Interestingly, TSH increases during the colder winter months and decreases during the summer months. Go see your doctor and seek medication to correct your problem which can become serious if you do not do what I have said. If you're already being treated for a thyroid disorder, your doctor will probably consider. If the TSH level is between 4mIU/L and 10mIU/L, treatment may still be warranted in various situations: if the levels of actual thyroid hormones in the bloodknown as thyroxine (T4) and triiodothyronine (T3)are abnormal shaws Administrator 8 years ago Have you been diagnosed with Hypothyroidism? Now that you have a basic understanding of thyroid physiology we can discuss another physiologic change that may make understanding your lab tests difficult. Treatment For Hashimotos With Normal TSH Levels | Paloma Health Treatment For Hashimotos With Normal TSH Levels Find out when treatment is necessary for Hashimoto's, and how else to manage symptoms. This can occur if a person's TSH level is significantly elevated. The hypothalamus signals the pituitary gland, which sends thyroid-stimulating hormone (TSH) to the thyroid to trigger the release of thyroid hormones. An expecting mom should test their thyroid hormone levels every month in the first half of pregnancy and may be checked less often during the second half of pregnancy.. Cookies collect information about your preferences and your devices and are used to make the site work as you expect it to, to understand how you interact with the site, and to show advertisements that are targeted to your interests. This liquid solution containing just three hypoallergenic ingredients (levothyroxine, glycerol, and water), is sold in single-dose ampules. And stress, your diet, medications, and having your period can all make TSH fluctuate. In addition to the conditions listed above, there are a few other states that make the TSH less reliable. In lay terms, it reduces your metabolism or the number of calories that you burn on a daily basis. Most people who develop hypothyroidism after radioactive iodine treatment can expect to take some form . This patient requires a significantly higher dose than expected, and his thyroid levels are fluctuating. As thyroid hormone levels change during pregnancy, the hormone replacement dose may change with them. Thyroid disease can progress or stabilize as the year's pass due to any number of reasons: One of the most common contributing factors of fluctuation in your thyroid levels is your age. DEAR MAYO CLINIC: I recently was diagnosed with mild hypothyroidism that isn't causing symptoms. Dr. Danielle Weiss is double board-certified in internal medicine and endocrinology. I have been taking a thyroid adrenal . Guidelines for the treatment of hypothyroidism: prepared by the American Thyroid Association Task Force on Thyroid Hormone Replacement. HealthTap uses cookies to enhance your site experience and for analytics and advertising purposes. Can You Eat Soy If You Have a Thyroid Condition? Some known interactions occur between thyroid medication and corticosteroids, cholesterol-lowering drugs, corticosteroids, amiodarone, and lithium. Not only does it help you establish a habit and make it less likely for you to miss a dose, but it also ensures that you always take it in the same way. Her TSH was still 2.37 (so within the normal range) with a reference range of 0.45 to 4.5 uIU/mL: At first glance her labs look decent but how can you reconcile these labs with her clinical symptoms? This guide will walk you through everything you need to know about TSH including why it isnt always the best marker of thyroid function in the body and which conditions make the interpretation of TSH less accurate. If hypothyroidism persists for more than a few months, treatment Disease progression can impact thyroid hormone levels. The normal range of TSH levels in non-pregnant adult women is 0.5 to 5.0 mIU/L. High TSH High TSH indicates you're hypothyroid. Thyroid. It produces hormones that regulate your body's energy use, along with many other critical functions. Never disregard the medical advice of your physician or health professional, or delay in seeking such advice, because of something you read on this Site. They maintain the rate at which your body uses fats and carbohydrates, help control your body temperature, influence your heart rate, and help regulate the production of proteins. The thyroid is the butterfly-shaped gland at the base of your neck. indicates that your Thyroid is not producing enough, ). Have your T3 and T4 levels tested, if you haven't already. In this way, D2 helps regulate how much thyroid hormone each cell gets by activating or inactivating thyroid hormone as necessary. But if the decrease in has a different demand for thyroid hormone depending on the situation, time of day, stress you are under, etc, never seen a healthy individual with a TSH > 1.0, That means it is entirely possible to have a normal but less than optimal TSH, several conditions where the TSH can be