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Chris Wyatt
Chris Wyatt, Medical Doctor (M.D.)
Category: Endocrinology
Satisfied Customers: 37
Experience:  Physician and psychiatrist.
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I was diagnosed with adrenal insufficien in 2009. I had been

Customer Question

I was diagnosed with adrenal insufficien in 2009. I had been sent to an endocrinologist before carpal tunnels surgery, my TSH and FT4 were the exact same numbers...Free T4 was .87 with range of .71-1.85
TSH was .87 with range of .45-4.67. I know they are not supposed to be low together. Endocrinologist started with basics. My FT3 was just above the bottom of the range. She ran multiple tests, and at one point looked at my blood work and said she had never seen this before. My DHEA was low, my testosterone was low, my SHBG was high. My estrogen was about 1100. That was checked by my obgyn....he figured I had just ovulated, levels were back to normal. She ran a cortisol test, which came back pretty low in the range. She also ran an ACTH test, which was also pretty low in the range. She ordered an ACTH stim test. I had very painful feet, and after getting the low results on both cortisol and ACTH.--cortisol was 6.3--range 5-25 and ACTH was 9 range 6-58. When those came back so low, an ACTH stim test was ordered. I have fibromyalgia, and the bottoms of my feet were so painful to walk on. I was given a kenalog shot in each heel. 18 days later, i had the acth stim test done. my levels were:
baseline cortisol 2.4--range 5-25
baeline ACTH 5 --range 5-27
these levels were drawn at 8:10 am--and i was fasting. the lab recieved both samples at 8:12
after stimulation agent was injected, my first draw was at 8:50 and recieved in the lab at 8:52
my cortisol level was 9.5
the next draw was done at 9:20 and recieved at the lab at 9:24
my cortisol level was 11.6
the lab report read as follows:Peak cortisol level greater than 20ug/d. Peak value is more important than incremental change. The incremental change may not be seen at times of stress, when the adrenal output of cortisol is already maximally stimulated by endogenous ACTH.
Dexamethasone suppression
Below basal values. I was diagnosed with secondary adrenal insufficiency, and possible central hypothyroidism of unknown entity. I was put on 30 mgs of hydrocortisone, and told I should start feeling better. She also put me on 1/2 grain of armour thyroid. I did not feel any better. The office was unorganized, and I eventually went to another endocrinologist a couple of years later. First appt. he told me to drop my HC from 30 mgs to 20 mgs. Too big of a drop! arthrtis and rashes flared. By phone, talking to nurse, I was told to continue to wean off my HC, and that I would probably be weaned off thyroid medication, also. I was on 60 mgs of armour thyroid at this time. After 6 months, I had blood work done on a Monday. I was not fasting, and had taken 5 mgs of HC. My cortisol level was either 16.? or 18.? We drove 2 1/2 hour on Wednesday to see the endo. I saw his PA. She said she was ging to run an ACTH stim test. She said she could use my blood result from 2 days before as the baseline. So, no baseline cortisol and no ACTH baseline. I was injected with stim agent. One draw was done in 30 minutes, and I was told we could leave. They were not going to test anything else. The doctor said that the kenalog shots I had in each heel had shut down my adrenals. None of my other doctors agreed with what that endo said. I saw a holistic doctor, who said two serum cortisol levels were high, but a 24 hour urine cortisol was a little low. When he examined me, he said I had orthostatic hypotension, and a delayed ankle reflex. He said my clinical exam showed adrenalinsufficiency. I was put back on HC and put on NP thyroid I think my dose was 180 mgs. After being frustrated by conflicting information. I weaned off cortisol, thinking i wouldget retested. I have not been able to find anyone to restest me. I recently had a total knee replacement, and was given a bolus of steroids, because of low adrenal concerns. I did fantastic in physical therapy, reaching full range of motion they wanted 2 weeks after my surgery. I had a fundoplication a hiatal hernia
JA: When was the last time you had your levels checked? Have you noticed any weight loss or weight gain?
Customer: My cortisol and ACTH levels have not been tested for about 3 years, I think. I dropped 10 lbs in a week, and continued to lose weight until I went from 130 to 114, for no apparent reason. I stabilized, and gained back to 125 lbs. This was before I was diagnosed with adrenal insufficiency the first time. I used to wake up with sharp pains in my stomach with the firt couple of breaths I took. I have been on two different medications that made me gain weight. I stopped each of them as soon as I realized they were causing weight gain.
JA: Anything else in your medical history you think the doctor should know?
Customer: I had osteomyelitis at 3, bilateral shingles at 4. I will turn 54 next month. I have had 10 pregnancies, 2 miscarriages, and a set of twins. My 3rd c-section wa done without anesthesia, just locals. I was packed and they waited for someone to put me out to finish. I lost a lot fo blood, but not enough to need a transfusion. I have battled depression and anxiety for years. I had 2 other c-sections with were both incomplete. The first one was just like having 2 miscarriages, he second one, blod tests were run, and my levels stopped dropping. Had a D&C, and had a bad reaction coming out of anesthesia. I was wretching, my blood pressure was so low it kept setting off the alarm, any time they tried to get me up, everything would start to get dark. They would put me down before I passed out. Tonsillectomy at 24, carpal tunnel x2. Arthroscopic kne surgery x 2. Doctor insisted second arthroscopic June or July of 2015 be done at hospital because I was still on HC for adrenal insufficiency. Tubal 11 months after last baby (had her at 40 yrs old), became very anemic, had ysterectomy 11 months after tubal. Baby is now 13, born Oct. 6, 2003. I had the unexpected weight loss 4 years later. I weaned off narcotics for fibromyalgia in Augus of 2016, after almost 17 yrs. Started with headaches and stiff neck. Taking 200 mg gabapentin 3x daily and 35 mg amitriptyline, and Ibuprofen. I occasionally take a lower dose norco. Total knee was in October 2016, fundo was done Dec. 2016. energy level is low, also have a lot of apathy, can't get myself to do the things I want to do. I also take 300 mgs of wellbutrine, 40 mg of cymbalta, 2 mgs of clonazepam up to 3 a day...which do not work very well anymore. 600 mgs of long acting guaifenisen 2x daily. Ibuprofen varies from day to day, but usually 800 mgs at a time.
Submitted: 6 months ago.
Category: Endocrinology
Expert:  DrRussMd replied 6 months ago.

