Elevated TSH on TRT/HCG

[bluezebra5]

I've been on HRT for almost 2 years, HCG monotherapy for the first year, test+HCG for about 8 months. I had several normal thyroid studies prior to beginning HRT, and one normal study while on HCG.



Today, as part of a work up for a new physician, my TSH came back at 8.005 (.45-4.5).



I am waiting to see my endocrinologist, but wanted to see if any of our Thyroid experts would weigh in on this. Obviously we need to see a full panel, but should I be expecting hypothyroid?



It may be pertinent to note that the bloodwork was at peak testosterone levels. Total and Free T are just over the top of the reference range. DHEA-S is good. Could high T explain the TSH overdrive?



Thanks guys.

 

[CoastWatcher]

Is this the first time you've had an elevated TSH? Has it been trending upward? And, more importantly, do you have a full thyroid panel?

 

[bluezebra5]

Is this the first time you've had an elevated TSH? Has it been trending upward? And, more importantly, do you have a full thyroid panel?

This is the first time I've had TSH elevated out of range. I am currently digging for those old labs to see if they were telling me something that no one noticed. No full panel yet, getting one tomorrow.

 

[Vettester Chris]

More labs (as noted) are needed (Free T4, Free T3, Reverse T3, TPO & TgAb antibodies), which will help decipher between overt and sub-clinical. Even with extremely low T3 & T4 levels, TSH "usually" doesn't elevate that high. Not saying it can't or won't, just saying it's not everyday that patients with evident overt hypothyroidism present a TSH reading 6.00 < .

On your "High T" ... I see you are on HRT, so in essence your LH should be suppressed. my first paragraph was leaning towards this direction ...

TSH is one of several hormones produced by the anterior pituitary. LH & FSH (responsible for testicular activity) is also produced in this region, as is ACTH, prolactin, GH, and a few others. If you have a recent LH/FSH lab, it would be helpful? Again, those should be suppressed due to exogenous testosterone.

I'll keep an eye out for your labs and responses.

 

[bluezebra5]

More labs (as noted) are needed (Free T4, Free T3, Reverse T3, TPO & TgAb antibodies), which will help decipher between overt and sub-clinical. Even with extremely low T3 & T4 levels, TSH "usually" doesn't elevate that high. Not saying it can't or won't, just saying it's not everyday that patients with evident overt hypothyroidism present a TSH reading 6.00 < .

On your "High T" ... I see you are on HRT, so in essence your LH should be suppressed. my first paragraph was leaning towards this direction ...

TSH is one of several hormones produced by the anterior pituitary. LH & FSH (responsible for testicular activity) is also produced in this region, as is ACTH, prolactin, GH, and a few others. If you have a recent LH/FSH lab, it would be helpful? Again, those should be suppressed due to exogenous testosterone.

I'll keep an eye out for your labs and responses.

I hoped I might get a response from you, Chris. Thank you.

Out of curiosity, what does a TSH this high usually indicate? Are we talking autoimmune or infiltrative disease?

LH is essentially zero and has been for some time. This bloodwork was actually the workup for a Defy consult.

In addition, if this helps, labs ~6 months ago showed normal IGF and prolactin

 

[Vettester Chris]

I hoped I might get a response from you, Chris. Thank you.

Out of curiosity, what does a TSH this high usually indicate? Are we talking autoimmune or infiltrative disease?

LH is essentially zero and has been for some time. This bloodwork was actually the workup for a Defy consult.

In addition, if this helps, labs ~6 months ago showed normal IGF and prolactin

OK, good to know on the other labs. That eases some of the concern with the pituitary.

There's a myriad of factors that can lead to the elevated TSH. Honestly, sometimes it's just as simple as getting adequate iodine and selenium supplemented. At one point early on with my treatments, my thyroid hormone level was actually pretty good, but TSH was hovering over 4.00. I started adding 225mcg/day of Kelp and a small amount of selenium, my numbers were mid 2's in no time. Yes, it was as simple as that.

That's just one example, but YES, autoimmune can play a role, or other factors that tap into hypothyroidism. I suggest getting all the labs so that you don't have to second guess any of it. If there are imbalances with FT4 and/or FT3, and/or FT3/RT3 ratios are not where they should be, then it will require further investigation with other attributed labs, i.e., cortisol, iron/ferritin, D3, electrolytes, and possibly a few others.

For now, without getting wound up in the speculation, you might get the answers you need just with the thyroid labs. Check it out, let us know ...

 

[bluezebra5]

OK, good to know on the other labs. That eases some of the concern with the pituitary.

