develops when the thyroid doesn't make enough hormones. By using this Site you agree to the following, By using this Site you agree to the following, TSH fluctuations without medication or diagnosis, Diagnosis Purgatory, looking for a second opinion. So lab tests in this instance would look something like this: This pattern is seen very frequently in patients who are treated based on the TSH alone but have insulin/leptin resistance and/or a history of calorie-restricted dieting. Common early Levels vary by time of day. Why was the test ordered? In general, normal TSH levels during pregnancy include: First trimester (9 to 12 weeks): 0.18 - 2.99 (uIU/mL). Fortunately, it is relatively easy to check for and just requires the complete thyroid panel which we will be going over below. Usually, this is characterized by low thyroid hormone levels and high or low TSH. If hypothyroidism doesn't go away on its own within several months, then treatment is . Please advise? But that does not mean that the other tissues in your body are getting enough thyroid hormone. Below you'll find 7 reasons your TSH may be increasing. Find inspiration for a healthy way to support your thyroid. And stress, your diet, medications, and having your period can all make TSH fluctuate. Support Your Thyroid. TSH levels change inversely with how much thyroid hormone is in your body. Normal TSH Level in Adults. The liver has the greatest regenerative capacity of any organ in the body, making it possible for surgeons to treat cancerous and noncancerous diseases with Mayo Clinic in Rochester is again ranked No. Formally, menopause is a period that begins once a woman's body is done having menstrual cycles. The pituitary is a gland in your brain that attempts to tell your thyroid how much thyroid hormone to produce. The condition occurs in about one to four of every 1,000 pregnancies, according to the National Institutes of Health. Educational text answers on HealthTap are not intended for individual diagnosis, treatment or prescription. T3, or triiodothyronine, is a thyroid hormone produced in small amounts by the thyroid gland. It is not intended to be and should not be interpreted as medical advice or a diagnosis of any health or fitness problem, condition or disease; or a recommendation for a specific test, doctor, care provider, procedure, treatment plan, product, or course of action. 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). The hypothalamus signals the pituitary gland, which sends thyroid-stimulating hormone (TSH) to the thyroid to trigger the release of thyroid hormones. often is recommended. Her free T3 was at the low end of normal and her reverse T3 was greater than 15. As we age, especially women, our thyroid function tends to slow down. To check your level of thyroid hormone. I also happen to formulate the best supplements on the market (well, at least in my opinion!) decreases, and the level of TSH increases to encourage the thyroid gland to The following table provides. Then, "the patients returned 2 hours after breakfast for their samples to be rechecked between 10:30-11:00 am on the same day.". 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. Can TSH levels fluctuate without medication? Still, other factors like age, hormonal changes, and medication variations may also alter your thyroid hormone levels, producing a variety of symptoms. 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". metabolism slows down. For example, a 29-year-old woman may have normal TSH around 4.2 mU/L, while an 88-year-old man may reach 8.9 mU/L at their upper limits. These small, almond-shaped glands are located in the neck, near or behind the thyroid gland. They can produce a significant change in thyroid status within weeks or months. For example, TSH naturally rises somewhat during colder months and drops back down in the warmest months. 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. I am a former Doctor of Osteopathic Medicine (no longer practicing) that now focuses on producing the information you see here while also formulating some of the best supplements on the market (in my HUMBLE opinion) :). P.S. The foods you eat hugely impact your thyroid function and your overall health. 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. Signs and symptoms will be expected to progress without thyroid supplementation such as with Synthroid. Hyperthyroidism: a condition where the thyroid gland is overactive and produces too much thyroid hormone. She was a non-smoker and mother of two (last childbirth 2 years previously). That is, sit and wait until your body destroys your thyroid gland from inflammation and autoimmunity, and then you will need thyroid hormone. I am a 57 year old female who has had hypothyroidism for 20 years. A normal Total T3 level in adults ranges from 80-220 ng/dL. Thyroid hormone levels may fluctuate over time. Drugs that interact with thyroid medication. May 18, 2020. At that point, Often, over time, the thyroid hormones and TSH eventually return to normal. This helps your cells get what they need, but it also may falsely make your lab tests look more normal than they really are. However, according to the American Thyroid Association, doctors generally consider levels are within a normal range between 0.4-4.0 milliunits per liter (mU/l). My wife is on thyroid medication, we are planning on starting a family. for several years, monitoring usually can switch to once a year. My doctor says