What if telogen effluvium is caused by stopping Ryeqo (hormonal contraception) after 2 years and having Mirena (levonorgestrel-releasing intrauterine system) inserted, and also being put on 25 mcg levothyroxine, with a history of mild hypoferritinemia (ferritin 49.82 ng) and normal thyroid function (TSH 1.5, FT4 15.4)?

Telogen Effluvium Following Ryeqo Discontinuation, Mirena Insertion, and Levothyroxine Initiation

Your telogen effluvium is most likely triggered by the hormonal transition from stopping Ryeqo and inserting Mirena, compounded by borderline-low ferritin (49.82 ng/mL), while the 25 mcg levothyroxine dose is appropriate given your normal thyroid function and should not be contributing to hair loss.

Primary Trigger: Hormonal Contraceptive Changes

The abrupt cessation of Ryeqo (relugolix combination therapy) after 2 years followed by Mirena insertion represents a significant hormonal shift that commonly precipitates telogen effluvium. 1, 2

• Telogen effluvium typically manifests 3-4 months after a triggering event, which aligns with hormonal medication changes 2
• Both starting and stopping hormonal contraceptives are well-established triggers for diffuse hair shedding 1, 3
• The transition from systemic hormonal suppression (Ryeqo) to localized progestin delivery (Mirena) creates a physiologic stress on hair follicles 2

Levothyroxine Assessment: Not a Contributing Factor

Your current levothyroxine dose of 25 mcg is appropriate and should not be causing telogen effluvium given your normal thyroid function (TSH 1.5, FT4 15.4). 4

• With TSH of 1.5 mIU/L and normal FT4, you are euthyroid and properly treated 4
• Hypothyroidism itself can cause telogen effluvium, but your thyroid function is well-controlled 2, 3
• The 25 mcg dose is a conservative starting dose that avoids overtreatment, which could theoretically worsen hair loss through iatrogenic hyperthyroidism 4
• Do not discontinue or reduce levothyroxine, as maintaining euthyroid status is essential for hair recovery 4

Critical Nutritional Factor: Suboptimal Ferritin

Your ferritin level of 49.82 ng/mL is below the optimal threshold for hair health and represents a significant contributing factor to your telogen effluvium. 5, 6

• While not technically "deficient" by standard laboratory ranges, ferritin levels below 70-80 ng/mL are associated with telogen effluvium 5
• Iron stores are preferentially diverted away from hair follicles during periods of physiologic stress 5
• Increase your iron supplementation beyond what you're currently taking, as ferritin optimization is one of the few evidence-based interventions for telogen effluvium 5

Specific Ferritin Management:

• Target ferritin level of at least 70-80 ng/mL for optimal hair recovery 5
• Add elemental iron supplementation (ferrous sulfate 325 mg daily or equivalent) taken with vitamin C to enhance absorption 5
• Recheck ferritin in 8-12 weeks to assess response 5
• Your current vitamin D3/K2, B12, selenium, and zinc supplementation is appropriate and should be continued 5, 6

Supplement Regimen Evaluation

Your current supplement regimen is generally appropriate, but requires iron optimization. 5, 6

Currently Adequate:

• Vitamin D3 (3000 IU) and K2: Appropriate dosing 6
• B12 (3300 IU neuromultivit): Adequate for hair health 5
• Selenium (200 mcg): Within therapeutic range 5
• Zinc (25 mcg): This appears to be a dosing error—zinc should be 25 mg, not mcg 5, 6
• Omega-3, berberine, copper: Supportive but not primary interventions 5

Requires Addition:

• Add elemental iron supplementation to raise ferritin above 70 ng/mL 5
• Consider vitamin C supplementation (500-1000 mg) if not already included, as it may have preventive value for stress-related hair loss 6

Expected Timeline and Prognosis

Telogen effluvium from hormonal changes typically resolves spontaneously within 6-9 months once the triggering factor stabilizes, provided nutritional deficiencies are corrected. 1, 2

• Hair shedding should gradually decrease as your hormonal status equilibrates on Mirena 1
• Visible hair regrowth typically lags 3-6 months behind cessation of shedding 2
• Chronic or recurrent telogen effluvium may occur if ferritin remains suboptimal or if additional stressors emerge 3

Critical Monitoring Parameters

Track both clinical response and laboratory markers to ensure recovery. 5, 2

• Recheck ferritin in 8-12 weeks after initiating iron supplementation 5
• Monitor TSH and free T4 every 6-12 months to ensure continued euthyroid status 4
• Document hair shedding patterns (daily hair counts or hair wash test) to objectively assess improvement 1
• Watch for trichodynia (scalp pain/burning), which may indicate autoimmune-type telogen effluvium requiring different management 3

Common Pitfalls to Avoid

• Do not stop levothyroxine, as maintaining euthyroid status is essential for hair recovery and your dose is appropriate 4
• Do not accept ferritin of 49.82 ng/mL as "normal" for hair health purposes, despite being within standard laboratory reference ranges 5
• Do not expect immediate improvement—telogen effluvium has a delayed response pattern, with shedding potentially continuing for 3-4 months before improvement 2
• Verify your zinc dose is 25 mg (not mcg), as inadequate zinc supplementation may perpetuate hair loss 5, 6
• Avoid starting multiple new treatments simultaneously, as this makes it impossible to identify which intervention is effective 1