decidedly normal in fact it can even be sometimes < 1.0 but the patient can still be hypothyroid, free T3 levels that are either at the low end of the reference range or barely below it, Generally, this means you will have to look outside of the insurance model (I know its not what you want to hear but its just the truth right now) because most Doctors practice what is known as the standard of care and that standard is to test only the TSH, calorie restriction can even cause low T3 syndrome, in fact some providers have recommended we change the range to include anything > 2.5 as abnormal, 3x more potent at decreasing your TSH than T4 thyroid hormone, B12 Shots Benefits: Weight Loss, Energy & More, Victoza Weight Loss Case Study: 50 Pounds Lost with Victoza & LDN, Thyroid Hormone Resistance: What is it & How to Diagnose it, Hypothyroid Supplements for Women: My Top Picks, How Thyroid Supplements Work & Why They Help you Feel Better. T4 ~ 1.0. With half of her thyroid gland, she was still able to produce some thyroid hormone but not an optimal amount. The list includes optimal ranges, normal ranges, and the complete list of tests you need to diagnose and manage thyroid disease correctly! Several factors can affect your TSH level, such as stress, lifestyle choices, medication, age, and thyroid function. Without pre-pregnancy thyroid disease: T3 and T4 tend to increase while TSH decreases during pregnancy. They can produce a significant change in thyroid status within weeks or months. #2. This illustration helps explain (in addition to the differences in deiodinases, tissue level demands, etc.) It also has an effect on the body's ability to effectively metabolize cholesterol. Alternations in thyroid hormone levels following growth hormone replacement exert complex biological effects. If you plan to change how you take your thyroid medication, make sure you clear it with your healthcare provider first. Living with an autoimmune condition and having been let down by the traditional healthcare system, Katie has a personal and professional interest in improving patient access to better care. These fluctuations can occur as your thyroid disease progresses. Does this mean I don't have Hashimotos anymore? This often leads patients with autoimmune thyroiditis until their TSH finally increases to a point where providers feel thyroid hormone is indicated. Hypothyroidism Hey! Most conventional physicians use the TSH test to determine if one has a thyroid disorder and to dose thyroid medications. Does a child with tsh level of 6.0 need medication? A list of national and international resources and hotlines to help connect you to needed health and medical services. Always check your lab's reference range on your results report. You can see the example below which shows a free T3 level of 2.5 with a reference range from 2.3 to 4.2. However, during the period of thyroiditis, your doctor may prescribe thyroid hormone replacement or antithyroid medications. Hypothyroidism can affect many different systems in your body. Test your thyroid levels from home and know your levels in days. Specific medications may interfere with your thyroid function and absorption of thyroid medication. bodily functions. This is another big one that I will occasionally run into and it highlights just how good the body is at preserving serum levels of thyroid hormone (or how inaccurate thyroid lab tests really are depending on how you look at it). Variances such as a change in health plans, change in primary care physician, or change in thyroid medication formulations may lead to an adjustment in your thyroid medication dosage or potency. The Best IOL for 2022 RXSight Light Adjusted Lens, Will refractive surgery such as LASIK keep me out of glasses all my life. That means it is entirely possible to have a normal but less than optimal TSH. Please note, we cannot prescribe controlled substances, diet pills, antipsychotics, or other abusable medications. Tests like free T3 and total T3? Clin Biochem. There are several conditions where the TSH can be decidedly normal in fact it can even be sometimes < 1.0 but the patient can still be hypothyroid. Most doctors agree that any TSH above 10, especially when combined with an abnormal T3 or T4 reading, should be. Overall, you might feel the symptoms of hypothyroidism, which include: Graves' diseasecan also progress, especially in the first few years after diagnosis. After that, blood levels generally That means your Doctor wont flag your TSH as abnormal unless it falls outside of those reference ranges. Harvard Health Publishing. The reasons that TSH levels can fluctuate is mainly due to levels of T3 or T4 in your blood. Alternately, you could take it at bedtime (at least three hours after your last meal). varies from person to person. Standard treatment for hypothyroidism involves taking a daily oral medication called levothyroxine, a synthetic form of thyroid hormone. Yes, TSH can go back to normal. Foods to Avoid if you Have Thyroid Problems: Ive found that these 