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Forum Name: Endocrinology Topics

Question: TSH levels indicate Hyper T3 and T4 normal but border hypo


 utleezard - Fri Jan 20, 2006 7:14 pm

My Ultrasensitive TSH levels are very low .04 indicating that my thyroid is hyperactive, but my T3, T4, and free T3 are all on the hypo side of normal. I have a consistent body temperature of 96.5 degrees, difficulty losing weight, headaches, anxiety, can't go to sleep at night and can't get up in the morning even after 8 hours of sleep. I am lethargic all day, and have recently developed a lot of acne on my neck and a muscle twitch in my eye lid. My doctor said to come back in six months to test my thyroid again, but I can't wait six months!! I have a family that needs me. Can anyone give me a clue as to what is wrong with me??
 Dr. Shank - Wed Feb 01, 2006 6:13 pm

Dear Utleezard:

You need to see an endocrinologist.

I am an endocrinologist with a Ph.D. in Physiology and Biophysics for work on the hypothalamic-pituitary-thyroid-peripheral tissues axis. It would be unreasonable to expect most physicians to have the expertise that I have in thyroid, but, unfortunately, most know only what I call the "cereal box" version.

In spite of what you were told, a low TSH does not indicate hyperthyroidism. Yes, hyperthyroidism is a possible cause, but it is hardly the only one.

TSH can also be low due to recent hyperthyroidism, despite current hypothyroidism. This is commonly seen in the early phases of a common self-limited condition known as subacute thyroiditis.

TSH, T3, free T3, T4, and free T4 are often affected in poorly predicted ways during non thyroidal illness, such as infections, trauma or surgery, caloric restriction, and even depression. By the way, most of what "everyone knows" about the patterns of thyroid function tests is correct for rats, but not true for humans.

From your symptoms, I suspect that you have true hypothyroidism and that this has been going on for longer than the roughly one month that this pattern of laboratory results could be seen in subacute thyroiditis. That tells me that you most likely have "central" hypothyroidism, meaning that there is an abnormality in your pituitary gland or hypothalamus (the part of the brain that controls the pituitary).

T3 and free T3 are usually very well maintained in hypothyroidism. The exception is when the hypothyroidism is severe.

Do not--repeat, do not--let anyone start you on thyroid hormones until a qualified individual has screened you for adrenal insufficiency and treated it, if you have it. If someone says that he is going to test that by a cosyntropin stimulation test, find someone else. The cosyntropin stimulation test is good for some things, but useless for evaluating the pituitary control of the adrenals (That does not keep non endocrinologists from using it for that purpose all the time, and then confidently interpreting it as if it were.).

Given what you have described, your headaches may well be due to a pituitary tumor, which may damage other structures (including the rest of the pituitary gland, resulting in possible deficiencies of other pituitary hromones) and secrete too much of another hormone. Depending upon your age, you may have a tumor called a craniopharyngeoma that can damage your pituitary gland. Brain tumors are rare and easily detected. Infections (such as tuberculosis) and other conditions (such as sarcoidosis) very rarely affect the pituitary gland. Head trauma is a common cause of pituitary damage, usually affecting the main adult pituitary hormone, somatotropin ("growth hormone," in kids), but infrequently affecting thyroid-stimulating hormone (TSH).

If you do have a pituitary tumor, make absolutely certain that you see an endocrinologist first, before going off to a surgeon. Most pituitary tumors should be treated with medications, not surgery! Even those few tumors that need surgical treatment need to be evaluated, so that the endocrinologist knows what it was producing and what to tests to follow after the surgery. Surgeons routinely say that "it wasn't cancer" (yeah, and it wasn't a jumbo jet liner, either!), he "got it all" (maybe, but you need proof!), and that there was no damage to the rest of the pituitary gland (and just how does he know that without testing??). If you must have surgery for a pituitary tumor or a craniopharyngeoma, make sure that you are referred by an endocrinologist who knows your regional endocrine surgeons to someone who does LOTS of pituitary surgeries, rather than doing them as a sideline to a general neurosurgical practice.

Waiting six months is not a good idea. If your primary physician will not refer you to an endocrinologist now, go to http://www.aace.com and look for an endocrinologist in your area.

You will be glad you did!

I hope that this is helpful to you.

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