A 43 y.o. mother of four presents to the office complaining of fatigue, listlessness, fluid retention, irritability, PMS, and easy weight gain. These symptoms came on 8 months ago after the birth of her fourth child. All of her blood tests are normal, and her body temperature averages 97.8 degrees during the day. She is started on 7.5 mcg p.o. BID of T3 compound (p112), and is instructed to increase the dose by 7.5 mcg/dose/day until her temperature is 98.6 on average during the day. Her temperature goes up to 98.6 when she reaches 22.5 mcg p.o. BID. Her symptoms respond dramatically.

She does very well for several days on 22.5 mcg BID, until on the fourth day on that dose her average temperature drops to 98.0 degrees. At this time, some of her symptoms return. The dose is increased to 30 mcg BID, and her temperature goes to 98.6 again and she again does exceptionally well until her temperature drops back down 4 days later. She is increased then to a dose of 37.5 mcg BID. Her temperature and symptoms respond for 4 days, then slip again. However, when her dose is then increased to 45 mcg p.o. BID, her temperature rises to 98.6 again, with her symptoms resolving, and remaining resolved even longer than 4 days.

About 7 days after her temperature and symptoms remain resolved on the dose of 45 mcg BID, it is felt that her temperature has been "captured." (p75) At this time, the patient is instructed that she is likely to do well weaning off the T3 therapy, and has a good chance of remaining normal off the treatment. She feels completely well, but is a little reluctant to wean off the T3 therapy right away for fear of feeling badly again. She has also noticed that she has lost 5 pounds without changing her exercise or eating habits and wonders if it would be all right for her to stay on the 45 mcg BID T3 for about a month or so longer while she works with good diet and exercise to get off the other 15 pounds.

She is without complaints of any kind, so the regimen is continued, and a month later she is doing well. The following month she is ready and confident to wean off the T3 therapy. She is able to decrease her dose by 7.5 mcg/dose every 2 days without her temperature dropping, and in a couple of weeks she has successfully weaned off the T3 therapy. Her temperature has remained 98.6 with her symptoms remaining resolved, even off T3 therapy.
 

A 43 y.o. businessman presents to the office complaining of severe fatigue, difficulty sleeping, and headaches. The symptoms first started about 10 years ago when his business went into bankruptcy. The symptoms persisted to roughly that same degree until about 5 years ago he was divorced, at which time his symptoms worsened considerably. His symptoms worsened yet again about 6 months ago when his brother died. To him, his symptoms are inexplicable since he feels that he has gotten over the loss of his brother, and he now is very happily remarried and the business he now owns is exceptionally successful. All tests are normal, but his temperature averages a degree low during the day.

He is started on a cycle of T3 therapy. He is started on 7.5 mcg p.o. BID and is instructed to increase the dose 7.5 mcg/dose/day if he is without complaints until his temperature is 98.6 by mouth on average, and to call the office if he does develop any complaints, and to return to the office in 2 weeks. At the 2w visit, the patient relates that he is taking 90 mcg BID and his temperature is still not up. Since his temperature did not budge at all during the first cycle and he has noticed no difference at all in the way he feels since starting the treatment, he is instructed to try weaning off the T3 therapy by 7.5 mcg/dose/day if he remains without complaints. This is done so that the treatment will not be unnecessarily delayed. He is able to decrease the dose every day without complaints.

The patient is then started on a second cycle, with the same instructions as the first. This time his temperature goes up to 98.6 on 75 mcg BID. His symptoms begin to improve, but after about 3 days his temperature drops back down again. The dose is increased to 82.5 and his temperature returns to normal. After about a week on that dosage, his temperature starts to go down again and he loses some of the clinical improvement he's gotten. The dose is increased to 90 mcg/dose, and his temperature goes up again, restoring some of his clinical improvement. His temperature went down again after an undetermined time (since he wasn't taking his temperatures very well). Since he had been showing a definite response to each recent increase, and he was without complaints, he was increased above the usual maximum dose of 90 mcg BID to see if his temperature could be captured (p75) with one or two more increases. The temperature responded and dropped again on the 97.5 mcg dose. Then his temperature went up and stayed normal on 105 mcg BID and did not drop again.

