Thyroid results - could low T4 be causing MGD?

[Jesslin]

Hi All,

I was wondering if anyone could please help me with a few thyroid questions?

I had a blood test recently and got the results over the phone and was told they were normal. I asked to get the paperwork as reference and noticed that the thyroid results are perhaps a bit interesting.

TSH: 2.55 with a normal range of (0.34 - 5.6)
Free T4 9.9 with a normal range of (7.5 - 21.1) (seems pretty low?)

I looked on a few thyroid websites and it seems a bit confusing. I read somewhere that the 'normal' values that the labs compare them against vary from lab to lab but I'm not sure if that was paid labs like you get in the US and if the NHS here has one static level they measure it against?

The Thyroid UK site seemed to suggest that a T4 of anything under 10 would be considered hypothyroid. I know this still only puts me as borderline but I have quite a few hypothyroid-like symptoms. My skin is only dry sometimes though, I produce a lot of oil on my skin as well as meibomain, this oil on my face almost seems wrong too though, as the skin is almost still dry despite the covering of it.

I was wondering if anyone who is hypothyroid thinks their MGD is caused by this or even if anyone has the same MGD problem as me (my meibomian secretions are free flowing but the oil has swirls and patches in it as well as white grainy lumps). If so did treatment help you at all?

Would be great to hear from anyone who can offer any advice as to whether this may be my problem.

Thanks,

Jess

[Súil Eile]

I would also be very interested in this! I recently got the results of a thyroid test and my TSH is 6.32. I'm hoping that this does have an affect on MGD, because the thought of a distinctive and treatable diagnosis is very appealing. I have an appointment with an endochrinologist next week so I'll be asking her lots of MGD related questions!

Out of curiousity, Jesslin - did you get a thryoid test or a thyroid anti-body test? My GP has been reassuring me for years that I was subclinical, but my opthamologist ran an anti-body test which showed different (and more severe) results.

Like you, I have dry skin, while my face can seem quite oily on the surface but still dehydrated. I don't have much mebomian oil at all, and sometimes it tends to be very thick and affects my visions. The oil seems clear, unlike yours which sounds very uncomfortable!

I tried searching the interent for Thyroid info too and got very confused! There seem to be so many contradictions and differing opinions.

My thyroid peroxidase levels are 284, and they should apparently be below 5.6. I have no idea what that means though! I think I'll be bringing a notebook with me to my appointment next week to keep track of all these terms

[y-gwair]

I'm afraid there is a lot of confusion about thyroid issues among doctors, and many endocrinologists to be honest. The core of this confusion is that the latter mainly see thyroid disease as a mainly a hormone issue whereas the reality is a lot more complex, with the full range of thyroid symptoms being a complicated mixture of both the results of autoimmune activity on nerves and glands as well as biochemical metabolism. The real issue is whether you have autoimmune thyroid problem or not, something you can only tell by measuring thyroid antibodies.

Thyroid antibodies don't solely affect the thyroid, they can also attack other tissues in the body that contain thyroid hormone receptors, and the other major area of involvement is eye tissue. This includes the lacrimal glands which can be infiltrated and scarred by thyroid antibody activity. Damage to lacrimal and thyroid glands can exist at a subclinical level for years before acute symptoms or significant elevation of TSH (my eyes were measurably dry as a teenager, full blown symptoms all through 20s, yet no diagnosis until TSH eventually shot up at the age of 35). In the early days autoimmune thyroid disease follows a flaring/remitting pattern so you need to test over a course of time to be sure that levels aren't fluctuating. A far better way to tell if you have autoimmune thyroiditis is to test for antibodies (which are predictive of eventual gland failure, regardless of current hormone levels). The last endocrinologist I saw was very angry about the failure of most GPs to diagnose the disease properly.

In the past, if hormone level results were borderline many GPs simply wouldn't bother to treat, or start people on uselessly low doses of replacement hormone which is a complete waste of time as this approach does not suppress the activity of thyroid antibodies, or other unpleasant consequences of the disease such as abnormally high cholesterol. There is growing evidence that people with so-called subclinical disease benefit from treatment, if only to help control cholesterol problems.

I mention this as personally I think there is a connection with MGD and thyroid disease, as well as aqueous deficiency due to lacrimal gland damage. Lipids chemistry is altered due to the metabolic nature of the disease, but there is also a inflammatory element which affects neurovascular mechanisms in the skin/eyes, possibly damage to autonomic nervous system (particularly in long-standing, untreated disease). Personally I've noticed that my eyes have always been worst when having a systemic flare of inflammatory symptoms, despite having longstanding and consistent aqueous dryness; I'm sure such fluctuations are caused by MGD responding to systemic inflammation. I only got acknowledgement that I have MGD at all about a month ago.