I don't need treatment now, but she wants me to come back for regular checkups. This is where things can get a little more complicated. hypothyroidism and too much can cause side effects, such as increased appetite, Why do my TSH levels keep fluctuating? Taking your medication at the same time every day is essential. I was nervous about going on medication after only one blood test and so I asked for a second. Plus some labs are better and more reliable than others. If you notice a change in your symptoms, be sure to tell your healthcare provider, who might want you to have your thyroid hormone levels retested. If you are on generic medication, work with your pharmacist to ensure that you always get medicines from the same generic manufacturer. Tsh tests are very sensitive but often not real reproducible. TSH can fluctuate when HypoT is developing - I can understand your doctor's point. While this is a great thing for thyroid control at the cellular level, it can also make diagnosing hypothyroidism more difficult. Problems can be either short term and transient, or longer and chronic. Obviously, there is a better approach and that is to look at and evaluate all thyroid laboratory tests (in addition to the TSH) and treat if there is a combination of symptoms + abnormal lab tests (even if those abnormal lab tests are just antibodies). (former Osteopathic Physician). medication because too little levothyroxine won't adequately control Your MD is working through this with you. Having said that they can be quite helpful, especially if you are thyroid hormone naive (meaning you havent been on medication before). But what if there was a better way? Fluctuating TSH and Thyroglobulin Levels. This illustration helps explain (in addition to the differences in deiodinases, tissue level demands, etc.) Tsh is secreted in spurts and may vary depending upon when it's drawn. Since it's a signaling hormone, high TSH indicates that your body detects low hormone, so it's turning up the volume on the signal to make more. 1 in the world byNewsweekin its list of the "World's Best Hospitals." If you are incredibly sick in the ICU of a hospital, does it make sense for your body to put energy into growing your hair follicles or making your nails strong? Patients with low Free T3 (and high reverse T3): So why do Doctors care what the pituitary is telling your thyroid gland? Get prescriptions or refills through a video chat, if the doctor feels the prescriptions are medically appropriate. Around this time is when the free T4 level also begins to drop as well below the normal range. Some medications and supplements may also affect your results. It is important to follow your doctor's advice and not make changes to your medication without discussing it with the doctor. I'm Westin Childs D.O. Without pre-pregnancy thyroid disease: T3 and T4 tend to increase while TSH decreases during pregnancy. Why do I still feel sick? Putting these together, it would be safe to assume she had a conversion issue leading to disordered thyroid hormone processing. Increasing doses of Synthroid or Levothyroxine will certainly drop the TSH (remember there is no competition for reverse T3 in the pituitary) but may actually make thyroid function in the peripheral tissues worse due to T4 to reverse T3 conversion. 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 . If they respond well to treatment, however, their goal may rise to the normal . 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. Pregnancy can affect thyroid hormones in many ways. Leptin resistance and hypothyroidism both appear to be caused and sustained by calorie-restricted diets (chronic yo-yo dieting) which cause high reverse T3 and low free T3 levels leading to clinical hypothyroidism. If you want the car to go faster, you need more T3 and for that T3 to actually activate a T3 receptor site. 2011 Aug;7(4):679-84. doi:10.5114/aoms.2011.24139, By Mary Shomon determine the right dosage for you, your health care provider will regularly Standard treatment for hypothyroidism involves taking a daily oral medication called levothyroxine, a synthetic form of thyroid hormone. Most doctors agree that any TSH above 10, especially when combined with an abnormal T3 or T4 reading, should be. Well TSH turns out to be a quick and dirty way to diagnose both hypothyroidism and hyperthyroidism but it falls short when things get a little more complex. Outside factors may affect the results of your thyroid blood test. If the TSH level is elevated due to a thyroid related issue, you may need treatment. Lets go through some examples so you have a better idea of what I am talking about. What would cause TSH at 8 go down to a normal level a week and a half later withouth meds. Guidelines for the treatment of hypothyroidism: prepared by the American Thyroid Association Task Force on Thyroid Hormone Replacement. Hypothyroidism can affect the brain and lead to difficulty with concentration and memory. Disease progression can impact thyroid hormone levels. Ultimately, when it comes to taking your thyroid hormone drug, consistency is essential. Sometimes when you are taking thyroid medication, your thyroid hormone blood levels may change. T4 ~ 1.0. All I can say is this week has been a tough one with regards to anxiety. bodily functions. There are enzymes in your body, known as deiodinases, which really help to control and regulate thyroid hormone at the cellular level. But other factors, such as