There's a myriad of factors that can lead to the elevated TSH. Honestly, sometimes it's just as simple as getting adequate iodine and selenium supplemented. At one point early on with my treatments, my thyroid hormone level was actually pretty good, but TSH was hovering over 4.00. I started adding 225mcg/day of Kelp and a small amount of selenium, my numbers were mid 2's in no time. Yes, it was as simple as that.

That's just one example, but YES, autoimmune can play a role, or other factors that tap into hypothyroidism. I suggest getting all the labs so that you don't have to second guess any of it. If there are imbalances with FT4 and/or FT3, and/or FT3/RT3 ratios are not where they should be, then it will require further investigation with other attributed labs, i.e., cortisol, iron/ferritin, D3, electrolytes, and possibly a few others.

For now, without getting wound up in the speculation, you might get the answers you need just with the thyroid labs. Check it out, let us know ...

Can't thank you enough, Chris.

I will report back ASAP with the full panel. Your note about iodine and selenium may be right on the money. Thinking about it, I've recently ditched my multi in favor of supplementing individual vitamins and minerals, specifically to address issues with B vitamins. Perhaps I shot myself in the foot, as I am really stingy with salt.

Haven't had D3 drawn in a while, but it was a tad low (in range) a year ago or so. I've since been supplementing 2000-4000iu daily depending on my time in the sun. Ferritin is normal- my grandfather had Hemochromatosis- we were dead set on that diagnosis when I presented with hypogonadism, but my iron studies are always normal and genetic test was negative. I know very little of the interplay between the thyroid and adrenals, but in my initial work up, I know my physician ruled out adrenal insufficiency, though this was 2 years ago.

 

[bluezebra5]

Results are in. WOW.

TSH: 5.5 (.5-4.7)

Free T4: .73 (.73-1.95)

T3 Uptake: 27%

TPOab: 594 (>9)

TGab: 1 (<4)

Working to get PCP on phone. Endocrinology appt on Monday. What should I prepare myself for?

 

[Vince Carter]

You mentioned Defy, if you're a patient, I'd dump that PCP and Endo and let Dr Saya weigh-in on it first. That's got to be an integrated layer to whomever you're seeking HRT from.

 

[bluezebra5]

You mentioned Defy, if you're a patient, I'd dump that PCP and Endo and let Dr Saya weigh-in on it first. That's got to be an integrated layer to whomever you're seeking HRT from.

I'm going to keep the appointment as I trust this guy, but I'm certainly pushing to get my consult ASAP

 

[Dr Justin Saya MD]

I would follow Vettester Chris' advice and start selenium NOW. Also have them check reverse T3 and free T3 if you can (T3 uptake isn't a replacement for those tests).

 

[Vettester Chris]

Yeah, you need to talk to your physician about Hashi's. Your enzyme related antibodies are concerning.

In the future dump those "Uptake" labs, and anything that says "index" on it! They're worthless and outdated about 30 years! Next time round, see if you can also get a Free T3 Serum and a Reverse T3 Serum lab(s).

As we already spoke about Selenium, it can work quite effectively on its own with Hashi's. 300 to 400mcg of selenium is usually a decent range with people having elevated TPO, plus a regular regiment of kelp/iodine as also mentioned. Additionally, NDT treatment can be administered effectively, and can make a HUGE dent on reducing and stopping the autoimmune attacks. The trick is titrating to a correct dosage; usually upwards of 3 grains or more.

With that said, just keep this and other information in the back pocket, do some additional research and cross check anything you read, and don't make any moves without the guidance of a trained physician. I'd run all this by your current guy, see what he says, then look at going to get a second opinion from Dr. Saya, or someone who is also specialized in the endocrine side of things.

 

[bluezebra5]

I would follow Vettester Chris' advice and start selenium NOW. Also have them check reverse T3 and free T3 if you can (T3 uptake isn't a replacement for those tests).

Thanks Dr. Saya. I will pick up a selenium supplement this evening, and I look forward to our consultation. Your front office team has been great.

 

[bluezebra5]

Yeah, you need to talk to your physician about Hashi's. Your enzyme related antibodies are concerning.

In the future dump those "Uptake" labs, and anything that says "index" on it! They're worthless and outdated about 30 years! Next time round, see if you can also get a Free T3 Serum and a Reverse T3 Serum lab(s).

As we already spoke about Selenium, it can work quite effectively on its own with Hashi's. 300 to 400mcg of selenium is usually a decent range with people having elevated TPO, plus a regular regiment of kelp/iodine as also mentioned. Additionally, NDT treatment can be administered effectively, and can make a HUGE dent on reducing and stopping the autoimmune attacks. The trick is titrating to a correct dosage; usually upwards of 3 grains or more.