In short, if you suspect you have a thyroid problem, get your antibodies tested (TPO and TgAb); if they are elevated, insist on starting hormone replacement and aim to gradually raise your dose until free T4 is within range, and TSH is around 1.0 and antibody levels are significantly reduced ( or even normalised). The sooner thyroid antibody levels are suppressed, the less opportunity for damage to non-thyroid tissues, hopefully.

Re. endos, most will tell you that if your lab results are within normal ranges, everything should be ok, and express surprise at ongoing problems. Good endos will tell you that whilst this is theoretically the case, in practise many people continue to experience ongoing problems with dryness, rheumatic pains, neuropathy due to the autoimmune element of the disease, which is beyond their control unfortunately.

[Súil Eile]

Thanks for such a detailed reply y-gwair! It's great to get such info from someone who's been through it.

[Jesslin]

Thanks for replying both of you, and yes, thanks to you y-gwair for all your knowledge on the subject, very interesting information. I didn't realise it affected other of the body with thyroid hormone receptors. I'll be sure to ask for those tests when I go to the doctors next week. Good luck with your appointment next week Suil Eile, do let me know how you get on.

[jads]

I'm afraid there is a lot of confusion about thyroid issues among doctors, and many endocrinologists to be honest. The core of this confusion is that the latter mainly see thyroid disease as a mainly a hormone issue whereas the reality is a lot more complex, with the full range of thyroid symptoms being a complicated mixture of both the results of autoimmune activity on nerves and glands as well as biochemical metabolism.

I agree. Having been to GPs and an Endo with Thyroid antibodies and low thyroid numbers a couple of years ago, I've witnessed the confusion first hand! In my opinion, unless you have an overt Thyroid disorder, i.e Hyper or Hypothyroid, you are wasting your time - and money - at the Endocrinologist. Many, many people are sub clinical, meaning that their thyroid numbers aren't low enough to qualify for treatment, however you may be still feeling pretty poorly. This is unfortunately a grey area for the medical profession.

Suil, talking about MGD with your Endo is akin to talking to your mechanic about the stock market. They work from the text book and are not interested in anything in between or even remotely outside their direct sphere of experience. Don't be dejected if\when questions about MGD are met with a dismissive tone. Specialists can be quite arrogant, however there are always exceptions.

Jesslin, that T4 number is low. You are right to question that. T3 is synthesised from T4 as you may already be aware. Unless you have enough T4 in the system, your body runs out of T3 at some stage during they day, much like a car runs out of gas. When the body cannot produce enough T3 to provide energy, your cortisol levels are also likely to be low, which has a connection to Adrenal fatigue. Symptoms between Adrenal fatigue and Hypothyroid overlap for this reason. It's a double whammy in many respects.

There are natural ways to increase cortisol to within healthy ranges, that then has a tendency to gradually increase T4\T3 levels.

[y-gwair]

I think the only doctors I've ever met who have been the least bit interested in thyroid antibodies are ophthalmologists, as they are more alert to the damage they can do to eyes. I had to pay for my own antibody tests. Even when the ophth. recommended redoing TPO recently (to check periorbital oedema wasn't thyroid eye disease), my GP was very reluctant; she said it really didn't matter, as I was taking thyroxine anyway. Absolutely no clue about the underlying processes of thyroid disease.

I think I had a problem with adrenal fatigue when I started thyroxine, I felt absolutely terrible for ages. I was tremendously thirsty all the time, craved salt, had very low blood pressure/fainting spells, plus a host of other strange symptoms that took a couple of years to resolve. I remember reading the guidelines for Synthyroid re. care in prescribing thyroxine in individuals who have longstanding untreated disease (sure mine started when I was 19-20, dx when I was about 35) and realised what the problem was. Tried to discuss with GP who'd never heard of the problem, and was completely dismissive.

Re. T3, the last Endo I saw privately 2 years ago was willing to let me try a small amount (.5mcg) and I have found it very helpful with 'brain fog' symptoms, and energy levels. He believes that certain tissues in the body (including the brain) are simply not very good at converting T4 to T3, and that there is growing evidence for this now. He didn't feel it would make any difference to other symptoms, which it hasn't in my case.

[Angela]

I know exactly what you mean about your skin being covered in oil yet still being a bit dry. I guess they call that combination skin...I call it annoying. I really suspected I had a thyroid problem in the beginning of this too, only I suspected Graves or a hyper thyroid. My mom actually has hypothyroidism. I've had tons of doctors tell me that there are plenty of people who are symptomatic but come back with normal testing. I hope you find some answers soon! Have you tested other hormones?

