35 - on synthroid
Notes: Weight gain, irritability, brain fog. Hyper/Hypo both. rT3 high. Next I plan to get docs to replace 25 mcg T4 with 5 mcg T3

3/15/15 7 AM, 125 mcg T4, 5 mcg T3, FT4 1.5, FT3 2.65, rT3 20, TSH 0.6
Take 125 mcg synthroid AM, half of cytomel in AM, half at 3 PM
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 symptoms. rT3 still high. Will try 2.5 grains NDT

5/1/15 7 AM, 95 mcg T4, 22.5 mcg T3, FT4 1.1, FT3 3.9, rT3 13, TSH 0.1
Take 2.5 grains Nature-throid, half in AM, half at 3 PM.
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.

There are many positive articles on T3 and NDT but most doctors completely ignore them. 

 For the opposing view and why some articles miss the mark on finding where T3 is needed I have read some of these articles and found these faults:

1) The conversion charts of T4 only to NDT are so far off. They use completely inaccurate dosing based on charts made around the 1950's, ahead of FT4, and FT3 testing.

2) They primarily still gauge on TSH instead of FT4 and FT3, plus rT3. TSH just is not a good measure when on any form of T3 or NDT, as some people become completely suppressed (myself included) and this often differs from those on straight T4. One can't "force fit" T3/NDT into the model of T4 only, one must use the FT3, FT4 and rT3 when using NDT or T4/T3 combo's.

3) They never take the goal we may have of aiming for good or very good FT3, at moderate to middle of the road FT4, and low rT3. The likely goal would be something like TSH of a target value or range.

4) They give T3 or NDT once a day,

5) They convert from T4 only to NDT in a single day even if the FT4 is too high to switch

6) Pre-determined very biased research finds the answers it wants always.

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Links to doctor lists
See the very END of the blog.

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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 (defunct). Seems to have gone out of business....

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?

Common mistakes in switching over to NDT/DTE (Armour or similar) or T4/T3 combos

 

Cytomel, liothyronine = T3 (synthetic)

Levothyroxine, Synthroid, Tirosint = T4 (synthetic)

Armour, NP Thyroid = natural thyroid or NDT/DTE with both T4 and T3

 

1 Failure during switchover to reduce T4 dosage and give time for the FT4 to fall before starting Armour, or adding T3 (cytomel) to the reduced T4 dose. This is worse in cases where the FT4 is up at the top of range. It takes over a whole week for the FT4 to fall in half by not taking any (none), and often the FT4 is just way too high to start anything with T3 in it especially the amounts in NDT/DTE. If adding cytomel, it should generally be when the FT4 is moderate or light moderate, generally never near top of the FT4 range because it potentially causes many issues when added at above moderate FT4.

 

2 Failure of doctor to tell patient that T3/NDT is spread over the day, and that these are not once a day medication like Synthroid/Levo/T4.

 

3 Failure to get or doctor to prescribe appropriate doses of NDT and/or T3. This includes some really bad charts out there of what is the right NDT dose if going that way. About 60 to 70 mcg T4 is about 1 grain of NDT (60 or 65 mg depending on brand), not 100 mcg!

 

4 Failure of doctor or you to request monitoring the FT4 and FT3 once patient is on a combo or NDT, and still using TSH alone. One wants a moderate FT4 and very good FT3. Here is an example of a person that likely will have fewer issues, USA lab type values
Free t4: 1.09 ng/dL
Free t3: 3.72 pg/mL
Reverse T3: 10.8 ng/dl

 

5 Not considering that fillers can be causing some of your issues. Pill fillers combined with your metabolism all in a pill can cause various issues for many people. Acacia/ other gums, sugar alcohols (end in “ol”), talc, cornstarch are common issues for people.

 

6 Not checking for other issues, optimizing vitamin levels, or dealing with anemia even if a borderline anemia. One really wants the ferritin say 60 or 70 or so, not 12 or 18 and certainly not 250, plus CBC showing no issues like anemia or borderline anemia. Vitamin D a good lab is say 65, not 20.

 

7 Not timing labs. Free t3 is time sensitive, you can’t take NDT or T3 and go out and do a lab an hour later. We often mention on the list 8 hours after half (afternoon lab), or 16 hours after second half (an AM lab)

 

8 Not bringing FT4 up to reasonable if Armour/NDT doesn’t do the job and you have given it time and tried increases. Some people need a small amount of T4 to feel right and get the FT4 up to a more reasonable level, just some never think of this and lag not doing great for sometime before figuring this out.

 

9 Not doing some of your own work and documenting it so you, your doctors, and those you communicate with can understand what you have tried. Only you can determine if you are feeling well/normal or 100%. It can take some months or years to work out what is working and not working. Only you can do it with a doctor being flexible to your requests. Doctors these days often have MBA’s pushing them for productivity, like they are real estate agents or factory workers. You need a flexible one but you need to do a lot of work yourself, documenting problems, documenting successes, how you take your meds, how many hours since meds was the lab, What were the Free's, What were the issues and problems, HYPO/HYPER symptoms, etc.