10 foods cause the most problems for thyroid patients. Arch Med Sci. In this situation, you can also develop symptoms of hypothyroidism. Im not going to go into detail on this now, but just realize the lab tests arent the end-all-be-all for diagnosis. It can also lead to irregular or missed periods. We disclaim all responsibility for the professional qualifications and licensing of, and services provided by, any physician or other health providers posting on or otherwise referred to on this Site and/or any Third Party Site. If they respond well to treatment, however, their goal may rise to the normal . Our website is not intended to be a substitute for professional medical advice, diagnosis, or treatment. a repeat TSH measurement showed a spontaneous decrease in TSH to 14.2 U/ml, without any treatment, and the scintigraphy showed a homogeneously increased iodine uptake, suggestive of Graves' disease . Plus some labs are better and more reliable than others. The amount of levothyroxine needed If you are working with someone and they dont order the tests or balk when you ask for certain tests that is a good indication they are not the provider for you. And we are going to talk about it in detail below. I am 23 years old and My TSH level is 5.52 , if I donot take any medication , will that increase ? This indicates your total dose will likely need to be much higher than someone who drops their TSH down to 0.05 with the same dose. Sleep problems. Some medications and supplements may also affect your results. hypothyroidism and too much can cause side effects, such as increased appetite, Just take a look at the comment section of any post and you will find plenty of people posting their labs with that exact question. So everything was totally normal this time. Tsh level is 0.023 Dr lowered medication to 77mcg from81 mcg. T3, or triiodothyronine, is a thyroid hormone produced in small amounts by the thyroid gland. This highlights that each patient has a unique demand for thyroid hormone in their body and standard dosing should not apply to everyone. Unfortunately, patients who fall into any of these categories tend to get misdiagnosed and/or mismanaged by providers who rely solely on TSH levels for diagnosis. TSH can be a helpful test but it really falls short under many circumstances in both the diagnosis and management of hypothyroidism. It's important to receive the correct amount of this Sometimes when you are taking thyroid medication, your thyroid hormone blood levels may change. If the TSH level is elevated due to a thyroid related issue, you may need treatment. The doctor said that this doesn't mean I'm out of the woods and his . T3F ~ 321 (230-420) Anti-Thyroglobulin Ab ~ <20 (<41) Anti-TOP Microsomal Ab ~ 17 (<35) Last time: TSH ~ 7.36. P.S. TSH can actually be very helpful in initially diagnosing hypothyroidism and (sometimes) in helping to determine the ideal dose of thyroid hormone medication. These fluctuations happen because human chorionic gonadotropin (HCG), a hormone produced during pregnancy, stimulates the production of T3 and T4. energy. Get prescriptions or refills through a video chat, if the doctor feels the prescriptions are medically appropriate. In men, high prolactin levels can cause . Let us not fight with mother nature! Is it normal for TSH levels to drop from 19 to 8 without Levothyroxine? Some surprising foods can also negatively affect thyroid function. She had a small goitre, but no ophthalmopathy or dermopathy. A TSH measurement at 09.00 has been shown to strongly correlate with the total 24-hour TSH secretion, sampled at 10-minute intervals. Please note, we cannot prescribe controlled substances, diet pills, antipsychotics, or other abusable medications. The following medications can cause your thyroid hormone levels to fluctuate: Oral contraceptives Iron, calcium or biotin supplements Anti-depressants Corticosteroids Cholesterol-lowering drugs It is important that you inform your doctor if you're taking any of these. medication because too little levothyroxine won't adequately control Then, if the levels stay within the normal range Verywell Health's content is for informational and educational purposes only. Below Ive included an example from a recent patient who had undiagnosed autoimmune thyroiditis for many years: You can see the TSH at 12.27 with a reference range of 0.40-4.50 in a patient with debilitating fatigue and weight gain for years (undiagnosed) with accompanying elevation in both thyroglobulin and TPO antibodies. But in order to come to this conclusion you really have to look at the whole picture. Switching to a new brand of thyroid medication may lead to fluctuation in thyroid levels as your body adjusts.. Occasionally this scenario will prompt a physician to simply recheck the thyroid lab tests within a month without proper treatment with thyroid hormone. Thyroid hormone is activated inside the cell of the target tissues and it does this through a nuclear receptor(2)(actually thyroid hormone has both genomic and