DESSICATED THYROID CONTINUES HAVING ZERO EFFECT ON TSH; ELEVATED FT3, NORMAL FT4

[mcs]

All NP Thyroid seems to be doing is spiking my T3 and doing nothing for my TSH as evidenced on my latest thyroid function labs. Even worse, my TSH INCREASED despite taking my morning dose 4h prior to my lab draw. I do not have Hashimoto’s after having test TPO and TgAb several times over the last few years, so no reason to keep testing them.

Current dose @ 90mg q.d. I have been on every conceivable combination of thyroid replacement since 2010 and I’ve never been able to get a consistently suppressed TSH no matter what I’ve tried. I have been taking 90mg q.d. NP Thyroid now for 6 mos.

What causes I’m guessing at:

- Reduced pituitary/thyroxine signaling; High TSH; T3/T4 levels normal, but not getting into cells
- chronic LCHF diet > possible thyroid resistance and/or hormone suppression (ref: Paul Jaminet - Perfect Health Diet)
- SIBO/SIFO: I take betaine-HCL and pancreatin with meals, so I would think I got any possible malabsorption issues covered.
- under-dosed at 1.5 grains (90mg) according to this dose calculator by 10mcg T4 equivalent. Is that really enough to make a difference?

What possible actions to take:

1) Switch back to:
a) T4 monotherapy (this time with Tirosint-SOL) - based on successful past suppression of TSH with regular old levothyroxine (I realize that NDT is usually the better choice [contains T4, T3, T2, T1, calcitonin, iodine], but it simply isn’t suppressing TSH, and in my case, seems to be failing to make a difference). I had a good response early on trialing thyroid replacement meds and levo was the only med in which my TSH suppressed to <2.0. Unfortunately, the effect didn’t last for whatever reason.

b) compounded NDT (pure porcine powder from same supplier as the commercial brands with either sodium bicarbonate or ascorbic acid as filler); pre and post standardized (pharmacy will provide COA which shows T4/T3 ranges per batch) as opposed to reliance upon commercial brands, once the gold standard of reliable standardization and stability but have been recalled due to variations in potency, minor as it may be.

2) increase dose of NP Thyroid to 105mg which would give me 160.4mcg T4 equivalent/day, slightly over my limit of 150.2mcg.

3) Iodine intake - keeping in mind the advice from a naturopath. Until I can test correctly using UIC ratio, iodine intake will remain an open item.

Can you guys think of anything else that as to why NP Thyroid has failed me and what I can do for now?

It will take some time, effort and finagling to switch meds.

 

[Gman86]

Wow, A+ in regards to the effort u’ve put into trying to figure out this issue, and in regards to ur level of perseverance. Extremely impressive. The thyroid is arguably the hardest hormone system to dial in by far. So I feel ur pain and frustration.

So u said ur diet is low carb high fat, what exactly does ur diet look like? Would u be comfortable with increasing ur carbs a bit if it helped decrease ur TSH? Do u follow Dr Paul Saladino at all? He did strict carnivore for quite a while, as it’s very close to the optimal diet for humans, but he ended up figuring out that not only did he feel better with upping his carb intake a bit, his labs looked better when adding in the carbs as well. Here’s the most current video of what he eats in a day

How much iodine are u getting? Iodine, as I’m sure u know, is extremely important/ mandatory for proper thyroid function. Dr Westin childs is the top doc that I’ve found in regards to information about the thyroid. Here’s a good video where he talks about his iodine recommendations

And here’s a few videos where a guy went on iodine and had labs done before and after I believe.

And here’s a video of dr Westin childs talking about 3 supplements to take for ur thyroid. I have it saved, so must have some significant info I wanted to remember, and might help u out

 

[Gman86]

And here’s a couple other videos on iodine dosage recommendations I have saved. They both recommend around 1-3mg/ day IIRC

 

[Gman86]

Do u eat any organ meats, or take any desiccated organ supplements? Vitamin A (retinol) is very important for proper thyroid function, and most people don’t get near enough retinol in their diet

Also, are u getting enough selenium in ur diet? I’m sure u know that selenium is an extremely important cofactor for proper thyroid function

 

[Vince]

Do u eat any organ meats, or take any desiccated organ supplements? Vitamin A (retinol) is very important for proper thyroid function, and most people don’t get near enough retinol in their diet

Also, are u getting enough selenium in ur diet? I’m sure u know that selenium is an extremely important cofactor for proper thyroid function

I may have missed it, what's level is your reverse t3 at?