 

10. Failure to examine Methylene tetrahydrofolate reductase (MTHFR) and looking to reduce homocysteine. If your homocysteine tests above 10 (USA lab), it is potentially likely you have some issues caused by MTHFR genetics. Most people should test 6 to 10 area on homocysteine. It is very common to have thyroid disorders with MTHFR genetics. The easiest cure is to stop buying/eating food with folic acid, and using Betaine HCL w/pepsin.


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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 calculated 1.4 to 1.7 grains: Low possible 1.25 grains, average 1.5 to 1.75 grains, high possible 2.0/2.25 grains
125 mcg pure T4 calculated 1.75 to 2.1 grains: Low possible 1.5 grains, average 1.75 to 2.0 grains, high possible 2.25/2.5 grains
150 mcg pure T4 calculated 2.1 to 2.5 grains: Low possible 2.0 grains, average 2.0 to 2.75 grains, high possible 3.0/3.25 grains
175 mcg pure T4 calculated 2.5 to 3 grains: Low possible 2.25 grains, average 2.5 to 3.0 grains, high possible 3.5 grains
200 mcg pure T4 calculated 2.85 to 3.3 grains: Low possible 2.5 grains, average 3.0 to 3.5 grains, high possible 4/4.5 grains

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)?

For the VAST majority of people: The stomach digests the Tg and breaks it down to proteins.

For a few of us, we have another likely issue, low stomach acid. Animal based thyroid hormones do contain thyroglobulin (Tg). In the case of low stomach acid, Tg might 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 very very few people get a rise in Tg from natural thyroid. I have gotten that when my homocysteine is high indicating an MTHFR issue and low stomach acid. There are no studies that I know of on this. See the MTHFR info later in the blog or start yourself on Betaine w/pepsin

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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 near time of taking.

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

If you get a positive Thyrogobulin (positive Tg or cancer marker) from it, check the MTHFR information below.

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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.

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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.

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:) 8,16, 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?

1) 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 below 1.2 or 1.1, then try again adding T3.

2) 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.

3) 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 1.0 (US labs) before starting T3 or NDT. Occasional people may need to bring this level down even more. Adding T3 or NDT at higher FT4 is often the problem.

Too much thyroid hormone 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 Iron/Ferritin. MTHFR. Bone and Joint. Thyroid friendly doctor links

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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 60-80 ng/mL
Female 50-70 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.

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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 problems 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.


----Basics of MTHFR-----------

Just the basics, no personal claims on any info just something I learned to start dealing with. Most doctors won’t help too much with this, but it could be a factor for some. Inputs/changes welcome.

Methylene tetrahydrofolate reductase (MTHFR) is when your body builds up toxic levels of folic acid (man-made synthetic form), and you lack enough of the enzyme function to convert it to the active and natural form Folate (Vitamin B9 a.k.a. methylfolate). The un-natural and fully synthetic Folic acid is added to wheat and many other products in the USA, just tons are in cereal, bread, other products. I have even seen it added to dried fruit. If you don’t convert it to folate very well due to some genetics you may have, it builds up and becomes toxic, then after decades of running very high levels it can cause issues (toxicity)

Some of the symptoms of too much folic acid/toxicity - you might get variations or just some

  • Thyroid issues are very common
  • A feel that for some is just like acid reflux, one that actually is caused by low stomach acid – working in Betaine w/pepsin during meals is the often the answer and not proton pump inhibitors. Even if you don't get the reflux feel most everyone gets low stomach acid.
  • Sensitivity to medications/pill fillers
  • Autoimmune issues
  • Depression - Some people get an anti-serotonin effect
  • Foggy thinking in some
  • GI issues and or problems, food sensitivities
  • Prostate or endometrial/uterine issues
  • Metals – Some may get higher metal levels because they might absorb them more than average person, so testing for some metals advised by some websites – arsenic, copper, mercury, lead, cadmium
  • MANY more issues

What happens is the low stomach acid can't break down various molecules and they absorb down in the GI below the stomach, which normally they wouldn't because they would have been broken down. This lack of ability to break things down from low acid, then causes the various food and pill filler or additives sensitivity.

The easiest cure for some - Simple solution

  • Stop buying/eating food with folic acid added, this includes cheapo multi-vitamins and enriched wheat (just enriched wheat, not all wheat).
  • Buy Betaine w/pepsin and take daily in the middle of food but only with big meals, AM and PM meal suggested, or at your largest meals of day

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Some lab tests of note you can ask your primary care to run - may help some in more complex cases

Keep in mind never take biotin the week you do labs.