Since he did not demonstrate any clear compensation time (p85), he was left on 105 mcg BID for at least 3 weeks to help make sure that his temperature was indeed captured. During that 3 week period of time, he wasn't able to take his medicine very well on time for a few days, and he began to notice feeling a little headachy, tired, and more on edge. His temperature log revealed that his temperature had become a little more unsteady at that same time. His temperature was ranging more widely across his 3 daily temperatures (p41). He was then given a T4 test dose of half a .025 mg tablet (.0125mg) of levothyroxine, and within 45 minutes his complaints resolved completely.

Anxious to see if he might be able to capture his temperature with a smaller dose of T3 on the third cycle (p77), he was weaned off the second cycle. Since unsteadiness of the T3 level had been demonstrated in the second cycle with the T4 test dose, and since the patient was wondering how well the T3 therapy was going to end up working for him (even though he had gotten a fairly good response to treatment so far), it was decided to let him remain off for 10 days between cycles to let the T3 level steady down as much as possible so that he could get as fresh a start as possible (p96). He tried weaning down off the T3 every 2 days, but with the third decrease his temperature started to drop a little. Since it looked as if he might have a cycle or two more to go, he did not increase his dose back up, but simply decelerated his wean to going down a 7.5 mcg decrement every 4 days (c12). He was then able to wean off without much of a drop in his temperature.

On the next cycle, he was able to capture his temperature on 60 mcg BID. His symptoms were all but completely resolved at this point. He was without complaints. After a few weeks he was ready to proceed with the therapy and be weaned off the T3 to see if he could capture his temperature with less medicine on a subsequent cycle for complete resolution of his symptoms. He decreased the dose by one decrement every 4 days without any drop in his temperature.

On the fourth cycle, his temperature was captured with 15 mcg BID, and his symptoms resolved completely. He was later able to wean off the T3, and remain improved even after the T3 had been discontinued. His temperature remained normal as well.
 

A 36 y.o. real estate agent presents to the office complaining of PMS, depression, fatigue, and admits to a peculiar throat sensation (she says it feels as if someone is pressing his thumb against her trachea toward the base of her neck). Her symptoms came on about a year ago. The only thing she can remember about that time, is that's when she was having some problems with her 12 y.o. daughter, and that's also when she received increased management responsibilities at the brokerage.

After evaluation, she was started on a cycle of T3 therapy with the usual instructions. The day after starting the T3 therapy, she called the office to point out that her temperature had gone down instead of up. Her temperature was lower the day after starting than it was before she started. She was also experiencing a little bit of tightness in the rings on her fingers, but no other complaints. It was explained to her that she may very well be a one-day compensator (p91) and that she was going to need to be extra careful to take the medicine exactly as possible on time, and to call the office at the first sign of any complaints. It was explained that her chances of developing side effects might be a little higher than usual, and she needed to consider whether or not she wanted to proceed. Also, if she did want to proceed then she would have to increase the T3 very deliberately (p98) and carefully, or not at all.

She opted to proceed, and since it was agreed that the potential benefits outweighed the risks, her T3 dose was increased by 7.5 mcg/dose/day. Her temperature reached 98.6 on 30 mcg BID, but dropped back down again later that day so her average was below 98.6. She stated feeling noticeably better when her temperature had gotten up to normal. She went up to 37.5 mcg and her temperature went up, and then back down again in one day. This same thing occurred when she increased to 45 mcg and 52.5 mcg BID. After a weekend, she called to say that she was feeling more irritable, and bloated, and achy almost as if she had the flu. Her complaints had started over the weekend. As it turned out she had gone to the store with her daughter on Saturday morning and missed taking her dose by about an hour and a half. She denied any irregular heart beats, increased awareness of her heart beat, shortness of breath, or any other complaints. Her side effects resolved completely within 45 minutes of a T4 test dose (p129). She was able to get a timer and organize herself such that she was then able to make sure and take her T3 very much on time thereafter.

She proceeded with treatment and was able to capture her temperature on 60 mcg BID. Her symptoms began to resolve, and continued to get better and better over the next 2 weeks or so (p103).