[y-gwair]

Been looking into the links between dyslipidemia, MGD and thyroid disease. There is some evidence that there is a link between MGD and abnormal lipid metabolism. Hypothyroidism was originally diagnosed by measuring cholesterol, before the advent of more specific tests, and the link between the two long-established. There seems to be a general agreement that both overt and subclinical hypothyroid disease result in raised total cholesterol and elevated LDL, but evidence of some variability and/or disagreement on the effect of autoimmune thyroid disease other lipid profiles (HDL, triglycerides).

Association of dyslipidemia in moderate to severe meibomian gland dysfunction
"Patients with moderate to severe MGD have a higher incidence of dyslipidemia with respect to elevated total cholesterol than the general population. Surprisingly, the component of total cholesterol that contributed most to this increase in total cholesterol came from elevated serum HDL levels. To our knowledge, elevated HDL has not been associated with any pathologic state.
... There was a statistically smaller number of MGD patients with high triglycerides (TG > 150 mg/dL), 15.2%, when compared to controls, 33.1% "


Thyroid disease and lipids
"The high-density lipoprotein (HDL) levels are normal or even elevated in severe hypothyroidism because of decreased activity of cholesteryl-ester transfer protein (CETP) and hepatic lipase (HL), which are enzymes regulated by thyroid hormones...However, thyroxine therapy, in a thyrotropin (TSH)-suppressive dose, usually leads to a considerable improvement of the lipid profile...Subclinical hypothyroidism (SH) is associated with lipid disorders that are characterized by normal or slightly elevated total cholesterol levels, increased LDL, and lower HDL"


Serum lipid profile in patients with thyroid disorders in central Nepal.
"There was a positive association between hypothyroidism ...48.4% of hypothyroid patient had hypercholesterolemia and 32.3% had hypertriglyceridemia. The mean TC, LDL and TG levels were increased progressively with the increase in the serum TSH. It was noteworthy in this study that even a slight increase in serum TSH (between 6.2-10 mIU/L) showed significant increase in serum lipid level. "

Minimal thyroid failure: ef fects on lipid metabolism and
peripheral target tissues

"... this issue of European Journal of Endocrinology reports a study in which the lipid profile in a selected group of patients with high-normal TSH and increased cholesterol were evaluated, with the aim of investigating the ef fect of thyroxine treatment. One hundred and ten consecutive hypercholesterolaemic patients with TSH concentrations in the high-normal or in the low-normal range were assigned randomly to groups to receive either 25 or 50 mg thyroxine per day for 2 months. There was a significant reduction in total cholesterol and low-density lipoprotein (LDL) cholesterol concentrations only in patients with high-normal TSH (2.0 – 4.0 mU/l) treated with the higher dose of thyroxine. A significant reduction in cholesterol was observed only in patients with positive thyroid antibody titres. The authors conclude that patients with autoimmune thyroiditis with high-normal TSH concentrations have subtle thyroid dysfunction leading to an increase in serum cholesterol. They assume that these subjects may have SCH at a very early stage, presenting with increased cholesterol concentrations, and that this group may possibly benefit from thyroxine treatment. "

[Jesslin]

Thanks for all the information on the lipids y-gwair. From what I understand from reading it, are we thinking that the changes in the lipids because of the hypothyroidism could alter the lipids in the meibomian secretions? That's a really interesting idea, I've been trying to research it myself but with much less success...

Jads - thanks for all your information too, I've been reading your posts about using natural ways to heal and find them very interesting. Are you being treated for your thyroid problem or have you treated it naturally? Any advice you can offer would be greatly appreciated.

One thing I don't understand is why my TSH is only 2.55 when my T4 us much lower than other people's results I've seen (even just on this board!). People with a t4 of 12 or 13 seem to have a very high TSH of 20 or even 30, so why with a T4 of only 9.9 is my TSH so low? It's annoyting because I'm well within the normal range for TSH so no doctors will treat me for it because they only want to treat you to get you within normal TSH range (apparantly 5.5 is fine here) so if I'm already in that range they think I'm ok. I'm also within normal range for T4, so I really don't think I'm going to have much luck convincing them to let me trial a dose of thyroid hormone. Does anyone have any tips for getting docs to give it a go?

I'm also going to see if the doctor can do some hormone tests. I asked for some with the thyroid test and general bloodwork they did last time but when I said 'my opth thinks my hormones may be off' they for some reason tested a load of fertility hormones... errr..not quite what I was after....!
Any advice on what I should be getting? Estrogen and testosterone? I've heard about maca root for balancing hormones, not sure if that's been of use to anyone for eyes?

Realistically, could this borderline T4 be causing my problems? Plenty of hypo people have no eye symptoms so I wonder if I'm clutching at straws. I never even had a sore or pink eye in my life no matter what I subjected them too until I woke up with my eyes stuck together after using BAK but I'm struggling to believe a month long use of BAK and other drops could still be causing worsening problems 6 months on. I'm struggling to work out what's wrong with me and I so desperately want some relief. None of the normal methods seem to make the slight bit of difference to me!