non-genomic actions but the genomic actions are particularly important for symptomatic control). Usually, postpartum thyroiditis will resolve itself. Outside factors may affect the results of your thyroid blood test. Thyroid hormone doesnt do anything if its in your bloodstream. As a result, your We offer this Site AS IS and without any warranties. Pregnancy can affect thyroid hormones in many ways. Often, people can decrease or discontinue these medications if and when the condition improves. Well, the pituitary gland is just another tissue in the body that has a demand for thyroid hormone and sensitivity to thyroid hormone. The surge of pregnancy hormones can cause your TSH, T3, and T4 levels to fluctuate. These studies suggest a peak of T3 at around 4 am with a nadir between 3 to 5 pm; this appears to lag behind TSH levels by about 90 mins [ 62 ]. So lets say you are convinced that your thyroid is suboptimal and youd like to prove it. Work with your doctor to manage thyroid level fluctuations. During the exam, your health care provider may check for: Slight tremor in your fingers and hands. The experiment was simple: First, "Phlebotomy [blood sampling] was performed after an 8-12 hour overnight fast between 7:30-8:30 am for free T4 and TSH measurements.". There was no history of thyroid disease or drug consumption. Too High: The TSH level is far too high, indicating your thyroid is not sending out enough thyroid hormone to support your body. Tests Thyroid Stimulating Hormone (TSH) Measurement of TSH is the principal test for the evaluation of thyroid function in the vast majority of circumstances 10 provided there is no clinical or historical evidence to suggest damage or disease of the hypothalamic -pituitary axis.Hypothalamic and pituitary disease can cause central hypothyroidism, which is rare 11, 12. In simple words, it means that thyroid hormone gets inside the cell and directly turns on genetic transcription (it changes your DNA/RNA directly). While this is a great thing for thyroid control at the cellular level, it can also make diagnosing hypothyroidism more difficult. Your doctor should also be testing the actual thyroid hormones, FREE T3 and FREE T4 every time you have blood work. Occasionally, the condition may resolve without treatment. It is fortuitous that typically only a very low amount of thyroid replacement is necessary for most people. Symptoms can include fatigue; weakness; dry, rough or pale skin; muscle cramps and aches; constipation; depression; irritability and decreased libido. Alternately, you could consider switching to a brand name to avoid this issue. Top answers from doctors based on your search: Created for people with ongoing healthcare needs but benefits everyone. Why was the test ordered? Some prescription meds that can influence thyroid hormones: We suggest regular monitoring of your thyroid function during the long-term use of any of the therapies listed above. At any rate, certain dietary choices and lifestyle practices can help you lower and stabilize your TSH levels. Free T3 may be included in a thyroid panel, but it's not an accurate measurement of thyroid dysfunction. If it does, how is it treated? Data mining: seasonal and temperature fluctuations in thyroid-stimulating hormone. Dont worry, we arent going to jump into advanced thyroid physiology (you can find more about that here if youd like) instead I want to keep things basic: TSH stands for Thyroid Stimulating Hormone and it comes from your pituitary gland (1). of hypothyroidism, called subclinical hypothyroidism, are associated with an Tsh is secreted in spurts and may vary depending upon when it's drawn. If your TSH is outside of this range then you should be evaluated further and you should consider a trial of thyroid medication. In your level of thyroid hormone. Overactive reflexes. And yet despite the fact that the TSH is > 3.0, in this case, their free T4 is still relatively normal at 1.17 with a reference range of 0.89 to 1.76. Get prescriptions or refills through a video chat, if the doctor feels the prescriptions are medically appropriate. develops when the thyroid doesn't make enough hormones. . When one has thyroid antibodies that make one's thyroid go out of whack one can even go back and forth between HypoT and HyperT (but I wouldn't worry about that at this point). Last month's labs stated I am now at a TSH of 2.77 they never bothered to test my T4's. #supplements #lifestyle #medication #thyroid doctors #symptoms #hashimoto's #blood tests #diet & recipes Often, over time, the thyroid hormones and TSH eventually return to normal. TRAb antibody levels can fluctuate widely and unexpectedly, and when they do, they can immediately begin to affect thyroid biochemistry. In the most basic sense as leptin levels and insulin levels increase, the body preferentially converts T4 to the inactive thyroid metabolite reverse T3. But as I mentioned above it is important to consider that your pituitary is the MOST sensitive tissue to thyroid hormone in your body. Why