Need help solving fatigue. Very high Reverse T3, low-ish cortisol.

[miked123]

Hi folks,

Been on TRT and with Defy since Thanksgiving 2016. Primary goal was to solve fatigue problem, with libido being a secondary goal.

Unfortunately, I haven't really gained a lot of ground. Energy during the morning and day is below average, with it dropping off significantly in the evening. Upon starting my protocol, the incessant yawning I would experience around 5-6pm everyday went down to a trickle, but energy levels have barely improved. When I get home from work, I just want to veg out on the couch.

Libido is essentially unchanged. I did have a honeymoon period of crazy libido, but it has since gone back to normal. Dr. Saya put me on low dose Anastrozole, as my first blood work after 6 weeks showed high E2 (61). That turned me psychotic and I have since lowered my dose (and HCG dose) and ditched the AI, and these latest labs show E2 (41) in a much better spot.

I really want to improve energy levels and climb out of this fatigue funk. I lift weights regularly, count calories and macros, and have lost a few pounds and gained a little muscle since starting TRT. Sleep could be better, but I have had bad fatigue for the last 4 years and during that period there would be times when sleep was dialed in and fatigue remained the same.

I am unsure what to investigate next. Reverse T3 is very high (no infections, sickness, or stress at time of test). Free T3 is slightly below mid range. TPO is high, although been dropping from a high of 54 at the start of TRT. Cortisol is lowish, with first sample good but remaining 3 low. Any suggestions would be appreciated.

Current protocol:

18mg Test Cyp daily
100iu HCG daily
500mg Metformin 2x

DHEA
Selenium
NAC
Ubiquinol
fish oil
B12
B6
Vit C
Vit D
Vit E
Vit K
magnesium
iron

Salivary Cortisol x4 - 5/30/17
Blood work - 6/15/17

 

[Vince Carter]

Thyroid isn't quite my thing we need some one to weigh in on those antibodies thats what stands out for me...any past talk about Hashi's for you?

 

[miked123]

Don't know about Hashimoto's disease, but had a thyroid ultrasound right before starting TRT and it was negative.

 

[miked123]

Bump.

I have a follow up with Dr. Saya on Monday, anyone have any insight into what these labs might suggest in relation to fatigue/low energy?

 

[HarryCat]

The elevated TPO antibodies means there is probably some sort of autoimmune disease present. Could be autoimmune thyroiditis, or Hashimoto's, but elevated TPO ab can also be caused by other autoimmune diseases. The high reverse T3 certainly indicates something is going on that your body is interpreting as stress.

The usual treatment would be to take a T4 or NDT medication.

Some patients have found switching to a gluten free diet to be helpful as an adjunct to thyroid hormone treatment. Do a search on diet and Hashimoto's.

 

[miked123]

The elevated TPO antibodies means there is probably some sort of autoimmune disease present. Could be autoimmune thyroiditis, or Hashimoto's, but elevated TPO ab can also be caused by other autoimmune diseases. The high reverse T3 certainly indicates something is going on that your body is interpreting as stress.

The usual treatment would be to take a T4 or NDT medication.

Some patients have found switching to a gluten free diet to be helpful as an adjunct to thyroid hormone treatment. Do a search on diet and Hashimoto's.

Thanks for the response. Do you think there are other reliable tests to run to give a wider perspective on what may be happening with the thyroid?

 

[HarryCat]

Thanks for the response. Do you think there are other reliable tests to run to give a wider perspective on what may be happening with the thyroid?

You're going to be talking to one of the top minds in hormone treatment and overall men's health on Monday. I'd just try to relax, enjoy the rest of the weekend as best you can, and see what he has to say.

 

[Nelson Vergel]

I created this panel for fatigue diagnosis:

https://www.discountedlabs.com/comprehensive-fatigue-panel

For ExcelMale members: 15 % off coupon (one time use): 15percentoff

 

[Vettester Chris]

Yes, definitely stuff going on with RT3, which can stem from many areas, including illness, fatigue, imbalances, and other stress markers as indicated by HarryCat. The other criteria is measuring the FT3/RT3 ratio. Anything > 20 is ideal, yours is at 11.5, obviously confirming there's an issue. Also, keep in mind, the body will shift the demand for RT3 when Free T3 starts pooling, meaning it is 'not' adequately reaching the cells of the body. The two (2) primary markers to look at it cortisol and iron/ferritin (other electrolyte areas important too).

My initial take is you have some adrenal issues taking place (?). You will find many of the top adrenal specialists like Dr. Lam and Dr. Wilson note that A.M cortisol should be right towards the top of the reference range, call it 90% or even more. Yours is sitting at 60.8%. The two mid-day labs just drop to the bottom from there, below reference range (which is the two (2) that DiagnosTech will focus on when evaluating adrenal fatigue), and PM just barely hangs on at the bottom end of the ref. range. There's no DHEA correlation, which I don't think LabCorp provides (?), but my opinion is that you're somewhere in the Stage 5 to Stage 7 Adrenal Fatigue, based on Total Burden values and your circadian profile.