 

[Gman86]

I may have missed it, what's level is your reverse t3 at?

Mine or the OP’s? My most recent RT3 came back at 9 I believe

 

[mcs]

Do u eat any organ meats, or take any desiccated organ supplements? Vitamin A (retinol) is very important for proper thyroid function, and most people don’t get near enough retinol in their diet

Also, are u getting enough selenium in ur diet? I’m sure u know that selenium is an extremely important cofactor for proper thyroid function

I take selenium and take a raw spleen supplement as well as Vitamin A. As to iodine, too much is just as bad as too little and it's guesswork when you take as many supps as I do which may have trace amounts that add to an excess which is why I mentioned the UIC ratio test in my post. That's the only way to assess iodine status AFAIK. I don't think micronutrition is the issue.

As far as diet, here's the last few days from my Cronometer food diary (I do eat liver occasionally. I don't always include salads and veggies in my diary unless they are calorie-dense which most aren't):

 

[Vince]

Mine or the OP’s? My most recent RT3 came back at 9 I believe

You should post your complete thyroid panel. It would make it a lot easier for us to discuss your issues.

 

[Gman86]

You should post your complete thyroid panel. It would make it a lot easier for us to discuss your issues.

U referring to the OP again?

 

[mcs]

You should post your complete thyroid panel. It would make it a lot easier for us to discuss your issues.

I posted my results in the link. The only marker missing was rT3. Up for debate as to whether it even has the value I once gave it after consulting with this endo (he doesn't even test for it): Reverse T3: The Four Top Causes of High Reverse T3 | Dr. Alan Christianson

Past rT3 levels here. Last one done in 05/20 was @ 18.0.

No reason for TPO or TgAb since I already tested for those many times in the past and was negative.

 

[Vince]

I posted my results in the link. The only marker missing was rT3. Up for debate as to whether it even has the value I once gave it after consulting with this endo (he doesn't even test for it): Reverse T3: The Four Top Causes of High Reverse T3 | Dr. Alan Christianson

Past rT3 levels here. Last one done in 05/20 was @ 18.0.

No reason for TPO or TgAb since I already tested for those many times in the past and was negative.

Okay, thanks. I see your labs. I wonder what your labs would look like, if you did labs before you took your thyroid meds. That's how I do my thyroid labs.

 

[mcs]

Okay, thanks. I see your labs. I wonder what your labs would look like, if you did labs before you took your thyroid meds. That's how I do my thyroid labs.

My last labs were done 24h after my last dose as I posted in this historical chart (see 09/07/21 date). I periodically run labs soon after taking my dose to check how well it's working.

I'm now wondering if it's a problem with my pituitary/hypothalamus. Like a bad thermostat, I keep "adjusting the dial" (i.e. adding T3/T4) but the temperature (i.e. TSH) stays the same.

A partially-empty sella was found in my sella turcica as an incidental discovery on a brain MRI some years ago. I have mentioned this finding to just about every practitioner I can think of and the answer was always the same: you would know if you had ESS (empty sella syndrome) because most or all of your hormone levels would be out of range.

Maybe I should look into getting a TRH (Thyrotropin-releasing hormone, what the hypothalamus releases to get the pituitary to release TRH) drawn and see if it is unusually high.

If the TRH is good then it may be a "stuck" pituitary (i.e. hypothalamus properly senses T3/T4 but pituitary keeps pumping out TSH). If the TRH is unusually high it may signal that the hypothalamus is the issue. Despite proper levels of T3/T4 it continues to release too much TRH.

It may therefore be an exercise in futility, but to rule it out, neither Quest nor LabCorp offer TRH since it’s a stim test, so definitely haven’t had that done. Needs to be performed in a doc’s clinic or hospital. May also be a challenge to get the endo to do it since I have no other signs or sxs of ESS.

At the end of the day though, the treatment for that is usually T4 as indicated in this study. Re-trialing T4 was on my above list of possible actions to take anyways, so maybe give it a shot again to see if it corrects? My guess is that's what any endo would advise before subjecting myself to a TRH stim test.