do I still feel sick? As part of the endocrine system, the thyroid gland makes and stores hormones that help regulate the body's metabolism in the form of blood pressure, blood temperature and heart rate. However, many organizations agree that a reading of 2.5 or less is truly ideal for normal thyroid levels, with anything 2.5 - 4.0 mIU/L considered "at risk". Hypothyroidism, sometimes called underactive thyroid, is a condition in which your thyroid gland doesn't produce enough T3 or T4. Therefore, they may not raise the issue with their doctor or seek treatment., Your thyroid levels may also vary due to medication type, potency, and dosage. A normal Total T4 level in adults ranges from 5.0 to 12.0g/dL. Dr. David Sneid answered Endocrinology 43 years experience Thyroid inflammation: Can cause variable TSH results. I have a tsh level of .31 T3 T4 are good I had unintentional weight loss of 80 lbs in 6 months have diabetes 2 and My A1C is 5.3 no medication for it is this part of the cause for my extreme weight loss my doctor just srugged it off help? Never disregard or delay professional medical advice in person because of anything on HealthTap. That's because food may delay or reduce the drug's absorption by changing the rate at which it dissolves or by changing acid levels in the stomach. Get answers from Endocrinologists and top U.S. doctors, Our doctors evaluate, diagnose, prescribe, order lab tests, and recommend follow-up care. insomnia, shakiness, and heart palpitations or an irregular heartbeat. The last rsc 5month was 0.275. Free T3 is an active thyroid hormone. Levels vary by time of day. Educational text answers on HealthTap are not intended for individual diagnosis, treatment or prescription. Even if the TSH is used in tandem with free T4, this combination still is less sensitive when compared to rT3:T3. #supplements #lifestyle #medication #thyroid doctors #symptoms #hashimoto's #blood tests #diet & recipes Does Levothyroxine Cause Hair Loss? If you are pregnant, it's normal for TSH levels to become slightly elevated. Endocr Pract. In the process, her body transformed and she was able to lose more than 50 pounds. Thyroid Hormone Preparation. TSH tells your thyroid to produce hormones called T3 and T4. What causes tsh level to go up and down without medication? Medical history and physical exam. Even those optimal reference ranges listed above can be misleading in certain cases, but if used in combination with hypothyroid symptoms (and occasionally basal body temperature + resting metabolic rate) its possible to avoid misdiagnosis. TSH can fluctuate when HypoT is developing - I can understand your doctor's point. Since I was complaining of feeling really tired, plus I get cold easily and my mom has Grave's, the doctor thought it was a pretty standard case of hypothyroid, wrote me a prescription for Synthroid and sent me on my way. Occasionally, the condition may resolve without treatment. It restores the body's hormone levels to normal, which reverses the signs and symptoms of hypothyroidism. This may be because they change your thyroid function. I've had rapid weight gain. Does a child with TSH level of 6.0 need medication? Tsh tests are very sensitive but often not real reproducible. If you look at laboratory tests you will see that a normal TSH level generally falls within 0.5 to 4.5 (or some small variation). This is what will happen to your thyroid gland over time assuming you dont treat the autoimmunity or inflammation, and it just doesnt make sense to wait until the damage is greater than 50% to prove it. Some people developthyroiditis after pregnancy. Dr. Robert C. Smallridge, Endocrinology, Mayo Clinic, Jacksonville, Florida. Inflammation of the thyroid gland can disrupt normal thyroid hormone levels in numerous ways. Rapid or irregular pulse. Without TSH, the system would fail. A normal Total T3 level in adults ranges from 80-220 ng/dL. Parathyroid hormone (PTH) is a chemical made by the parathyroid glands. If left untreated, this condition eventually may lead to serious health problems. I am 23 years old and my tsh level is 5.52 , if i donot take any medication , will that increase ? Now having said all of those things it doesnt mean that the TSH is entirely useless (in fact I will talk about how it can actually help somewhat helpful later). I recently attempted to get back on medication because I feel awful but my TSH was 3.80. How likely would you say I am positive for hashi's I've never been tested yet. The seasons - spring, summer, fall, winter - can affect your thyroid. Ultimately, when it comes to taking your thyroid hormone drug, consistency is essential. A woman is said to have entered menopause once her body has not menstruated for 12 months, as . Didn't find the answer you were looking for? Video chat with a U.S. board-certified doctor 24/7 in less than one minute for common issues such as: colds and coughs, stomach symptoms, bladder infections, rashes, and more. It is important to follow your doctor's advice and not make