She did well on that regimen for about a month or so, until she had a bout of missing several times her dosage an hour here and two hours there. She began noticing feeling a little jittery, achy, bloated, and tired. Her temperature had also dropped about half a degree (p121). She responded fairly well to a T4 test dose, but when it was repeated an hour and a half later, her complaints had not resolved sufficiently enough to comfortably allow any further T3 increase in this cycle. She was weaned off the T3, so that her system could settle down, and to see if she could get on less medicine on the next cycle, which would be easier to manage (easier to keep the T3 level steady)(p122). She was able to wean down off the T3 every 2 days without her temperature dropping. Her side effects diminished more and more as she went off the T3, but did not disappear completely until after she had been off the T3 for about 3 days, so she was left off the T3 for another 3 days after that (for a total of 6 days) to give her T3 level more time to steady down very well (p133). On her own she opted to stay off a couple of days more (for a total of 8 days between cycles) to get a nice fresh start (p96), since she wanted to see if she could get as much correction as possible out of the upcoming cycle.

On the second cycle, she was able to capture her temperature on 30 mcg BID, and she felt far better than she ever had on the first cycle. Her symptoms were almost completely resolved. About a week after her temperature was captured, she wanted to see if she could wean off and stay improved off T3 therapy. To her amazement, her temperature held as she weaned off the T3 therapy, and her symptoms actually got better and better. This continued until it got to the point that her symptoms only resolved completely after she had been off the treatment for a few days. It was only after the treatment had been discontinued, that she felt completely normal; she felt better after the treatment than she ever had during the treatment (p76). And after treatment she felt as good or better than she did before she ever got sick in the first place.
 

A 50 y.o. woman presents to the office with a long history of "thyroid" trouble. Her symptoms of decreased energy, decreased ambition, listlessness, dry skin, fluid retention, and cold intolerance began in her late twenties. She also remembers a distinct down-turn in her condition after a series of Cortisone shots she received received when she was 32 years old. When she was 33 y.o. her family doctor felt her symptoms were characteristic of low thyroid function, even though her blood tests were just within the limits of normal. He started her on half of a grain of dessicated thyroid (e.g., Armour Thyroid) to see how she'd do. Her symptoms responded dramatically well to the Armour, so it was felt his suspicion of low thyroid was confirmed.

Unfortunately, her symptoms started to return about 3 months later. Her dose was increased to 1 grain, and she improved again. Again, 3 months later, her condition slipped back downward. He did not increase her dose at that time. She took that same dose for many years, and did fairly well. She didn't complain of any side effects. Occasionally, she wondered if she needed more thyroid medicine but her doctor didn't agree. Over the years she has been to several doctors, but none of them felt she needed to take more thyroid medicine since her tests showed a TSH near the lower limits of normal. About a year ago, a doctor she was seeing agreed to increase her dessicated thyroid to 1.5 grains to see if that would help any. Her symptoms improved markedly, and both patient and doctor were well pleased. She became disappointed when the symptoms started coming back again about 3 months later. Her doctor, who was somewhat surprised when her symptoms returned, was even more astonished when he increased her dose to 2 grains only to see her symptoms of hypothyroidism get even worse!

To remedy the situation, a doctor knowledgeable about Wilson’s Temperature Syndrome instructs her (after evaluation) to decrease her dessicated thyroid to 1 grain for 2 days, and then to discontinue it (she is otherwise in good health, and she hasn't noticed too much of a change in the way she feels when she skips a day here or there of her Armour). She is concerned however when she's told she is to stay off all thyroid (if without complaints) for 10 days before starting the T3 therapy (p156). She feels she needs more thyroid stimulation, not less, and can't picture how she might feel if she goes off her thyroid treatment. She is reassured that she may start on the lowest dose of the T3 therapy before the 10 days are up, should she notice any worsening of her symptoms, and that she may increase the T3 as much as one 7.5 mcg increment/day to prevent any worsening of her hypothyroid symptoms during those 10 days. Further she is counseled that she'd be better off not to start or increase the T3 therapy at all for those 10 days if she doesn't worsen (p156).

She is able to remain off all thyroid without discomfort for 10 days, and then begins a cycle of T3. She gets to 90 mcg BID without a noticeable difference in her temperature or the way she feels, so she is weaned off the first cycle, or reset cycle (p125). She is able to wean off by 7.5 mcg/dose/day without complaints.