hormonal changes and medication variations, or significant weight gain or loss, can alter your thyroid hormone levels as well; in some cases progression of a thyroid condition (such as a nodule) may be responsible. I am 23 years old and my tsh level is 5.52 , if i donot take any medication , will that increase ? HealthTap uses cookies to enhance your site experience and for analytics and advertising purposes. These fluctuations happen because human chorionic gonadotropin (HCG), a hormone produced during pregnancy, stimulates the production of T3 and T4. Is it normal for TSH levels to drop from 19 to 8 without Levothyroxine? That can lead to a rise in blood cholesterol, increasing the risk of heart disease and cardiovascular events, such as heart attack and stroke. I like to think of it as the gas pedal to the car. 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? My TSH levels recently came back out of range. and I'm proud to say that over 80,000+ people have used them over the last 6 years. level is far too high, indicating your thyroid is not sending out enough thyroid, to support your body. You should take thyroid replacement or antithyroid medication on an empty stomach. In the case of standard hyperthyroidism, your TSH decreases. To learn more, please visit our. In addition, there are some other things to keep in mind when taking thyroid medication. Thyroid. symptoms of hypothyroidism include unexplained weight gain, fatigue and low Due to the natural course of the condition, As a response to significant changes triggered by the treatment (such as, Competing with the body's thyroid hormone activity, Increasing the effects of thyroid hormones, Altering medication absorption and activity. As this enzyme increases in activity, it can do a lot with a little and it can make what little thyroid hormone you have more effective by keeping it active inside the cell. Normal TSH levels for the average adult range from 0.4 4.0 mIU/L (milli-international units per liter) ( 3 ). #4. Hereditary factors, gender, radiation exposure and pregnancy all influence a person's likelihood of getting Hashimoto's . 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. This can change or stop ovulation (the release of an egg from the ovary). Get answers from Endocrinologists and top U.S. doctors, Our doctors evaluate, diagnose, prescribe, order lab tests, and recommend follow-up care. Hashimoto's Disease and Blood Sugar Imbalance How Oxalates Impact Your Thyroid Health Hashimoto's Flare-Up: One Day Meal Plan He checked my thyroid levels and my TSH was 7.36. But unless you check the reverse T3 level your free T4 may appear falsely normal despite the fact that your body is lacking thyroid hormone at the cellular level. All rights reserved. In simple words, it means that thyroid hormone gets inside the cell and directly turns on genetic transcription (it changes your DNA/RNA directly). A suppressed TSH is defined as any TSH level which is undetectable by standard lab testing assays and is usually reported as a value that is less than some specified amount. DEFINITION: WHAT DO THE FOLLOWING PATIENTS OVER THE AGE OF 60 YEARS HAVE IN COMMON? In the winter, your body may have difficulty keeping up with its hormonal needs, resulting in the TSH rise. If your thyroid isn't or cannot respond because it's compromised in some way, you'll produce more and more TSH. Sign up for our Health Tip of the Day newsletter, and receive daily tips that will help you live your healthiest life. It's important to receive the correct amount of this Some herbal supplements and medications can have an impact on thyroid hormone levels. Last month's labs stated I am now at a TSH of 2.77 they never bothered to test my T4's. Remember that T4 is simply a reservoir hormone for T3. Treatment. Hey von-1, I found the following extensive list of possibilities: There are various causes for thyroid levels to change or fluctuate: Thyroid hormones can very throughout the day - example if TSHPituitary and tsh. Doctors typically provide answers within 24 hours. Thyroxine (T4) is responsible for your metabolism, mood, and body temperature, among other things. Thyroid disease and pregnancy. of hypothyroidism, called subclinical hypothyroidism, are associated with an 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. These attacks make your thyroid less able to produce thyroid hormone on its own. In this way, D2 helps regulate how much thyroid hormone each cell gets by activating or inactivating thyroid hormone as necessary. Do TSH levels fluctuate during menstrual cycle? The downside is that unlike other tissues in the body the pituitary is the MOST sensitive tissue to thyroid hormone in your body. These fluctuations can occur as your thyroid disease progresses. Overactive reflexes. Dr. Maritza Baez and another doctor agree. Think of your pituitary gland as a thyroid thermometer: Abnormally high TSH levels usually mean that your thyroid is underperforming. 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. These hormonal fluctuations can produce a variety of symptoms. Check out my own personal health story. Can You Eat Soy If You Have a Thyroid Condition? Have your T3 and T4 levels tested, if you haven't already. 