Elizabeth’s Question: 

I just got my lab results back and they are: TSH, Thyroid-stimulating hormone, is 1.33, Free T4 is 1.64, Free T3 is 2.9, thyroid peroxidase antibodies, that’s for the Hashimoto’s, is 16. My doctor said my Free T4 was a little high so she suggested cutting my levothyroxine, which is a T4 only medication, 50 micrograms in half, which would be 25 micrograms and to come back in a couple of months for labs. Do you think my Free T3 levels are low? I’ve been having terrible issues with my muscles and heart palpitations. –Elizabeth.

Short Answer: 

Lowering her dosage is a common reaction, but is not the right one. In this case, we would most likely switch the medication to a compounded, sustained-release combination of T4 and T3. As for the heart palpitations, it is probably not related to her medication because the dose is only 50 mcg. Women in perimenopause and going into menopause will commonly experience heart palpitations and be related to adrenal dysfunction and declining estrogen levels.

PYHP 079 Full Transcript: 

Download PYHP 079 Transcript: 

Dr. Maki: Hello, everyone. Thank you for joining us for another episode of the Progress Your Health podcast. I’m Dr. Maki.

Dr. Davidson: And I’m Dr. Davidson.

Dr. Maki: How are you doing today?

Dr. Davidson: I’m doing great this morning. Thank you. It’s springtime, the birds are singing. The flowers are blooming, the weather’s finally getting to be about 50 degrees, which is good here, which is actually really, really good.

Dr. Maki: Yes, we can’t complain. There’s been less rain, more sun, that’s always fun. The weather’s definitely picking up, now, it’s interesting here in Bellingham where we live. There’s not a lot of difference between– like winter it averaged, this, at least this winter anyway, which I thought was odd. It averaged 40 degrees almost the entire winter which is pretty nice. I’m originally from Minnesota, Wisconsin area and 40 degrees in the wintertime is there wouldn’t be any snow, there wouldn’t even be winter if it was 40 degrees all year. So, we got pretty lucky this winter.

Dr. Davidson: And your sister, my sister-in-law, she still lives in Minnesota. When I send her the– you know, “how warm it is?” I’m like, “Oh, it’s cold. It’s 41.” And she’s like, “That’s t-shirt weather.”

Dr. Maki: Yes, yes yes, she thinks worse, and living in Las Vegas, like we did for so long. We’re getting acclimated certainly to the northwest and I think we’ve transitioned pretty well, but she still thinks we’re wimps when it comes to the weather. I don’t consider that. I think that back there, I think the weather is just a little bit ridiculous. It’s not as bad as it used to be like, I remember being a kid, and it was in January, it was always below zero all the time. Just frigid temperature, it doesn’t seem like it gets that cold anymore like it used to.

Dr. Davidson: I can’t even imagine what that feels like. We only go visit in the summer, by the way.

Dr. Maki: Yes, yes. June through like September it was like the window. And so, the winter, yes, we went back there, I think one time in December. And that was it, we’re not going to do that. No offense for anyone that lives in the Midwest, we totally understand. But at the same time, we are a little bit very sensitive to the cold, to say the least. So, this one, we’re going to do another listener question. This one is from Elizabeth. So why don’t we just dive right in, Dr. Davidson why don’t you go ahead and read her question.

Dr. Davidson: Sure. So, Elizabeth, her question she actually is a podcast listener. So hi, Elizabeth. Thank you for sending your question. It’s really about low levels of T3. So, we have an episode that we did, what number was that?

Dr. Maki: 38.

Dr. Davidson: Episode 38 about “Do You Have Low Levels of T3? So, Elizabeth’s question is I just got my lab results back and they are: TSH, Thyroid-stimulating hormone, is 1.33, Free T4 is 1.64, Free T3 is 2.9, viroid peroxidase antibodies, that’s for the Hashimoto’s, is 16. My doctor said my Free T4 was a little high so she suggested cutting my levothyroxine, which is a T4 only medication, 50 micrograms in half, which would be 25 micrograms and to come back in a couple of months for labs. Do you think my Free T3 levels are low? I’ve been having terrible issues with my muscles and heart palpitations. –Elizabeth.

Dr. Maki: Yes, right. So, that’s a very common response by her doctor, right? To see the Free T3 a little bit high. So, they automatically–

Dr. Davidson: Free T4.

Dr. Maki: I’m sorry, yes. Free T4 to be a little high.

Dr. Davidson: Honestly, it’s not high.

Dr. Maki: Yes, no, no. But to reduce the medication by half at 50 micrograms or even 25, you might as well not even be on anything, right? I mean, that’s not really going to do too much, very conservative, very common, but nonetheless, it’s not going to help the patient feel any better.