  • Homocysteine. If your homocysteine is above 10 (don't use the range - use above 10), that is indicative of issues. Most people the homocysteine should only run 7 or 8, not 15 or 16 or some number like that.
  • “Folate” lab. This lab does not break down synthetic and natural (methyl) versions of Folate. So it is a gross measure of all forms. It should only test some value like 6 or 7 (ng/mL), if you read >14 or >20 (ng/mL) or any other value that has no upper limit it is too high. RBC Folate is sometimes said to be a better measure than Folate.
  • Genetic test, you can ask for one if you can find a doctor willing to order. You can also use the promethease website to upload ancestry raw DNA file, or 23 and me file, then look it up for yourself (more advanced and you need to learn the nomenclature of genetics).

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More complex solution - if the simple solution does not work

1. You can avoid folic acid added to your food, this includes cheapo multi-vitamins and enriched wheat products (wheat is ok, but not enriched wheat). At first it is hard to find foods in stores but eventually you find replacements to the added folic acid foods and enriched wheat.

2. Betaine w/pepsin. Take daily in the middle of food but only with big meals, AM and PM meal suggested, or at your largest meals of day

3. Akkermansia - probiotic

4. Take a B minus for several or more months. This is a higher dose of other B vitamins and no folate included, this forces some folic acid to convert and your blood level to fall.

5. My advice is just eat foods with natural folate and not bother with a high dose supplement. If anything a multivitamin with methylfolate. 

6. Every year or two have Homocysteine and Folate lab, if elevated take "B minus" again for awhile.

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The MTHFR gene sits on Chromosome 1. It only matters if you build Folic acid up and get issues, this is an estimation of your loss in ability to convert folic acid to folate based on the genetics you might have. Source.
Heterozygous = 1 copy of the gene from either parent
Homozygous = 1 copy of the gene from each parent
MTHFR C677T Heterozygous = approx. 40% loss of function
*MTHFR C677T Homozygous = approx. 70% loss of function *
MTHFR A1298C Heterozygous = approx. 20% loss of function (research not known)
MTHFR A1298C Homozygous = approx. 40% loss of function **
MTHFR C677T & MTHFR A1298C heterozygous = compound heterozygous = 50% loss of function

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Additional supplements in some cases

· Modified Citrus Pectin – GI help

· Apple Peel Powder – Probiotic help

· Chanca Piedra – liquid drops several times a year if gallbladder shows sludge

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More Info/references to read

Dr Lynch/Dirty Genes

Dr Amy Myers


----- BONE and JOINT----------

Combine a moderated FT4 with good FT3 with the below

Two bone booster

1 A nice collagen mix to take as desired. Your favorite collage powder mix - mix below into it

  • Boron liquid drops
  • Biosil liquid drops
  • If you tolerate Magnesium like a citrate it is a powder and can mix in - I can't handle magnesiums well so it isn't for everyone

2 Then buy yourself a D3 with K2 that also has strontium, they sell that as a single pill d3, k2, strontium.


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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/

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/

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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 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 described as helpful in converting T4 to T3. If you want to look into this, be sure to have some or tests before supplementing (ask your doctor to test the level). 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. Many supplements make it too easy to take too much, and you don't want that.

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 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 among 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.
 

-------More Links and Info---

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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, the links keep changing so I can only post a general link and even that might not work:

Posted on Inspire by reneeh63
https://www.healthonelabs.com/

There is also mymedlab.com :
https://www.mymedlab.com/

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

Canary Club which is great for cortisol and others, but their thyroid labs are too differing to compare to LabCorp for example in my own experience (experience may vary):
http://www.canaryclub.org/

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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:
(sorry now defunct)

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

Mary Shomon – outstanding author (links not working)

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

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

----Links to doctor lists---


Your local pharmacist can sometimes tell you physicians in your area that prescribe NDT/DTE.
 
The links keep changing so I can only post a general link and even that might not work:

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:

 Adthyza doctor links

RLC labs links, location keeps changing on website making this link difficult to give. See "Find a doctor"
https://getrealthyroid.com/

NP Thyroid "Find a doctor"
https://npthyroid.com/

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 (link not working well)
http://www.osteopathic.org/

Naturopaths in some states can give prescriptions.
The states that license Naturopathic Doctors or Naturopathic Physicians are Alaska, Arizona, California, Colorado, Connecticut, Hawaii, Kansas, Maine, Maryland, Montana, New Hampshire, Oregon, Utah, Vermont, Washington, and Washington DC. In licensed states NDs practice as independent primary care general practitioners, with the ability to diagnose and treat medical conditions, perform physical exams, and order laboratory testing. In these states many health care consumers specifically choose NDs as their primary care providers. Select Adrenal/endocrinology disorders and enter zip code.
http://www.naturopathic.org/AF_MemberDirectory.asp?version=2

WorldLink
https://worldlinkmedical.com/directory?&tab=2

Hypothyroid mom lists
http://hypothyroidmom.com

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