Sunday, January 29, 2012

Hypothyroid? Post Menopoausal? PCOS? A complicatd case...

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My hair falls out like crazy, my periods have been irregular for 20+ years, I have started breakthrough bleeding, my pubic hair is falling out, I've gained a LOT of weight over the years, and my skin is incredibly dry.  My mother and three sisters have hypothyroidism.  I've had my thyroid checked many times over the past 5 years.  Twice the TSH level was undetectable, it was so low, and the last two times it was 3.45 then 2.0.  Any ideas why I am having these symptoms?  Also my internist ran an FSH test that came out at 30.65, and he says I am post-menopausal (so did the gastroenterologist I saw), but I am having periods and breakthrough bleeding.  Why do they think I am postmenopausal?

Gender: Female
How tall are you (feet and inches)?: 5' 3"
What is your weight in pounds?: 280
How old are you?: 47
How long has this been going on?: More than a year

Check all symptoms you are currently experiencing:
Diarrhea
Genitourinary
Describe associated symptoms not listed above: Hair loss (everywhere), irregular periods, breakthrough bleeding, extremely dry skin

What have you done so far to remedy this condition? Please include tests and relevant studies here.

My doctor is testing me for cushing's disease and PCOS, but no results yet. I have had several thyroid tests and they have come back all over the place; two came back with no TSH level at all and two came back with levels of 3.45 then 2.0.  He said my testosterone level came back at 137.

Please list any chronic medical problems and also list any prior surgery: Mixed connective tissue disease, asthma, sinus problems, severe allergies(inhalation/food/
medicines), hypertension, GERD, low vitamin D and B-12 levels, atrophic gastritis not caused by H-pylori bacteria
 
Surgeries include:  Sinus surgery (deviated septum) 1997, tonsillectomy 1995, and foreign body removal from right foot (glass) 2011
Procedures include colonoscopy and EGD done 12/2011
Check all conditions present in your immediate family... :
Asthma / Lung Problems
Cancer
Cardiac Disease
Diabetes
Hypertension
Please list any medication allergies that you have : : Medical Glue (anaphalaxis)
Iodine
Penicillin
Tylox
Please list any medications you are currently taking (and dosage if known) :: Advair 250/50 b.i.d.
Proventil HFA prn
Protonix 40 mg q.d.
Gaviscon prn
Diovan 160 mg q.d.
Norvasc 10 mg q.d.
Flonase b.i.d.
Triamcinolone Acetonide Cream 0.1% b.i.d.
Plaquenil 200 mg b.i.d.
Ibuprofen 800 mg b.i.d.
Vitamin B12 1000 MCG q.d.
Vitamin D 2000 MCG q.d.
Allergy shots QWK
Zyrtec 24 hr q.d.
Epi-Pen 0.3 mg prn

When was your last menstrual cycle?: 4 weeks ago
Are you currently using or do you have a history of tobacco use?: No
Are you currently using or do you have a history of illegal drug use?: No
Please describe your alcohol consumption :: Never

HOW QUICKLY DO YOU NEED THIS TO BE ANSWERED?: Within the next few days

1) I'd like to know if you have any suggestions as to what's causing my symptoms.  Could I have hashimoto's thyroiditis?  Why does my thyroid test normal while I'm having these symptoms?

2) Why does my doctor think I am post-menopausal when I am still having (albeit irregular) periods?
_________________________________
I think your doctors are concerned about the bleeding and that you make an assumption that this is menstrual bleeding when it is likely to be from another cause. As you can see from this link here yours is a problem that NEEDS a correct answer. You may have PCOS, and it may be that you need a uterine biopsy to rule out cancer. You could have uterine fibroids
 
But as to the FSH question your level of 30+ would be very suggestive of menopause as you can see from this very good Web MD article.  To quote the relevant portion....

"...the most important test used to diagnose premature menopause is a blood test that measures follicle stimulating hormone (FSH). FSH causes your ovaries to produce estrogen. When your ovaries slow down their production of estrogen, your levels of FSH increase. When your FSH levels rise above 30 or 40 mIU/mL, it usually indicates that you are in menopause."
 