With the second cycle, her temperature and condition still do not improve in spite of her reaching 90 mcg BID. The second cycle is weaned as the first.

On the third cycle, her temperature begins to go up, and she begins to feel better on 67.5 mcg BID. On 75 mcg BID her temperature reaches 98.6 and she feels even better. Two days later her temperature slips back down a little, and so her dose is increased to 82.5 mcg BID. 2 days later it slides back down again, and she is increased to 90 mcg BID. She is without complaints. Her temperature does not drop back down in 2 days, so the patient begins to wonder if her temperature is captured. Three days after that (a total of 5 days) her temperature still has not dropped so it is felt her temperature is pretty well captured.

She subjectively felt about 40% of what she imagined a normal person to feel like when she started T3 therapy, and now she feels about 60% normal.

She begins having some stress at work, on top of getting the flu, and missing some of her dose times (she missed one dose entirely), and begins noticing some lightheadedness, shakiness, and palpitations when she stands up quickly. Her side effects respond partially to a T4 test dose. Since she is having some side effects, and since this is a reasonable time to wean anyway it is determined that it would be best for her to wean off the present cycle at this time. Her side effects resolve when she has weaned about half-way off the present cycle, so she is kept off the T3 therapy for only 2 days between cycles (p133). On the next cycle she is able to capture her temperature on 52.5 mcg BID, and feels 80% normal.

After a time (Q9), she is weaned off the present cycle, to start another. On the next cycle (her sixth overall) she is able to capture her temperature on 15 mcg BID and she feels 100% normal, subjectively. This cycle ends up being her last since she is able to wean off the T3 and stay normal even after the treatment is finished.
 

A 48 y.o. college administrator presents with extreme fatigue and listlessness, as well as difficulty sleeping at night, cold hands and feet, and irritable bowel syndrome. Twenty two years ago she developed hypothyroidism, with a low T4 and a high TSH. She is well acquainted with some of her symptoms, as she has had them to varying degrees for the last twenty two years. Her symptoms are severe enough now, that she "just knows there's something wrong," in spite of the fact that her thyroid blood tests are normal. She is currently taking .2 mg of levothyroxine (e.g., Synthroid, Levothroid).

After evaluation, she is instructed to decrease her T4 dosage from .2 mg to .1 mg for 2 days and then to discontinue it. She is instructed that she should try to remain off all thyroid medicine for 10 days, but that she should start and increase the T3 therapy as is necessary (and only as is necessary) to prevent a worsening of her symptoms. After the 10 days are over, she may then increase the T3 by 7.5 mcg/dose/day if without complaints until her temperature is 98.6 or until she reaches 90 mcg BID, and to call the office if she has any questions or problems, and to return to the office in 3 weeks.

At her next visit, she relates that after she was off all T4 for 2 days, her hypothyroid symptoms started to worsen, and her temperature dropped from averaging 97.8 to about 97.5, so she started taking 7.5 mcg BID. Her symptoms did not continue to worsen, so she did not increase the dose any further, until 3 days later (fifth day of being off T4) when her symptoms started worsening again. At that time she increased her dose to 15 mcg BID, and with that she was able to hold her own until the rest of the 10 days had passed.

At that point she began increasing the T3 therapy by 7.5 mcg/dose/day in an effort to bring her temperature up to normal. Her temperature normalizes at 52.5 mcg BID, and her symptoms improve markedly (she feels 80% normal when she had been feeling 20%).

After a time, it is determined that she should proceed with treatment to see if she can completely resolve her complaints and go back on T4 therapy (p162). She begins to wean down by 7.5 mcg/dose/2 days (and she is further challenged by not adding back any T4 at first). Her temperature begins to slip after the second decrease, so it is felt that she may be weaning the T3 dose too quickly. This suspicion is confirmed by going back up one increment of T3, waiting 4 days before the next decrease (instead of 2), and seeing her temperature hold this time. She continues to be able to decrease the T3 by 7.5 mcg/dose/4 days without a drop in her temperature until she gets down to 22.5 mcg BID. She finds that she cannot decrease the dose past this "wall" without experiencing a drop in her temperature, so it is felt that she probably is not producing sufficient T4 to support endogenous T3 production sufficient to replace the exogenous T3 being weaned. So, .025 mg/day of levothyroxine is begun. After a day or so, she is then able to finish weaning off the T3 therapy without problems. At this point, she is still feeling about 70-80% normal (Q5).