With that said, just keep this and other information in the back pocket, do some additional research and cross check anything you read, and don't make any moves without the guidance of a trained physician. I'd run all this by your current guy, see what he says, then look at going to get a second opinion from Dr. Saya, or someone who is also specialized in the endocrine side of things.

Thanks again Chris. I will get on this and update with any additional info on Monday. I wish I had nearly the understanding of the thyroid gland as I did the HPA stuff, otherwise I would have respectfully suggested which labs I needed.

 

[bluezebra5]

Beginning selenium and kelp now.


This is just the latest in a series of things that I'm beginning to think must be related, despite what I'm being led to believe.


I had a vasovagal/neurocardiogenic syncopal attack back in 3/2012 (with aura/prodrome). Cardiac and neuro workups all unremarkable. Infrequent auras, but no syncope through 2/2014, when I was diagnosed with hypogonadotropic hypogonadism (idiopathic).

Second syncopal episode 10/2014. Led to placement of loop recorder. Quickly observed that auras corresponded to asystole (true sinoatrial arrest) between 3-10 seconds, even those that did not result in loss of consciousness.

Third blackout was this month- same exact scenario- aura, tunneling, out (4 sec asystole).

Now, only by pure chance had TSH pulled for Defy workup. Now looking at autoimmune thyroiditis. Is Dr. House in the house?

 

[Dr Justin Saya MD]

I believe you *may* have found the source of your hypogonadotropic hypogonadism as hypothyroidism, especially severe, can suppress the HPTA.

Further, both hypo and hyperthyroidism can cause arrhythmias. Now intermittent asystole is certainly a less common arrhythmia, but within the realm of possibility.

You may have found the missing piece of your medical puzzle!

 

[bluezebra5]

I believe you *may* have found the source of your hypogonadotropic hypogonadism as hypothyroidism, especially severe, can suppress the HPTA.

Further, both hypo and hyperthyroidism can cause arrhythmias. Now intermittent asystole is certainly a less common arrhythmia, but within the realm of possibility.

You may have found the missing piece of your medical puzzle!

so I should have added this- I had "normal" thyroid studies following HH diagnosis. I say "normal" because I felt the interpretation was rushed, at best. I remember TSH was high, but in range (say, 4.4), fT4/fT3 were about mid range, and I don't think they ordered the Ab tests (god that's frustrating).

Do you still think this is a possible culprit, Dr. Saya? Again, I appreciate your help so much.

 

[bluezebra5]

2/2014

TSH 3.94 (.45-4.5)
T4 1.00 (.82-1.77)

3/2014

TSH 2.96 (.45-4.5)
T4 5.2 (4.5-12)
T3 Uptake 35 (24-39)
Free Thyroxine Index 1.8 (1.2-4.9)

1/2015

TSH 4.5 (.45-4.5)
Triiodothyronine 3.7 (2.0-4.4)
T4, free, direct 1.14 (.82-1.77)

Sorry in advance for the archaic tests. If only I'd known about this forum back then.

 

[Dr Justin Saya MD]

so I should have added this- I had "normal" thyroid studies following HH diagnosis. I say "normal" because I felt the interpretation was rushed, at best. I remember TSH was high, but in range (say, 4.4), fT4/fT3 were about mid range, and I don't think they ordered the Ab tests (god that's frustrating).

Do you still think this is a possible culprit, Dr. Saya? Again, I appreciate your help so much.

Yes, I do believe it is still a possible culprit, but only speculation without the antibody tests back then. The TSH ~4.4 back then is suspicious, especially with what we know now with your TPO Ab, even if fT3/fT4 were indeed midrange. In the absence of head/pituitary trauma, there is usually a distinct (or several concurrent) cause of secondary hypogonadism. I gather they didn't attempt a HPTA stimulation test (Clomid)?

 

[bluezebra5]

Yes, I do believe it is still a possible culprit, but only speculation without the antibody tests back then. The TSH ~4.4 back then is suspicious, especially with what we know now with your TPO Ab, even if fT3/fT4 were indeed midrange. In the absence of head/pituitary trauma, there is usually a distinct (or several concurrent) cause of secondary hypogonadism. I gather they didn't attempt a HPTA stimulation test (Clomid)?

I have a pituitary microadenoma that is (supposedly) nonfunctioning. I did try clomiphene, I believe up to 50mg, which pushed my total T near 600 or so, but without significant symptomatic relief.