However, your case is more complicated with the thyroid issue being thrown in. I hope I have given you a good starting point in your search for answers, and a good starting point for the other docs on MD STAT to jump in and respond as well. We will keep at this question as it is a very complicated one and one that needs to be answered. That being said, it sounds like your doctors are taking very good care of you and it seems that they are zeroing in on a unifying diagnosis.... one diagnosis that explains everything... most problems CAN be explained this way and it's what look for before considering multiple diagnoses. 
 
Keep checking back with us and you may want to subscribe to the this thread as you will then be informed when a new post has been made. 
 
Be well.  
 
 

15 comments:

MDSTAT_InternalMed_Doc 1 said...

What a wild ride.

First, at it's basic level you're having some serious endocrine systemic issues.

Next, you are having MULTIPLE endocrine systemic issues, and I think it's important to not think about these issues as unrelated singularities but as a grouped problem.

Hormones from any source rely on a balance from the other sources of hormones. Hormones (be it estrogens, androgens, thyroid hormones, etc) all compete for space on blood proteins and a change in output from one area (especially if abrupt) will affect the others.

Ok. Almost all of your symptoms can be due to hyperthyroidism., but your lab signs don't all add up to just that and include what MIGHT be premature ovarian failure (early menopause). Your bleeding might have nothing (or everything) to do with perimenopause. You have a history of mixed connective tissue disease. Perhaps your autoimmune disease is lighting up your endocrine system or parts thereof. .

I'm going to cut to the chase on your case, because I could conjecture all day and night long.

I think your doctor needs to not mess around with this and get you to a good endocrinologist who can make close communication with a good rheumatologist. Your answer lies somewhere within a workup by both I think. Furthermore, if you are close to a university-based medical group with multi-specialties, it's all the better.

I believe that I could ask you questions all day long, but it would just take longer to get to what it is that I think you really need.

Your family doc/ internist doesn't have the time to embark on this workup and do you a good service. Trust me on this. If your primary doc does a lot of workup, he/she is only going to end up sending you to these specialists and the wheel will be created again.

That's my two-cents worth.

IM doc

space doc said...

Dear medical mystery woman: Alot of stuff going on!!

1) Possible hypothroidism.

Hair loss, weight gain, dry skin, strong !! family history of hypothroidism and a low TSH. I wonder if you had a free T-4 &/or a free T-3 blood test done? If these were low as well as the TSH it certainly could be hypothyroidism secondary to a benign pituitary adenoma. An MRI of the pituitary could shed some light on that.





2) testosterone about twice the normal for women.

In women most of the testerone comes from DHEA
converting to testosterone in the fatty tissue (50%) and from the adrenal glands (30%) and ovaries (20 %). It is good that your doctor will be checking for Cushing's dis.---if the cortisol level is high and the ACTH level is also high, this could also be related to a pituitary cause.( (A blood prolactin level sometimes helps the diagnosis)

3) FSH (30.65--elevated). This is certainly elavated in menopause, but with some irregular bleeding going on I would agree with Doc # 1 that a gyn check with the possibility of biopsy would be a good idea.
There are also cases where elevated levels of FSH can come from pituitary adenomas.

4) possible polycystic ovaries.

Good that you are getting this checked out also. Polycystic ovaries are often associated with irregular uterine bleeding. An ultrasound can usually pick this up. Polycystic ovaries are frequently associated with an excess of body hair (hirsutism) rather than rthe losing of body and scalp hair that you have experienced.

5) In summary:

Keep in mind the possibility of a pituitary cause for the hypothyroid symptoms (free T-4 & ? MRI)
Possibility of Cushing's being either from the adrenals--or the pituitary.
PCOS--You've probably had your ultrasound along with the FSH and LH
Increased testerone can come from the adrenals and the ovaries--so it's good you are getting both these areas checked out .

Best of Luck! Would love to hear how this all works out.

Space Doc

Anonymous said...

Thanks for the answers, y'all are simply wonderful! I already have an excellent rheumatolgist, and my internist has said that when all of the results come back, even though I have seen every specialist in the county, he's probably going to send me to an endocrinologist. I am seeing an OB/GYN tomorrow morning. I will let you know what I find out, and will try to get copies of my test results to post here. Thank you again!

