Listers,

you wrote

<<...you have adrenal problems. That affects the conversion of T4 to T3, and
in the testing mentioned above or in your other detail I don't recall
hearing anything about testing fT3 (and testing rT3 might also be
valuable.)>>

When on the proper amount of replacement, I don't actually exhibit adrenal
insufficiency.  It is corrected with the right amount of steroids.  TSH and
free T4 have been measured; i think he said these could be influenced by
steroids; however, he said even more strongly that T3 numbers would be
inaccurate 'because I take steroids.'  Do you know if T3, free T3 and rT3
would really give the actual 'picture' of what's going on conversion-wise?
or would the results be so skewed that they would not easily be interpreted?
No matter what is occurring with the conversion, it would seem that free T4
results should give us some useful information.  (regardless of the affect
of steroids on tsh)

SOMEone out there must have done studies on thyroid testing for
addisonians...!

<<Two, is that if you have a pituitary problem, TSH is completely
irrelevant. Your TSH is slightly higher than the norm shown in large
studies.>>

I have not been diagnosed with pituitary problem.  Very strong diagnosis of
Primary AI.  Cause is, as well as can be established, autoimmune.  I am
surprised that ACTH is low.  It has been very high and very low.  Lots of
factors influence it.  Time of day of testing, stress, methods used to test,
etc.  Even how soon the technician gets the vial on ice!!  you might as well
throw it away if it is not placed on ice immediately after it is drawn.  It
is possible I am developing panhypopituitarism.  Autoimmune-related, of
course.  However, may be more likely that the cells of the pituitary that
are responsible for ACTH production, are simply 'burned out.'  That can
occur as well, in my understanding.

Regarding the study you cite, I will check it out.  My endo is quite
well-researched and would have input.  (strong research background--told me
I had 'made his research' upon my diagnosis--i was presenting uniquely in
many ways!)

<<In additon, if you check out the Prednisone or corticosteroid literature,
it mentions it can artificially lower TSH and affect conversion of T4 to
T3.>>

Yes, at therapeutic, or 'pharmacologic' levels.  Replacement therapy aims to
fine-tune glucocorticoids to the lowest possible dose that prevents symptoms
of insufficiency.  Therefore, we could have very slightly more or less, but
we strive for optimum available cortisol at the cellular level.  (Also, if
anything I am more prone to be 'at the wire' of underreplacement rather than
overreplaced simply because I have concerns re: osteopenia.  another issue,
but certainly related!)

<<Drinking a ton of water isn't typically good for one with low adrenals,
unless the water is salted, since that dilutes the sodium, and we have
problems retaining it.>>

This is a typical problem with Addison's Disease.  Very well-meaning persons
tell us, drink more water!  for stress!  for infections!  for health!  and
guess what?  you are right.  Excess water dilutes sodium, so I only drink
when I am thirsty.  And I eat salt when I crave it.  Works, for the most
part.  [After having Syndrome of Inappropriate Anti-Diuretic Hormone once in
1993, I learned about fluids fast!!]   (what I had meant to say was,
drinking more water than I usually do--which isn't alot--but would help
correct a problem of dehydration)





So far so good off the Synthroid.  I do have a few more hot flashes,
though--probably dropping the HRT is now affecting me more.  If I can adjust
to the lower estrogen well, then perhaps sort out the thyroid/adrenal
symptoms.  It is nearly impossible to sort out all three at the same time!!

Perhaps I should develop a list of "Truisms and Principles to Remember"
regarding hormonal interactions, for future reference.  Haven't ordered or
edited them yet, but here's a beginning, as they have occurred:

*       Adrenaline 'surges' could indicate mineralocorticoid deficiency.
Increase in Florinef to adequate replacement level caused 'surges' to vanish
*       When HRT is reduced, Florinef may need to be increased.  Cortef may
also require increase.
*       When HRT is reduced, sweating can increase.  Sodium & fluids must be
replaced.
*       When HRT is dropped, likely that TSH will drop  (less thyroid
replacement will be required) (binding protein decreases, causing more
thyroid hormone to be useable)
*       When HRT is reduced, more T4 is available to the body.  TSH could
fall.  Synthroid may need to be reduced.
*       Hyperthyroid symptoms increases clearance of steroids in the body.
Steroids may need to be increased.
*       Hypothyroid symptoms decreases metabolic clearance of medications.
Steroids may need to be decreased.  Keep watch of electrolytes for low
potassium.  Adjust mineralocorticoid as necessary.
*       Acute adrenal crisis can cause rise in TSH; after treatment begun,
tsh can fall to normal levels.


Thanks for all the input!  I am quite new to these thyroid issues.  Not
comfortable with it yet, but with your assistance getting there.

Holly


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