Dr. Davidson: And I understand that too. Anytime you have a patient that says they’re having heart palpitations, the first thought is, “Okay, is their thyroid too high?” We’ve got to reduce it down. They’re having palpitations if their heart rate is up if they’re having anxiety or that kind of thing. So, I can understand the doctor feeling a little bit more like, “Okay, well, they’re having these symptoms, maybe it’s the T4, let’s cut it in half and see what happens because with low thyroid, let’s say, we have low thyroid, you’re not going to die, you’re just not going to feel great. So, they’re comfortable doing that, and I understand that but I would say with looking for Elizabeth, that her heart palpitations and terrible issues with the muscles might be something completely different from the thyroid, or maybe only a piece of the puzzle.

Dr. Maki: And with her being on 50 micrograms and having muscle problems and heart palpitations we could definitely assume, at least from our perspective, that the palpitations are coming from something completely different. If a woman’s in perimenopause, menopause, that can cause heart palpitations, stress. So, I look at or we look at heart palpitations as being more of an adrenal issue, as opposed to being strictly a cardiovascular issue. Now, cases like this, a woman has palpitations, that might be one of the first symptoms that she has, or she’s being under someone’s care and they send her to a cardiologist to get those palpitations evaluated. It always comes back normal, they do a stress test, they do all these different cardiology-related testing, comes back with a clean bill of health, but the palpitations keep happening, partially because there’s no treatment for the palpitations. So, when someone’s on thyroid medication of any sort, they get a little freaked out. Even you and I, if someone’s having palpitations that’s something that you can’t ignore. We have to kind of–

Dr. Davidson: Yes. I want to know about it right away. I don’t care if it’s a Saturday at nine o’clock in the morning, I want to know.

Dr. Maki: Yes. But when you know more about the history or the situation or the patient and if they’ve been on a dose for a long time, and all of a sudden, they just randomly start having palpitations, it’s more than likely not. We don’t know how long she’s at the 50 micrograms. But from a dosing perspective, that’s not a very high dose. Her numbers don’t look great. They don’t look terrible, but they don’t look great. So, the likelihood of that causing her palpitations is probably fairly low. It would be nice to know how old Elizabeth was because if she’s the late 40s or early 50s that would tell us what we really need to know when estrogen level starts to drop, those palpitations start to become more prevalent.

Dr. Davidson: Yes, estrogen, low levels of estrogen at the beginning for menopause or perimenopause will cause like little– they feel like little like flip flops like your heart is doing a summersault. And it always seems to happen when you’re laying down at night and everything’s quiet and so it’s scary, but she’s saying she’s having more heart palpitations and problems with her muscles. That would make me think that there’s probably maybe a little bit, like Dr. Maki said, something going on with the adrenals that are affecting her electrolytes and causing her sodium and potassium and magnesium and calcium. So, some of her mineral imbalances to go off a little bit because you think about what is a heart, a heart is a big muscle. So, just like if I don’t drink enough water or my electrolytes are off and I get a terrible Charley horse in my calf or on my foot, that’s a muscle cramp, you can have the same thing in your heart.

Dr. Maki: Yes, right. So, the term when you have a muscle spasm and when you have a–  it’s just kind of twitching there a little bit, that’s called a fasciculation. And when that happens in the heart, that is what basically atrial fibrillation is. So, usually, when people have palpitations there’s usually a couple of things that can usually show up, AFib is the most common arrhythmia there is. You see commercials online for blood-thinning medications that help to prevent stroke risk and things of that nature because there is no medication for the arrhythmia itself. So, they kind of redirect and focus more on stroke prevention than actually dealing with the arrhythmia directly because I think there’s a medication called Rythmol, a lot of times they use beta-blockers for AFib, but those don’t tend to really do all that well. And just because our patient base is in this very specific age-range and we see these palpitation things come up all the time. So, in a woman late 40s or early 50s, she’s taking care of the kids, she’s working full time, she’s got stress, stress, stress, she’s not sleeping very well, all of a sudden now these palpitations just come up out of nowhere, as you said earlier, it freaks them out as it should because it’s your heart. Nobody wants your heart to do funny things but the thyroid kind of gets blamed for that when most of the time it has nothing to do with the thyroid.