Thanks for you help everyone This is such a great and friendly forum.

[y-gwair]

Thanks for all the information on the lipids y-gwair. From what I understand from reading it, are we thinking that the changes in the lipids because of the hypothyroidism could alter the lipids in the meibomian secretions?

No direct proof, as no one has ever done any research on it, but there is evidence that abnormal lipids are common in people with MGD. Trying to improve lipids balance can only help MGD and general health, and in people with thyroid disease, the first step in improving lipids to treat the underlying disease. I seem to have problems tolerating some omega 3s (flax oil), so I wonder if thyroid problems are stopping me metabolising them in high doses.

One thing I don't understand is why my TSH is only 2.55 when my T4 us much lower than other people's results I've seen (even just on this board!). People with a t4 of 12 or 13 seem to have a very high TSH of 20 or even 30, so why with a T4 of only 9.9 is my TSH so low? It's annoyting because I'm well within the normal range for TSH so no doctors will treat me for it because they only want to treat you to get you within normal TSH range (apparantly 5.5 is fine here) Does anyone have any tips for getting docs to give it a go?

When I asked for a 'thyroid test', long before I knew anything about this, my TSH came out about 3, and I was told I didn't have a problem. This was when I felt at my worst in terms of thyroid symptoms, my body temperature was consistently about 2 degrees below the norm, I had all the classic symptoms. I probably had sky-high antibody levels too, but they didn't bother to test them. TSH isn't by itself a reliable test, a good doctor should take into account fT4 and antibody levels according to my Endo, was very angry that most GPs make diagnoses solely on the basis of TSH results. I also had high cholesterol and bad HDL/LDL ratio, I was only 30 at the time. So, ask for thyroid antibody tests, get your cholesterol measured, and if you do have autoimmune thyroid disease and elevated cholesterol, try to make a case for trying thyroxine in terms of lowering your lipids, there's plenty of evidence now that this is the best way to lower lipids in people who have subclinical thyroid disease.

Re. hormones, thyroid disease can have a major impact on hormones too, as can low body temperature. I had terrible gynaecological problems from puberty right to the day I started thyroxine, whereupon they resolved magically overnight.

[Súil Eile]

I know this is dragging up an old thread, but following on from my post above I've now been on Eltroxin for hypothyroidism for 3 months now. So far, the difference in my energy levels is phenomenal. I wish instead of just treating me for depression my GP had coped on to the thyroid problem. Would have saved me years of only half-living

I'm on 50mcg daily and I'll be slowly moving up to 125mcg, as I seem to be very sensitive to it. Regarding my eyes, so far I haven't noticed any significant difference in MGD or tear flow. However, my new found energy levels make it easier to deal with and I've been feeling more positive. I regularly have eye pain akin to a toothache. Normally I would experience this 70% of the time. This has now decreased to approx 50% of the time.

While treating my thyroid hasn't been a miracle cure, if anyone is thinking of getting checked for it (or is borderline clinical) then my suggestion would be to talk to your doctor about treatment. It has certainly made my life a lot more enjoyable.

[Jesslin]

Hi Súil Eile,

I was just wondering how you were getting on the other day! I'm so glad you're feeling better, even if your eyes aren't quite so much, maybe it will take time? I've been doing research and many view a TSH of anything over 2 to be suspicious. I went back to the doctor but she told me there was nothing wrong with me physically, it was all in my head including my eyes! She told me not to come back until I can accept mental help! Needless to say I won't bother going back there, looking at alternatives. I too have no energy, so I can imagine how nice it feels to have that back.

It's shocking you were just fobbed off with anti depressants when you had a thyroid problem, from what I've been reading it seems too common in the uk. I hope your treatment brings you good health, if you still have lingering symptoms when on your optimal dose of T4, i have read that some people do better on T4 and T3 or natural thyroid, but trying to talk to your doctor
about that will be even more of a struggle! There are lots of forums to help and I have been speaking to a lady whose dry eye that got much better when her thyroid was treated correctly.

Best wishes,

Jess

[Súil Eile]

Thanks Jess! I really apreciate that. I can't believe you were told it's all in your head! That certainly can't be helping your wellbeing. It's amazing how many people have to put up living with treatable unconditions until a doctor with a bit on sense comes along.

My opthmaologist said it would take 6 months before I'd begin to notice a significant difference, so I'm cautiously optimistic. Even if it has no benefit to my eyes, having the extra bit of energy is a blessing!

I'd definitely push for a more thorough thyroid workup. It could make the world of difference to you, even if your doctor thinks it a crazy notion.