Anonymous said...

PS No ultrasound done. Internist did not suggest it. Should I ask the OB/GYN about this?

MDSTAT_ER_DOC_1 said...

Juliet,
See how fast the spam goes away? And bovine supplements are for body-building cows dear.

space doc said...

Dear Anonymous:

Great that you will be getting to see an endocrinologist.

With all the things that need to be looked into I don't think there is any hurry to get an ultrasound, but that is something you can definitely check with your gynecologist about.

Sounds like you are on your way to getting some solutions.

Please do keep us posted on how things are turning out.

P.S. I just saw a note from Med Doc 1 to a Juliet about Spam and body-building for cows---I dont't think this is anything pertinent to your enquiries---but we can check to see if his mind has gone out to pasture with the cows!! (maybe he's trying to become spaced-out doc?)

All our best!
Space Doc

space doc said...

Dear Anonymous:

Great that you will be getting to see an endocrinologist.

With all the things that need to be looked into I don't think there is any hurry to get an ultrasound, but that is something you can definitely check with your gynecologist about.

Sounds like you are on your way to getting some solutions.

Please do keep us posted on how things are turning out.

P.S. I just saw a note from Med Doc 1 to a Juliet about Spam and body-building for cows---I dont't think this is anything pertinent to your enquiries---but we can check to see if his mind has gone out to pasture with the cows!! (maybe he's trying to become spaced-out doc?)

All our best!
Space Doc

Anonymous said...

Alright, so the OB/GYN was unconcerned with the FSH level because he said it was taken in the 1st week of my cycle, and that I was probably ovulating, which would make it high. I saw him today, which is the 3rd week of my cycle (according to him) and he says now is a perfect time to take the FSH level again, so he did. He also ran another thyroid test and told me to definitely see an endocrinologist. He also scheduled an ultrasound without me even asking about it. I have that on Thursday, and then go back in a week for a discussion of all the test results; will post the update then (and also when I see the endocrinologist). Thanks again!

Wendy said...

I love bovine thyroid and it is one of the best thyroid supplements I've ever had.

space doc said...

Dear Wendy:

Thanks for the input . I think Med Doc 1 not only likes the bovine thyroid but I think he has a thing for the whole cow!

Thanks again,
Space Doc.

space doc said...

Dear Anonymous:

Looks like you're well on the way to getting some answers.

Look forward to hearing about the results as they come in!

Keep up the good work!

Space Doc

Anonymous said...

Update: I had the ultrasound done on Thursday. I made an appointment for 02/10 to go over the results. I got a message on Friday evening @ 5:00 PM to call on Monday morning because "the doctor needs to see you immediately."

space doc said...

Dear Anonymous,

Got our fingers crossed!!

Good Luck!!

Space Doc

Anonymous said...

OB/GYN says I need a uterine biopsy to rule out cancer. I'm okay with that; he also recommended an endometrial ablation, but didn't explain anything about it. After researching this, I'm not so fine with it. What are your opinions on this? He says I am definitely not menopausal. FSH was 12.89 in the 3rd week of my cycle. TSH was 1.64 (lowest level so far, but OB says you can take a TSH level from someone three times in a day and get wildly varying numbers anyway), Total T3 was 120, Free Thyroxine was 0.72, and the Estriadiol Serum... was 179 pg/mL (hope these make sense; I'm copying directly from test results.

Anonymous said...

Meanwhile, my testosterone level came back at 137, and the internist says this is normal. Is it? My cortisol results are as follows: cortisol urine free level is 7.9 then it says creatinine urine 161, creatinine urine 1449, cortisol, urine free 8.83 ug/L aand finally cortisol 5.48 (I can scan the results and email them if necessary). These were flagged as low: Hemoglobin 12.0, Hematocrit 37.9, MCH 26.5MCHC 31.7 and my RDW was flagged as high with a value of 15.0, along with my IG Auto Count which was high @ 0.5. It says "Anisocytosis occasional polychromatophilia" and "adequate platelet estimate" and "occasional large plt" on the bottom. I have no idea what any of these mean, but thought maybe y'all would interpret for me. Thanks again so much!!