 

[mcs]

Trying to find a pattern isolating my TSH levels from my historical chart over the last 7 1/2 years. This is what I came up with:

Average TSH level @ <2.50 (12 times): 2.04
Average daily NDT dose for each of those levels: approx. 1.25 grains (~75mg)
Average daily TSH levels for last 2.5 years (18 times): 3.48
Average daily NDT dose for each of those levels: approx. 1.64 grains (~98mg)

Cannot understand why the climb in TSH when the dose of NDT was increased. Only main difference: for the majority of the last 2 years I was taking NP Thyroid as my NDT.

 

[BillyJ03z]

Trying to find a pattern isolating my TSH levels from my historical chart over the last 7 1/2 years. This is what I came up with:

Average TSH level @ <2.50 (12 times): 2.04
Average daily NDT dose for each of those levels: approx. 1.25 grains (~75mg)
Average daily TSH levels for last 2.5 years (18 times): 3.48
Average daily NDT dose for each of those levels: approx. 1.64 grains (~98mg)

Cannot understand why the climb in TSH when the dose of NDT was increased. Only main difference: for the majority of the last 2 years I was taking NP Thyroid as my NDT.

You need to bump the NDT up to at least 2 grains and also add straight T3 (25mcg to start).... T3 is what drives down your TSH. I just got finished reading all about this on Dr. Westin Childs site... and he states that when you increase NDT the FT4 will lower. He also said because there is such a small ratio of T3 to T4 that people wrongly increase the grains to get the t3 higher and then the T4 drops even lower. Like I said, try to 2grains with 25mcg T3.

 

[mcs]

You need to bump the NDT up to at least 2 grains and also add straight T3 (25mcg to start).... T3 is what drives down your TSH. I just got finished reading all about this on Dr. Westin Childs site... and he states that when you increase NDT the FT4 will lower. He also said because there is such a small ratio of T3 to T4 that people wrongly increase the grains to get the t3 higher and then the T4 drops even lower. Like I said, try to 2grains with 25mcg T3.

I recently (about 5 weeks ago) adjusted my dose to 1.75gr which is a little over my max based on this dose calculator which factors into account body weight. If you look at my spreadsheet, you can see I've already tried doses > 1.50:

- @ 3 grains (in early 2014), TSH was in the mid 2's and FT3 was in the high 2's-low 3's.
- @ 2.5 grains (late 2019-early 2020), I still could not suppress TSH much below 3.50. My FT3 levels were just < 3.0.

So, not much difference.

That's why I'm looking at other factors. Perhaps experimenting with adding in more T4 instead of more NDT since the most suppressed I ever was is when I was on T4 only. Some of my SNPs would suggest I have a conversion defect, but if I suppressed on T4 monotherapy, that would suggest I don't.

Some docs believe that TSH is irrelevant if T3 is optimized. I'm not so sure about that.

 

[BillyJ03z]

I recently (about 5 weeks ago) adjusted my dose to 1.75gr which is a little over my max based on this dose calculator which factors into account body weight. If you look at my spreadsheet, you can see I've already tried doses > 1.50:

- @ 3 grains (in early 2014), TSH was in the mid 2's and FT3 was in the high 2's-low 3's.
- @ 2.5 grains (late 2019-early 2020), I still could not suppress TSH much below 3.50. My FT3 levels were just < 3.0.

So, not much difference.

That's why I'm looking at other factors. Perhaps experimenting with adding in more T4 instead of more NDT since the most suppressed I ever was is when I was on T4 only. Some of my SNPs would suggest I have a conversion defect, but if I suppressed on T4 monotherapy, that would suggest I don't.

Some docs believe that TSH is irrelevant if T3 is optimized. I'm not so sure about that.

"If you are taking Armour thyroid and you find that your TSH is NOT decreasing then that is an indication that your dose is insufficient."

Armour Thyroid Dosage Guide (Are you taking enough?)

How do you know if your armour thyroid dosage is high enough for your body? These symptoms will tell you if you need more.

www.restartmed.com

 

[Nelson Vergel]

3) Iodine intake - keeping in mind the advice from a naturopath. Until I can test correctly using UIC ratio, iodine intake will remain an open item.

I am not clear. Are you taking iodine? If so, that is the reason for your high TSH even on thyroid Rx

 

[mcs]

I am not clear. Are you taking iodine? If so, that is the reason for your high TSH even on thyroid Rx

I take a small amount daily, however, to assess accurately to determine if my intake is too much or too little, the UIC test is the best.

I was not taking any iodine at the time of that test, though. I thought it was only biotin that elevates TSH level if you take it before testing.