29 year old male, 6'5" 230lbs, very active, very fit, don't drink, don't smoke, and no hypothyroidism symptoms but I was recently diagnosed with hypothyroidism in November of 2020. . These levels are influenced by many factors that affect protein levels in the body, including medications, sex hormones, and liver disease. Hypothyroidism The second set of tests in February 2020 were: TSH = 18 / T4 = 1.0 . But high thyroid hormone levels with low or high TSH can develop as well. The ranking is a tribute Moreyounger adultsare being diagnosed with colon cancer also known as colorectal cancer and at more advanced stages of the disease, says the American Science Saturday: Researchers elucidate details about the role of inflammation in liver regeneration, Mayo Clinic again recognized as Worlds Best Hospital in Newsweek rankings, Mayo Clinic Minute: Why millennials should know colon cancer symptoms, Mayo Clinic Minute: How the thyroid affects the heart, Study finds similar cardiovascular outcomes for generic, brand-name drugs for hypothyroidism, Consumer Health: Understanding hypothyroidism, Womens Wellness: Hypothyroidism and pregnancy, Mayo Clinic Minute: Postpartum depression is different than baby blues, In the Loop: Fun with Mayo Mayo Clinic in pop culture, a retro retrospective. Hypothyroidism can affect many different systems in your body. Postpartum Thyroiditis and Related Issues After Pregnancy, Guidelines for the treatment of hypothyroidism: prepared by the American Thyroid Association Task Force on Thyroid Hormone Replacement, Alternating hyperthyroidism and hypothyroidism in Graves' disease, Postpartum thyroiditis: management and treatment, Drugs that interact with thyroid medication, Data mining: seasonal and temperature fluctuations in thyroid-stimulating hormone, Alternations in thyroid hormone levels following growth hormone replacement exert complex biological effects. Do not copy or redistribute in any form! This would indicate, at least subjectively, that the ideal TSH (provided the disease is not present in any form) is somewhere around 1.0. Go see your doctor and seek medication to correct your problem which can become serious if you do not do what I have said. Ask him to test TPO ab and Tg ab. Thyroid Hormone Preparation. TSH levels fluctuate throughout pregnancy. Follow-up appointments are important to monitor hypothyroidism over time, however. So lets say you are convinced that your thyroid is suboptimal and youd like to prove it. Tsh level is 0.023 Dr lowered medication to 77mcg from81 mcg. Suppression of thyroid-stimulating hormone (TSH) after thyroidectomy for low-risk cancer can increase the risk of osteoporosis in women without cutting back on cancer recurrence, according to. When assessing thyroid function, thyroid hormone levels particularly free thyroxine (FT4) levels consistently show stronger associations with a wide array of clinical . Some known interactions occur between thyroid medication and corticosteroids, cholesterol-lowering drugs, corticosteroids, amiodarone, and lithium. The answer depends but usually is made clear by checking reverse T3 levels. TSH levels change inversely with how much thyroid hormone is in your body. It can affect the gastrointestinal system, too, causing less frequent bowel movements and constipation. 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. TSH can vary wildly based on your age, sex, and stage of life. What causes blood pressure to go down while the heart rate goes up with exercise. 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. In lay terms, it reduces your metabolism or the number of calories that you burn on a daily basis. My antibody tests came back fine, my T3 and T4 levels were fine and my TSH was within a perfectly normal range. body. 2 High TSH levels can mean that your thyroid is sluggish and underactive because there is not enough T3 or T4 being produced. Without TSH, the system would fail. the condition may not produce any noticeable symptoms. What Do Herpes Sores Look Like at Different Stages. Therefore, if you maintain the same treatment dose, your thyroxine (T4) and triiodothyronine (T3) thyroid hormone levels can drop. 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. Most people who develop hypothyroidism after radioactive iodine treatment can expect to take some form . My tsh level shows 13. but my doctor is not putting me on any medication.he says he wants to wait an watch.is this normal to do? Basically what happens is your body decreases the amount of free T3 and increases the amount of reverse T3 in your body. However, in some women, the increase can be too drastic, leading to hyperthyroidism. . #supplements #lifestyle #medication #thyroid doctors #symptoms #hashimoto's #blood tests #diet & recipes 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. Since TSH is secreted in a pulsatile manner, TSH levels also fluctuate over minutes. And this is good, but what is important here is that each tissue has a different demand for thyroid hormone depending on the situation. If your TSH is suppressed it will come back as < 0.005 or < 0.001 or something similar. This TSH is elevated at > 3.0 which most physicians would agree is suboptimal (in fact some providers have recommended we change the range to include anything > 2.5 as abnormal(6)). In the most basic sense as leptin levels and insulin levels increase, the body preferentially converts T4 to the inactive thyroid metabolite reverse T3. You start titration with Natural desiccated thyroid and after 2 months your TSH drops to 1.0 on 2 grains (130-135mg) of NDT. But in order to understand how to evaluate your TSH, you need to understand that there is a huge difference between