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CC: Fatigue, Hypothyroidism, and Hashimoto’s Thyroiditis

Alexandra was a 34 yo female with significant fatigue. She had been diagnosed with Hashimoto’s thyroiditis and associated hypothyroidism after the birth of her fourth child. She began taking levothyroxine thyroid supplementation but never regained her original level of energy. At first, there were many reasons to be fatigued - some mild anemia from the birth of her daughter, a new baby who didn’t sleep very well, a hectic schedule with work and little kids at home, etc. Her thyroid lab tests became “normal,” so she continued her current dose and hoped things would get better with time.

Now, her baby is two years old; she is sleeping through the night and feels like she should be feeling better. She just had a clean bill of health from her primary care doctor, including general blood work and a thyroid check which he reported as “perfect.” Alexandra continued to feel that something was wrong. She had difficulty exercising, had new issues with constipation, couldn’t lose weight, had flakey dry skin, and felt that her battery had simply run out of juice. She knows the fatigue of being a working mom, but this felt unique and worrisome to her.

Her lab work:

‍Additional History:

With four little kids at home, her diet has been heavy in simple carbohydrates and ready-made meals for the last few years. In a typical week, she eats pizza, sandwiches, fish sticks, and maybe 1-2 salads.

She sleeps 7-8 hours a night, but it is often interrupted 1-2x by her children.

She is trying to exercise every day for at least 30 minutes. Activities include taking the baby for a stroller walk, hiking with friends, and yoga classes.

Lab Analysis:

Alex’s lab work points to three core issues that are contributing to her fatigue:

1. Above Target TSH: Although her TSH and Free T4 fall within the standard reference range, they are not in an optimal range. TSH levels can vary widely by age. Although there continues to be controversy surrounding specific age-appropriate TSH targets, there is a general consensus that a young female should have a TSH of less than 2.5 (1). Her T4 is right at the lower range of normal. The combination of the low T4 with the above target TSH suggests that she would benefit from a higher dose of levothyroxine.
2. Low T3: Her Free T3 falls outside of the normal reference range. Her low T3 is likely the combined result of insufficient T4 supplementation plus poor conversion from T4 to T3. To better analyze this, I could have obtained a reverse T3 to see how much of her available to T4 was being converted to the inactive reverse T3. She has evidence of inflammation and deficiencies in B vitamins, both of which can inhibit the successful conversion of T4 to T3.
3. Evidence of Inflammation: Although many reference ranges have a CRP of less than 8 or 10 as normal, a CRP over 3.0 suggests a level of systemic inflammation that is associated with cardiovascular disease and other illnesses (2). The CRP marker can vary significantly from day to day, so if inflammation is a significant concern, it is recommended to recheck it a few weeks later and confirm a consistent elevation. I had a copy of the lab work from her physical just a month prior, and her CRP was also slightly elevated at that visit at 4.8, suggesting a chronic low level of systemic inflammation. Her Omega 3 index was also low, which can contribute to inflammation and is associated with cardiovascular disease (3) (4). Her diet is deficient in Omega 3 foods (fish, chia seeds, flax seeds, etc.) and high in Omega 6 foods (corn, poultry, etc.).
4. Low B vitamins: Her Folate RBC was low, suggesting a deficiency in her Folate. Her serum B12 was in the normal range, but methylmalonic acid, a more sensitive marker for B12 deficiency (6) was elevated. Blood levels of B12 can vary significantly based upon recent ingestion of B12 supplements or foods containing B12. Methylmalonic acid is a compound whose degradation is dependent on sufficient cellular levels of B12 and begins to build up when B12 levels are low. Taken together, these labs suggest a deficiency of B12 and Folate.

Interventions:

• Increase Levothyroxine dosage
• Start Ashwagandha supplement to aid the conversion of T4 to T3 (7)‍
• Start a multivitamin that contains selenium, zinc, and adequate B vitamins. In this patient, I chose Mitcore by Orthomolecular. Mitocore has adequate Folate but not quite enough b12, so I also asked her to take a B12 lozenge of 1000 mcg three times a week
• Start a fish oil supplement at 2 grams of combined DHA/EPA a day.
• Encouraged her to increase exercise to the point of breaking a sweat 3x a week
• Encouraged her to cut back on processed carbohydrates and sugar and set a goal of at least four servings of vegetables and fruits daily and some protein with every meal.

Outcomes and Follow Up Labs 3 months later:

At our follow-up visit three months later, Alex was feeling significantly better. While she was still not the “energizer bunny,” she felt much closer to her usual self. She was no longer constipated and was back to exercising. Her lab work had improved significantly, and her thyroid labs were now within the target range. Her B vitamin and Omega 3 labs, although not ideal, were trending towards normal.

This case demonstrates how powerful using optimal reference ranges and evaluating the whole thyroid hormone panel can be. It also highlights how someone’s nutrient status, diet and overall lifestyle can affect thyroid function. Alex knew something was wrong and was beyond relieved to find the root cause of the problem. This case highlights the importance of pushing past “normal” lab values to dig deeper.