changes to your medication without discussing it with the doctor. When hyperthyroidism develops, free thyroxine (T4) and free triiodothyronine (T3) levels rise above normal. The doctor told me he didn't see a reason but it was my blood and money and so getting another test was fine. It would be prudent to consult a gastroenterologist as you may not be absorbing your. Has your doctor taken a blood test for thyroid antibodies? Below is an example of a hypothyroid patient who underwent a partial thyroidectomy some 20+ years ago. How old is the child? Patients have low T3 but the problem is that they have a relatively preserved TSH (in the normal or even optimal range), but free T3 levels that are either at the low end of the reference range or barely below it. By these new standards, you can consider a TSH which is greater than 2.0 to be an early indicator of some thyroid dysfunction in the body. For these, please consult a doctor (virtually or in person). Assessment ofthyroidfunction duringpregnancy: the advantage of self-sequential longitudinal reference intervals. change would not help with this. Video chat with a U.S. board-certified doctor 24/7 in less than one minute for common issues such as: colds and coughs, stomach symptoms, bladder infections, rashes, and more. In the case of standard hypothyroidism, your TSH increases. Assessment ofthyroidfunction duringpregnancy: the advantage of self-sequential longitudinal reference intervals. In women, during the menstruation cycle, pregnancy, or after menopause, TSH levels may fall slightly outside the normal range, because of fluctuating levels of estrogen. This would indicate, at least subjectively, that the ideal TSH (provided the disease is not present in any form) is somewhere around 1.0. The big problem is that this condition is relatively new and our understanding is limited. I like to think of it as the gas pedal to the car. The addition of T3 can help patients who also have mood disorders like depression. for several years, monitoring usually can switch to once a year. My Dr. said it could be that the RAI treatment that I had several months ago is working or that she needed to reduce my medication, which she did by 1/2 a tablet. Understanding the way that these enzymes work is essential to understanding why treating TSH doesnt work for all people. weeks after you start taking the medication. I'm Westin Childs D.O. Again, it highlights the importance of not focusing solely on the TSH but instead using other markers to help diagnose thyroid-related problems. To start with I have never seen a healthy individual with a TSH > 1.0. Undiagnosed thyroid disease puts patients at risk for other ailments, such as cardiovascular diseases, osteoporosis, and infertility. often is recommended. Around 10 years ago I was diagnosed with Hashimotos Diease and my TSH level was 13. But what if there was a better way? Finding the right treatment and the proper dosage is a step-by-step process that takes time and requires monitoring. Too much levothyroxine can cause side effects, such as: Tiredness. Things that may help keep your thyroid levels stable include taking your thyroid medication at the same time every day and on an empty stomach; sticking with the same brand or manufacturer of your thyroid medication; talking to your doctor about other medicines, herbs, and supplements you currently take; and asking your doctor about adjusting your medication dose with the change of seasons. Postpartum thyroiditis: management and treatment. Signs and symptoms will be expected to progress without thyroid supplementation such as with. The amount of thyroid hormones your body makes is regulated by another hormone called thyroid stimulating hormone, or TSH, that's produced by the pituitary gland. A way that reconciles the fact that so many patients have a normal TSH, and yet, still experience the symptoms of hypothyroidism. For potential or actual medical emergencies, immediately call 911 or your local emergency service. Other factors that affect TSH levels include thyroid peroxidase (TPO)-antibody positivity, BMI, obesity, smoking, critical illness, and many xenobiotics, including environmental pollutants and drugs. Patients with low Free T3 (and high reverse T3): May 18, 2020. This is probably one of the most common questions I get on a daily basis (or some variation of are my lab tests normal). TSH Optimal range: 0.5-2 IU/L. Why Do I Have Thyroid Symptoms If My TSH Is Normal? These changes may occur for a couple of reasons: Hashimoto's thyroiditis often progresses over the first 10 years. 7 The circadian differences in secretion may cause a small variation in TSH levels in older literature a mean of 0.952 mIU/l although generally this does not result in TSH values outside the normal . My wife is on thyroid medication, we are planning on starting a family. The downside is that unlike other tissues in the body the pituitary is the MOST sensitive tissue to thyroid hormone in your body. how do i renew my blue handicap placard in michigan,