being normal and being optimal. However, when that happens, your T3 and T4 levels may decrease (while your TSH rises). Verywell Health's content is for informational and educational purposes only. How likely would you say I am positive for hashi's I've never been tested yet. Tsh level is 0.023 dr lowered medication to 77mcg from81 mcg. This liquid solution containing just three hypoallergenic ingredients (levothyroxine, glycerol, and water), is sold in single-dose ampules. If this is the case, then these ranges may be helpful for you: As you can see testing for hypothyroidism is far more complex than just testing the TSH (and maybe the free T4). All laboratory results need to be interpreted in the clinical context and the doctor who ordered the tests is usually in the best position to do that. More information is needed in order to answer the question. A 30-year-old woman presented for the first time in August 1990 with signs and symptoms of hypothyroidism: weight gain, fatigue, and muscle aches. Doctors typically provide answers within 24 hours. Switching to a new brand of thyroid medication may lead to fluctuation in thyroid levels as your body adjusts.. LaurieShay 6 May 2011. Does this mean I don't have Hashimotos anymore? Patients with little or no residual thyroid function require replacement doses of LT4 at approximately 1.6 g/kg/d, based on lean body weight. 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. Welcome to my website! What tests do you need and how do you interpret the results? Total T4 and Total T3 levels measure bound and free thyroid hormone in the blood. After that, blood levels generally The thyroid gland is a small butterfly-shaped gland in the front of the neck that makes the hormones triiodothyronine, or T3, and thyroxine, or T4. Interestingly, TSH increases during the colder winter months and decreases during the summer months. Levels of TSH and Free T4 were evaluated during the course of treatment in a STUDY entitled "The Effects of Simvastatin on the Serum Concentrations of Thyroid Stimulating Hormone and Free Thyroxine in Hypothyroidism." Forty-one patients taking 20mg of simvastatin were evaluated and their levels of Free T4 (FT4) and TSH were studied. I go to great lengths to help my users better understand their health; however, the content you see here is not a substitute for medical advice. Inflammation of the thyroid gland can disrupt normal thyroid hormone levels in numerous ways. 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. 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 . Standard treatment for hypothyroidism involves taking a daily oral medication called levothyroxine, a synthetic form of thyroid hormone. A biopsy would confirm possible Hashimoto's thyroiditis. Have you had your other lab tests evaluated? face, muscle weakness, hoarseness, and joint pain or stiffness. However, during the period of thyroiditis, your doctor may prescribe thyroid hormone replacement or antithyroid medications. results. To start with I have never seen a healthy individual with a TSH > 1.0. Specific medications may interfere with your thyroid function and absorption of thyroid medication. PTH controls blood levels of calcium, phosphorus, and vitamin D. The parathyroid glands produce more PTH when calcium levels in the body are low. In some cases, after months or years of taking antithyroid medications, your condition cango into remission. Keep your follow up appointment an As of february 2010, at most laboratories in the U.S., the official "normal" reference range for the thyroid stimulating hormone (TSH) blood test runs What causes tsh level to go up and down without medication? This hormone is at the center of your digestive and . Yes, TSH can go back to normal. TSH can vary wildly based on your age, sex, and stage of life. That means a 100-mcg pill can be considered potent even though it delivers anywhere from 95 mcg to 105 mcg of the active ingredient. The reasons that TSH levels can fluctuate is mainly due to levels of T3 or T4 in your blood. She also has hashimotos syndrome. Potency tends to be reasonably stable within a particular brand name or generic manufacturer. My TSH and Thyroglobulin numbers were way different from 4 months ago and I am wondering what they mean. Some surprising foods can also negatively affect thyroid function. If your TSH, T3, and T4 levels are all low, you might have a pituitary gland disorder. Is identical to that produced in the human thyroid gland; T4 has higher serum levels, slower metabolic clearance, and a longer half-life than T3; Example: Levothyroxine sodium tablets Check out my thyroid supplements. Hyperthyroidism is usually caused by Graves' disease (an autoimmune disorder) in expecting moms, where the immune . However, this test can often time be misleading, as levels of circulating hormones may fluctuate at different times, such as in Hashimoto's, the person affected may fluctuate between highs and lows. There was no history of thyroid disease or drug consumption. Sign up to receive 20% off your first order. When hyperthyroidism develops, free thyroxine (T4) and free triiodothyronine (T3) levels rise above normal. And we are going to talk about it in detail below. Depending on your condition, these potency variations can cause mild increases or decreases in your T4, T3, or TSH.
George Grizzard Cause Of Death,
Bubble Tea Consumption Statistics Australia,
Yavapai County Assessor Property Lookup,
Articles F