 

[MIP1950]

I recently (about 5 weeks ago) adjusted my dose to 1.75gr which is a little over my max based on this dose calculator which factors into account body weight. If you look at my spreadsheet, you can see I've already tried doses > 1.50:

- @ 3 grains (in early 2014), TSH was in the mid 2's and FT3 was in the high 2's-low 3's.
- @ 2.5 grains (late 2019-early 2020), I still could not suppress TSH much below 3.50. My FT3 levels were just < 3.0.

So, not much difference.

That's why I'm looking at other factors. Perhaps experimenting with adding in more T4 instead of more NDT since the most suppressed I ever was is when I was on T4 only. Some of my SNPs would suggest I have a conversion defect, but if I suppressed on T4 monotherapy, that would suggest I don't.

Some docs believe that TSH is irrelevant if T3 is optimized. I'm not so sure about that.

I don't think the issue of T4 to T3 conversion is as straightforward as it sometimes is presented. TSH is the hormone that stimulates the thyroid. There could be a problem in the pituitary or hypothalamus. Either add T3 or just take T3. Managing hormones is an art. Some doctors are good at it because they read everything and have an open mind. Other doctors just give you a prescription and if you don't respond or get worse, they figure it's something else. No curiosity nor do they enjoy a challenge.

One of the true pioneers is Dr. Tammas Kelly, a psychiatrist. I read his book and had a Zoom consult last year with him when he was in private practice. From his research and in citing other researchers, it's all about T3. But if you remain on NP, add some T3 to make it almost 1:1. However, there was another pioneer in thyroid treatment, Dr. Broda Barnes, PhD, M.D. He was first an endocrine physiologist, then became a physician/researcher, teaching and treating patients at the University of Chicago. His book, Hypothyroidism: The Unsuspected Illness is based on his experience, including his own hypothyroidism. He used Armour desiccated back when it was similar to NP. A third doctor to look at is the late Kenneth Blanchard who used microdoses of T4 and T3 with good results. It's all fascinating.

I'm saying that sometimes you have to be your own doctor, even if you're working with a doctor. If you're self treating you have to be willing to experiment. Even good doctors can't know everything and there are patients who are biochemical outliers, such as myself. Keep working on it.

 

[mcs]

I don't think the issue of T4 to T3 conversion is as straightforward as it sometimes is presented. TSH is the hormone that stimulates the thyroid. There could be a problem in the pituitary or hypothalamus. Either add T3 or just take T3. Managing hormones is an art. Some doctors are good at it because they read everything and have an open mind. Other doctors just give you a prescription and if you don't respond or get worse, they figure it's something else. No curiosity nor do they enjoy a challenge.

One of the true pioneers is Dr. Tammas Kelly, a psychiatrist. I read his book and had a Zoom consult last year with him when he was in private practice. From his research and in citing other researchers, it's all about T3. But if you remain on NP, add some T3 to make it almost 1:1. However, there was another pioneer in thyroid treatment, Dr. Broda Barnes, PhD, M.D. He was first an endocrine physiologist, then became a physician/researcher, teaching and treating patients at the University of Chicago. His book, Hypothyroidism: The Unsuspected Illness is based on his experience, including his own hypothyroidism. He used Armour desiccated back when it was similar to NP. A third doctor to look at is the late Kenneth Blanchard who used microdoses of T4 and T3 with good results. It's all fascinating.

I'm saying that sometimes you have to be your own doctor, even if you're working with a doctor. If you're self treating you have to be willing to experiment. Even good doctors can't know everything and there are patients who are biochemical outliers, such as myself. Keep working on it.

As I indicated in my post, I have already experimented with every possible combination, including adding T3 in various doses, over the last 10+ years. The only instance in that time frame I sufficiently suppressed was when I took T4 alone, go figure, but I wasn't able to maintain it for whatever reason. The only part of this that has me thinking why the TSH hasn't suppressed is a problem with the pituitary or hypothalamus, but if so, then the treatment is to increase the dose of thyroid replacement. T3 monotherapy works for some, but was ineffective in my case and made me feel worse, stresses the heart/adrenals, etc. in the long run. Since this post, I have increased the dose of NP Thyroid to 105mg and will retest. I also will be switching to compounded NDT which is a purer product to see if I get any better results on that. Failing that, experimenting with T4 only or T4 added to the NDT will be next.