Two days after the first cycle of T3 therapy has been discontinued, the levothyroxine dose is discontinued. She again is instructed to wait up to 10 days without starting the T3 if possible between cycles (since she is only on .025 mg of T4 5-7 days would probably be sufficient, but in cases of being on .1 mg or so, patients should wait the full 10 days). This time, she is able to remain off the T3 until she decides to begin the next cycle on the sixth day (which she has permission to do).

With this cycle, she is able to get her temperature up on 30 mcg BID, and she enjoys complete resolution of her symptoms. When she is weaned off the T3 therapy, she weans down every 4 days, and again needs .025mg T4 to be added back when she gets down to 22.5 mcg BID. When she gets down in the cycle to 7.5 mcg BID, it seems that she could use a little more T4 (based on her symptoms and temperature), and so her dose is increased to .05 mg/day. She remains very, very well off T3 therapy, and finds herself 6 months later, with normal thyroid blood tests and doing far better on .05 mg/day than she ever did on .2 mg/day!
 

A 38 y.o. woman had been fine until about 3 years ago when she developed signs of hyperthyroidism. Her T4 was very, very high, and her TSH was extremely low. She had lost 10 pounds in less than a month, was experiencing a rapid heart rate, and feeling quite ill. She underwent ablative radioactive iodine treatment, and her symptoms of hyperthyroidism gradually abated. She began gaining her weight back, and also felt more fatigued, with difficulty concentrating. A low T4 and an elevated TSH, revealed that she had been rendered hypothyroid, which was no surprise. She was started on levothyroxine, and after some adjusting, her blood tests were normalized with her being on a dose of .1 mg/day. The only problem was that she was still suffering from the symptoms she had developed after the ablative therapy. She was still gaining some weight and she was still exhausted. She also noticed she was retaining more fluid, and was loosing some hair; she was also developing very dry skin and dry, brittle hair. Since the thyroid tests were normal, her doctors felt that she was normal, and that if anything her complaints were from something else if not from simply getting older. They did not feel that increasing her dose would be indicated or helpful.

She had lived for 37 years previously without any trace of such a complaint, and she knew she felt nothing like the way she felt prior to developing hyperthyroidism. The symptoms she was experiencing were just like the ones she began to have after the ablative therapy, which had partially responded to levothyroxine to the satisfying of blood tests. Her temperature was running 97.0 on average.

After evaluation from a Wilson’s Temperature Syndrome perspective, it is determined that she should decrease her T4 to .05 mg/day for one day, and then discontinue it. She is instructed to start and increase the T3 therapy only as is necessary to prevent a worsening of her symptoms for 10 days (staying off T3 completely for 10 days if possible) and then to increase the T3 by 7.5 mcg/dose/day if without complaints until her temperature is 98.6 or until she reaches 90 mcg BID, and to call the office if she has any questions or problems, and to return to the office in 3 weeks.

She is able to stay off the T3 comfortably for 10 days after discontinuing the T4. She is able to capture her temperature on 45 mcg BID. Her symptoms of hypothyroidism almost completely resolve, but not quite.

She is feeling well enough, that she would like to stay on the 45 mcg BID for a time, since it has been a while since she's felt very well. After about a month on that dosage, she comes down with the flu. Although her temperature had been running normal before the flu, her temperature is now running close to 100 degrees. Since her temperature had been normal for a while on 45 mcg BID, she is instructed not to decrease her dose of T3. She is advised to treat this fever, the way anyone else would treat a fever they would get with a flu, and to call the office if she develops any unusual complaints. After 4-5 days her flu abates, and her temperature returns to normal, as does her previous level of well-being.

After a time (Q9), it is determined that she should wean off the present cycle in favor of the next cycle of T3. It is also hoped that she can avoid having to wean T4 before the next cycle, by not having to go on T4 after this cycle. She is instructed to wean off the T3 by 7.5 mcg/dose/2 days if without complaints, and to remain off for 2 days before starting another cycle. It is explained to her, that should her temperature begin to drop, and should she begin to feel significantly worse that some T4 will be added back.