Dr. Davidson: Yes, so looking at her electrolytes, maybe even supplementing with electrolytes, patients that I’ve had, that have had heart palpitations and muscle cramps is looking at just simple hydration, maybe they’re having hot flashes and it’s making them dehydrated. So, simple hydration and just some minerals and electrolytes can go a long way. So, I would definitely put that on the agenda if we’re looking at somebody like Elizabeth, but looking at her lab work for her thyroid. I agree with Dr. Maki. It’s not great, I mean, her TSH is just fine, the 1.33. Hey, that’s fine. Her free T4, 1.6., I usually like to see it a little bit lower like 1.2 and because our free T3 is low. What’s showing is that T4 is just building up in the system and not converting over to her free T3 hence her free T3 is at 2.9. Now if you look at these typical reference ranges, like we always talk about how ridiculous they are because they’re so huge is a reference range for free T3 is 2.2 to 4.4. So, you look at hers, it’s 2.9. Hey, you’re in range Elizabeth, your free T3 is fine, but it’s not fine, anything under 3.0 I definitely want to look into and anybody on some kind of thyroid medication shouldn’t have a free T3 of under three. So, definitely her T4 is not converting over to her free T3. So, we want to definitely address that by cutting her T4 down in half is probably not going to improve that.

Dr. Maki: Yes, no. It’s not going to make her feel any better. It’s just going to make her numbers look worse. So, in a case like this, usually, when someone comes to us on T4 monotherapy of oxo-levothyroxine Synthroid, we typically switch them to a compounded thyroid in a lot of cases. Because for the same reason, we don’t agree with the T4 monotherapy because the patient doesn’t feel better, their numbers might, their TSH will go down. Instant release T4 which is what T4 monotherapy is, has a very significant impact on lowering the TSH. So, from a very very simplified perspective, if you’re only focusing on the TSH and the medication you’re taking lowers the TSH very easily, then that’s a very easy problem to solve. But of the, what? 30 to 40 million cases of hypothyroid in America, everybody gets the same medication? That’s where it gets a little bit weird, thyroid’s way too complicated for that. There are too many factors and variables that go into thyroid function. We can’t look at one test and provide one medication for 40 million people. It just doesn’t work that well, okay? So, in this case, we would probably switch and increase her dose, right? Switch and increase her dose, and then maybe not right when she’s having the palpitations, deal with the palpitations first, get those under control. Whether that’s through estrogen whether that is BHRT whether that is addressing her adrenals or and mineral status, more than likely a combination of all three of those and then kind of coming back to the thyroid once those palpitations and the muscle issues are under control.

Dr. Davidson: Yes, I absolutely agree as raising up her T3 and trying to get that T4 to convert to T3 because in a beautiful perfect world our free T4 is supposed to convert to free T3 and then we have the active form of thyroid but things just don’t always work that way. And you often see that too in T4 monotherapy, is the T4 just kind of pools and then doesn’t convert over to that free T3 as well as it should. So, if we were to– I would automatically take her off, just like Dr. Maki said, take her off the levothyroxine do a compounded sustained-release T4, T3. Because what the conventional doctor doesn’t want to do and I understand this, is when you think a lot of doctors are afraid of doing T3 therapy and I can understand that because, conventionally, through the big box pharmacies the only prescription for T3 treatment is Cytomel which is, I kind of think, is kind of a dirty medication, it’s instant release so you take– if I took Cytomel it would instantly raise at my T3 way too fast. And that would give me heart palpitations, let alone Elizabeth. So, the last thing her doctor wants to do is give her a medication that’s going to exacerbate her heart palpitations. That’s why we never use of instant release T3, what we tend to use is a sustained-release T3 that just comes in your system very gently, it comes up and doesn’t have the cardiovascular effects. So, if her compounding pharmacies are all over the place, but a lot of doctors are just familiar with the big box pharmacies, and just what Big Pharma is offering. So, if they don’t have access or understand, “Hey, we could do a sustained-release free T3, that would take away the cardiovascular pressure on her system, raise up her T3, she’d probably feel better.” And then, as Dr. Maki said, is let’s look at it as a bigger picture. So, we’re looking at the thyroid, we’re looking at her minerals, we’re looking at her female hormone status and we’re looking at her adrenal glands.

Dr. Maki: Yes, right. I mean there’s this fear when it comes to T3 medication in a conventional setting, everybody is leery of prescribing Cytomel because those cardiovascular side effects are so common. I mean, most people can’t take beyond 10 micrograms, five to 10 micrograms of Cytomel before they start having those symptoms. So that’s why, one, we don’t like to use it. We might use it occasionally here or there. But it’s very rare, specifically for the palpitation issue, but because we’ve been working with women in this age range for so long. This heart palpitation issue comes up all the time and most of these women are very healthy. And they’ve been evaluated, they have lots of doctors on their team. They go through the proper evaluation, and they get a good cardiovascular bill of health that there’s nothing wrong, but they still keep having the palpitations. What are we going to do about those palpitations? So, mineral status, adrenal function and potentially changing the thyroid medication and looking at BHRT, specifically estrogen, that’s a pretty, for lack of a better term, a holistic approach to a problem like that. Now, once she’s going to feel better, and she’s not going to have that side effect on an ongoing issue or an ongoing basis.