So, I'd say there's probably a very 'good' chance that your thyroid situation is stemming directly from the adrenals; primarily your cortisol reserves. HC therapy and other treatments can get this on track, but I would think a doctor might want to look at things a little further, possible ACTH and other labs + exams? Trying to do some form of thyroid treatment could/might be a bit complicated, as stated earlier, FT3 is dependent on things like Cortisol and Iron to make it to the cells. When it doesn't have it, the body reacts with triggering RT3 to conserve energy and bunker down ... You can see how this all works full circle and in collaboration ...

Keep us posted on any updates. Thanks

 

[Dr Justin Saya MD]

Yes, definitely stuff going on with RT3, which can stem from many areas, including illness, fatigue, imbalances, and other stress markers as indicated by HarryCat. The other criteria is measuring the FT3/RT3 ratio. Anything > 20 is ideal, yours is at 11.5, obviously confirming there's an issue. Also, keep in mind, the body will shift the demand for RT3 when Free T3 starts pooling, meaning it is 'not' adequately reaching the cells of the body. The two (2) primary markers to look at it cortisol and iron/ferritin (other electrolyte areas important too).

My initial take is you have some adrenal issues taking place (?). You will find many of the top adrenal specialists like Dr. Lam and Dr. Wilson note that A.M cortisol should be right towards the top of the reference range, call it 90% or even more. Yours is sitting at 60.8%. The two mid-day labs just drop to the bottom from there, below reference range (which is the two (2) that DiagnosTech will focus on when evaluating adrenal fatigue), and PM just barely hangs on at the bottom end of the ref. range. There's no DHEA correlation, which I don't think LabCorp provides (?), but my opinion is that you're somewhere in the Stage 5 to Stage 7 Adrenal Fatigue, based on Total Burden values and your circadian profile.

So, I'd say there's probably a very 'good' chance that your thyroid situation is stemming directly from the adrenals; primarily your cortisol reserves. HC therapy and other treatments can get this on track, but I would think a doctor might want to look at things a little further, possible ACTH and other labs + exams? Trying to do some form of thyroid treatment could/might be a bit complicated, as stated earlier, FT3 is dependent on things like Cortisol and Iron to make it to the cells. When it doesn't have it, the body reacts with triggering RT3 to conserve energy and bunker down ... You can see how this all works full circle and in collaboration ...

Keep us posted on any updates. Thanks

Vettester Chris - that is about the most succinct and well-worded summary of the intricacies and interplay of adrenal-thyroid interaction that I've read in quite some time. Nicely done!

 

[Vettester Chris]

Thank you Dr. Saya!! That means a lot coming from you!

 

[miked123]

Thanks for the reply. Looks like I got some reading to do.

Dr. Saya prescribed low dose Pregnenolone, as well as an adrenal supplement, to get the adrenals functioning better. From there, I may also take T3 depending on what the next set of labs suggest.

 

[TRicker]

So, I'd say there's probably a very 'good' chance that your thyroid situation is stemming directly from the adrenals; primarily your cortisol reserves. HC therapy and other treatments can get this on track

I know this is a very old thread, but was hoping you or others would comment again.
I also have a high RT3, and have many of the same symptoms, fatigue, ed, weight gain, etc. despite being on TRT.

My thyroid labs are:
TSH: 1.7 (.45 - 4.5)
T4 Free: 1.36 (.82 - 1.77)
T3 Free: 3.5 (2 - 4.4)
Reverse T3: 25 (9.2 - 24.1)
DHEAS: 121 (71-375)

I've read exactly what you stated above, that T3 requires adequate iron and cortisol in order to work properly. If my iron/ferritin/iron binding are all adequate, that would suggest cortisol deficiency as the cause...However, everything I've read is that high RT3 is caused by HIGH cortisol, not low.
Is it possible to have low cortisol and have weight gain, fatigue, ed, etc?
How common is it for low cortisol to cause high RT3?

I'm scheduled to do a saliva cortisol test, although my endo is terrible, and ordered a one-time saliva test and probably won't prescribe anything regardless of the results. I've been told by my old Dr that I probably have high cortisol or adrenal fatigue (low cortisol). I'm trying to determine which is most likely.

 

[Nelson Vergel]

Don’t forget total and free T, iron and ferritin. Glad you are doing the morning and night saliva cortisol. Any chance for sleep apnea? Your CBC can tell you if your hematocrit and red blood cells are abnormal. Depression can also be an issue. How is your sleep and current life situation ? Are you using any meds that could be causing fatigue (there are many !!)?

 

[TRicker]

Thanks Nelson!
I believe everything else is normal/adequate:

Total T: 600 (trough)
SHBG: 17 (low from TRT, it goes up when not on TRT)
E2 Sensitive: 25
Iron: 145 (Range 38-169)
TBIC: 318 (Range 250-450)
Ferritin: 102 (Range 30-400)

TSH: 1.7 (.45 - 4.5)
T4 Free: 1.36 (.82 - 1.77)
T3 Free: 3.5 (2 - 4.4)
Reverse T3: 25 (9.2 - 24.1)
DHEAS: 121 (71-375)

Prolactin: 7 (4-15)
Progesterone: .3 (0-.5)
Pregnenolone: <10 (Range Unknown)

It's not just the fatigue, which I'm used to from having a stressful job, but the weight gain despite dieting, and ed/lack of sensitivity down there. I've tried higher and lower doses of test, more or less ai, hcg, and more or less T3 (even 50mcg of T3 made no difference).