As she weans off the present cycle of T3, her temperature slips a few tenths, and she feels a little more tired, but is sufficiently comfortable that she doesn't need to add back any T4 between cycles.

On the second cycle her temperature is captured on 30 mcg BID, and she enjoys complete resolution of her symptoms. She states that she feels the way she did before any of this ever started (before getting hyperthyroidism). She is allowed to remains on 30 mcg BID for two months because she does not have any complaints, and she is afraid she would not feel as well with the T4. Over that time, she begins to forget what it was like to feel badly, and becomes confident that she will be able to wean off T3 therapy. Since she is in no hurry to wean off, and because she wants to stay on the smallest amount of T4 that is effective, she weans down off the T3 by one 7.5 mcg every 10 days. As she weans down off the T3 therapy, her temperature slips some when she decreases the T3 dose to 15 mcg BID, so she is given .05 mg of T4. She is then able to wean off the rest of the way without difficulty. Her thyroid blood tests 6 weeks out are within normal ranges. She feels back to normal, and maintains a normal temperature on .05 mg/day of T4 (levothyroxine). These are two things she didn't have prior to T3 therapy even though she was on .1 mg/day of T4.
 

A 34 y.o. woman who is part Irish, and part American Indian presents complaining of fatigue, panic attacks, migraine headaches, and irregular menstrual cycles. She has a fair complexion and some freckles, and naturally has reddish highlights in her hair. She has been more tired than she thinks is normal, for as long as she can remember. Over the years, she has seemed to pick up more and more complaints. She remembers no obvious correlation between the onset of any of her symptoms with any identifiable stressful event, or identifiable change. Her temperature has run between 97 and 98 degrees for as long as she can remember. "I have to get sick to get a temperature of 98.6, and my doctor used to tell me that if I ever did get a temperature of higher than 98.6 that for me it was a fever and to treat it as such."

After evaluation, she is started on 7.5 mcg p.o. BID and is instructed to increase the dose by 7.5 mcg/dose/day if she is without complaints until her temperature is 98.6 by mouth on average (or until she is up to 90 mcg BID), and to call the office if she develops any complaints, and to return to the office in 2 weeks. The patient is very apprehensive about increasing the medicine every day since she has a history of being very sensitive to medicines. It is explained to her that she may go up on the medicine by 7.5 mcg increments every 3 or 4 days if she prefers, but that 10% of patients don't tolerate that very well, and that she might be one of them (p98). It is decided that she will increase the T3 every 3 days instead of every day, but that a careful eye will be kept on her to watch and make sure that she is not a one-day compensator (p91).

Her temperature first reaches 98.6 on 37.5 mcg BID. She feels significantly improved (from 30% normal to 60% normal). After 5 days on that dose, her temperature drops back down again, and so her dose is increased to 45 mcg BID. About 5 days later, her temperature begins to slip again, and so her dose is increased to 52.5 mcg BID. Her temperature again goes up, and she again feels well until about 3 days later, when she missed a couple of dose times by an hour or so (she admits that she has been having a little trouble getting her doses on time all along). At this time she doesn't haven't any complaints or side effects, but she is just not feeling as well as she was. She is given a T4 test dose (p129) and within 45 minutes of the dose she returns to feeling as well as she ever has during the T3 therapy. Two days later (her fifth day of being on 52.5 mcg BID) her temperature slips down again. She is increased and compensates again in 5 days, and then when she is increased to 67.5 mcg BID, her temperature appears to be captured (because more than 5 days have passed, and the temperature hasn't dropped back down again).

After being on 67.5 mcg for about 3 weeks, she again has some trouble getting her doses on time, and her temperature slips a little and some of her symptoms return. She improves a little with a T4 test dose but not as well as before, and no further improvement is obtained when the T4 test dose is repeated in 1 and 1/2 hours. Her temperature is raised back to normal when her dose is increased to 75 mcg BID, but she still is not feeling as well as she had been previously on 67.5 mcg BID.

It is determined that it would be best to wean her off the present cycle in favor of the next cycle, and she begins to wean off the medicine by 7.5 mcg decrements every 2 days. Her temperature starts to slip, so her wean is decelerated to one decrement in her dose every 4 days, which works out well.