Dr. Davidson: And just to also address her lab results here. Her thyroid peroxidase antibody was 16, which every lab’s a little bit different, some of them have been under 32. Some of them say under nine everyone is– she doesn’t have the actual reference range of the 16 like if it’s IUs per milliliter or IUs per deciliter. So, I’m not sure if she would be technically positive for Hashimoto’s or not, because typically, if she were a thyroid peroxidase antibody or they also call it a TPO antibody should be less than nine if it’s an IU over ML. So, this I’m thinking is probably more of the IU over DL or the other one that says less than 32. So, I’d have to probably really see her actual lab work to see if it’s truly Hashimoto’s or not.

Dr. Maki: Yes, right. And with her numbers, I don’t think it really matters too much. 

Dr. Davidson: It’s pretty low.

Dr. Maki: Yes, yes, right. So, as you said, it’s probably in the normal range. Or if it isn’t, it just barely outside the normal range and it’s not affecting her other numbers that much.

Dr. Davidson: Yes, we would need the units for that one. The other ones we don’t need the units we already know that we would just need those units for that. But I always do kind of keep an eye on all the Hashimoto’s antibodies like the thyroid peroxidase or also the one that’s not tested as often for Hashimoto is the thyroid globulin antibodies. Those are also part of Hashimoto. So, we always keep an eye on that too. So, with Elizabeth, I’m glad that her doctor is keeping an eye on those.

Dr. Maki: Yes, right, yes. So, we definitely think that her free T3 could be better. But really, the more important issue is the medication was just not going from 50 to 25, both of them I think are somewhat ineffective. Certainly going from 50 to 25 is ineffective, but just the medication itself is ineffective. So, switching her, for some people, NDT, non-desiccated thyroid or natural desiccated thyroid is certainly very popular, that would be a fine option for her. I know there’s some controversy as some of the sourcing and everything from China and all this kind of stuff, that is certainly going to have an impact since the coronavirus stuff has happened, realizing more and more, where some of those raw materials are coming from. Some of them we might not even have known where the raw materials are coming from but now, because everything was on lockdown for so long, we might be able to know where some of those raw materials are coming from. 

And it might have further effects as 2020 continues, but palpitations, that’s definitely a scary one, nobody likes to have their heart doing funny things like that. But rest assured, most of the time, just believe that that is usually not your heart, even though your heart’s doing funky stuff, just like I said, a muscle spasm in your thigh or something, that’s what your heart’s doing, it’s not supposed to do that. But it’s usually coming from some other reason than your heart itself and if you are having that issue, please go get it evaluated, you can’t take the risk of not having it evaluated. But usually, that is, we don’t need to get into the heart on this one. But usually, most of those types of arrhythmias are from the atria, okay? And your heart has the atria and the ventricles, arrhythmias that arise from the atria are usually not very serious, the ones that arise from the ventricles, ventricular tachycardia, ventricular fibrillation, those are much more serious. The ones from the atria, they feel like they’re problematic, but they’re not usually that serious. AFib, Aflutter, PVCs and PACs, premature ventricular contractions, premature atrial contractions, those also can show up in your heart can do funny things like that. PVCs, of the four that I just said, the PVCs tend to be maybe the most significant ones to pay attention to, but again, that’s a bigger conversation. But in this context, most of the time, heart palpitations are going to be AFib, very common, and usually, something other than the heart is leading to that. So, Dr. Davidson, do you have anything else to add for this one?

Dr. Davidson: No, no, I’m glad that you did add that in if your heart is doing some interesting things. I mean, it’s always great to have it checked out and honestly I think people need to have a healthcare team, their naturopath, their GP, their cardiologist, it’s good to have there a team put together. But I do think that if she went and got her heart testing, which is great, but most of the time people’s hearts are very strong and very healthy. It’s just more of an outline issue that’s creating that symptom. 

Dr. Maki: Yes, right. Yes. So, we’ll talk more about that because that does come up. I wouldn’t say necessary, “unfortunately” but it is something that we deal with and see quite often. So, we’ll talk more specifically about heart palpitations in the future. We do get questions and our own patients are dealing with those things from time to time, so I think this one is good. Any final words?

Dr. Davidson: Nope. Nope. That was great.

Dr. Maki: Okay. Until next time, I’m Dr. Maki.

Dr. Davidson: I’m Dr. Davidson. Take care.

Dr. Maki: Bye now.