After remaining off T3 for 3 days between cycles, she begins the second cycle. She is able to capture her temperature on 30 mcg BID this time. She now feels what she considers to be 80% normal. She is satisfied for now and would like to stay on this dose for a month or so, because she has some stressful weeks coming up and doesn't want to take the time to change her dosing, or take the chance of not feeling as well.

Two months later she weans off the 2nd cycle as she did the first, and 3 days later begins the 3rd. She captures her temperature on 15 mcg BID, and feels now what she considers 100% normal. After a couple of months she weans off the treatment and remains well off therapy.

Three months down the road, she makes a stressful presentation, and notices herself starting to slip clinically, over the next several days. Her temperature has slipped as well. She finds that she is able to get her temperature back up on only 7.5 mcg BID, which she discontinues successfully after about a week. She now uses small doses of T3 to quickly catch relapses. She has even noticed that if she takes 7.5 mcg BID the day before, the day of, and the day after a presentation she knows will be stressful (and would typically cause a mild relapse for her) she can often prevent the relapse from occurring at all.
 

The patient is a 45 y.o woman who is complaining of severe fatigue, headaches, depression, decreased memory, irritability, and easy weight gain. Her symptoms first appeared 10 years ago after the birth of her second child. Her symptoms tend to worsen each time she goes on a strict diet to lose weight (she often gains the weight back, and then some). They did seem to improve somewhat when she was treated on a clinical basis with some thyroid medicine for several months about 4 years ago. But she moved to another state, and could not find a doctor who would treat her with thyroid medicine, since her tests were normal.

Upon evaluation it was determined that her temperature averaged 97.3 during the day, and her blood tests were normal. Also, her EKG revealed her heart rate to be very slightly irregularly irregular. So slightly that most doctors would probably say that she had normal sinus rhythm. In the history she admitted to having noticed some skipped beats from time to time. She was counseled that she had a higher than normal risk of having cardiovascular side effects such as palpitations, skipped beats, or increased heart rate (p71). But all involved felt her potential benefit outweighed her risks.

She is started on 7.5 mcg p.o. BID and is instructed to increase the dose by 7.5 mcg/dose/day if she is without complaints until her temperature is 98.6 by mouth on average (or until she is up to 90 mcg BID), and to call the office if she develops any complaints, and to return to the office in 2 weeks. Her temperature first reaches normal on 15 mcg BID. Six days later it drops back down again. Her dose is increased to 22.5 mcg and then the next day to 30 mcg BID, which brings her temperature back up to normal. About 6 days later her temperature drops back down again, and her dose is increased again. Finally, her temperature is captured on 60 mcg BID. She feels very well. In fact, she is incredulous that she can feel so well after so many years of feeling so badly, and especially that the treatment was so simple. She finds it hard to believe/understand that this treatment wasn't thought of sooner.

She stays on 60 mcg BID for almost 3 months before wanting to proceed with the treatment's course. She has not had any complaints on the T3 therapy. Unfortunately, she misunderstood or forgot the instructions and weaned off the T3 therapy by 7.5 mcg/dose/day in spite of the fact that her temperature dropped after the third decrease. Some of her symptoms returned as she weaned off, and she was discouraged. It was explained to her how she should have weaned off more slowly, to give her own system a chance to come up and maintain her temperature.

She was started on a second cycle and was able to capture her temperature on 52.5 mcg BID (when she might have been able to on much less had she not squandered so much of the benefit from the first cycle by weaning off too quickly). After a month or so on that dose, she was ready to try weaning off again. This time, she began by decreasing the dose by 7.5 mcg/dose/2 days. However, when her temperature started to slip on the second decrease, she went back up an increment (since there was a good chance this could be her final cycle), and then decelerated the wean to 7.5 mcg/dose/4 days. After a couple of decreases, her temperature started to slip again, so she went back up an increment and decelerated the wean to 7.5 mcg/dose/6 days. She was then able to continue weaning off the T3 until she was off completely, and her temperature remained normal off the treatment.

She did very well for over a year, until her sister died in a car accident. Her temperature dropped and her symptoms began to return. She was started back on a cycle of T3 and after about one week, she was able to capture her temperature on 22.5 mcg BID. She stayed on that dose for about 2 months and then was able to wean off the T3 therapy again, without any difficulty in maintaining her body temperature on her own.