Welcome to just answer. I am here to answer questions for education and information. I will respond shortly with an answer, or a question for you

Expert:  DrRussMd replied 6 months ago.

I have read your extensive information.

You have not been tested in 3 years


Customer: replied 6 months ago.
The last blood test I could find was done in June of 2013. My free cortisol was .26 and he told me that the ideal would be 2.0. I don't know how he was measuring it, and I also know that he did not go by regular lab values, he went by optimal values. No one else has tested since then. I started waning off the HC in the fall of 2015. I knew my first stim test was done according to protocol, and I knew the second one was not. I did forget a medication I take. I take 20 mgs of adderall 2x daily. When I had my last serum cortisol test, I think I was on Vyvans, and I had to be off of it for 5 days before my blood test.
Customer: replied 6 months ago.
Everything I have read has said that The stimulants would raise my cortisol levels. My blood sugar first went high when I was put on HC, but it leveled out back to normal. In order for my FT3 to be at the top of the range and my FT4 to be midrange, by TSH has to be about .005. I think that indicates a pituitary problem, unless I have been misinformed. I weaned off HC in the Fall of 2015, because I was confused by the different tests and different doctors opinions. I thought I would get retested after I went off. I haven't been able to get anyone to retest me. I was on thyroid suppression therapy for about 10 yrs, for multiple thyroid nodules, and had been off suppression therapy for 1 1/2 yrs when I had the ACTH stim test done. The closest Endocrinologist we have, told me that I probably never needed to be on thyroid medication, and that I could have has secondary adrenal insufficiency caused by my pituitary still waking up from the thyroid suppression......I didn't think to tell him how long I had been off suppression therapy....and just on a low dose of armour thyroid when the stim test was done. I asked him for something to back up what he was telling me...they sent info on iatrogenic hyperthyroidism...he had not liked that my TSH was so low. I called back and said I did not have iatrogenic hyperthyroidism. The nurse then told me that my TSH was low because my pituitary wasn't functioning properly. This guy did not run any tests on me.
Customer: replied 6 months ago.
My GI internist told me that even if the shots had affected my adrenals, it would not have affected them for stimulation. Could my ACTH and cortisol shut down to a very low level just 18 days after a kenalog shot in each heel, and also drop my DHEA really low, and my testosterone low, and raise my SHBG? When I am in a hurry and have to get ready to go somewhere, I will often get really shaky...not sure why.
Expert:  DrRussMd replied 6 months ago.

There is no way to sort this out currently without the following up to date tests.

TSH and T4

Am cortisol and 24 hour urine for free cortisol.

Sex hormone panel, testosterone and SHBG

No, stress alone would not affect these tests, but you need the 24 hour urine before wasting time on stimulation and supression testing. If the urine test is normal, you do not need to do those and it is an adrenal problem. I don't see that you had a thyroid problem in the first place.

Stop doctor bouncing: get one up to date, board certified endocrinologist to test you. That will sort things out.

Please click a positive rating on the rating scale [we are paid on the basis of positive ratings] and be sure to let me know if you have not finished with any questions.

Customer: replied 6 months ago.
I am a little said I need an Am cortisol and a 24 hour urine for free cortisol. Then you said if the urine test is normal, then it is an adrenal problem. If my free cortisol in a urine test is normal, doesn't that mean that my adrenals are functioning normally? My thyroid levels have continued to drop. The last time a doctor tried to "normalize" my TSH, he kept dropping my thyroid medication, even though my FT4 was flagged low. He dropped it three times, even though every test showed that my FT4 was too low. My hair had starting falling out-----but he had gotten my TSH into normal range and my FT4 was still way too low. Another doctor in the same office saw my test results, and told me my thyroid was too low. It took about a year for my hair to recover from that. My thyroid function was normal when I was put on suppression therapy 19 years ago, but I have become hypothyroid since that time, and a TSH test alone will not show it. My first endocrinologist thought I might have central hypothyroidism of unknown entity.I asked about my adrenals on this board about 2012(?), because I was concerned about my adrenals after the second endocrinologist had not done a stim test properly, and had weaned me off of HC. A Dr. Aldi had told me that my first endocrinologist was right, that I needed to be on HC and that I needed to be retested. He told me this after the second endocrinologist only ran a TSH on me, so he could not see that my thyroid levels were dropping and did not do a stim test according to protocol. This was before I saw a doctor that worked on balancing the whole endocrine system, who had put me back on HC based on physical examination. My 24 hour urine cortisol was a little low, and my cortisol blood tests were a little high.I am wondering why I have been given such different answers when asking about the same thing on this board.
this is what makes me go to different doctors. I know that my TSH will not show that I am hypothyroid......but most endocrinologists say it is a very accurate test. It may be for other people, but it is not accurate on me. I cannot remember if I even discussed my thyroid with Dr. Aldi.How do I go about finding a Board Certified Endocrinologist that is up to date? We live in a small town, and have to drive a couple of hours to find an endocrinologist. I can look up doctors names, but that isn't going to tell me if they are up to date.
Expert:  DrRussMd replied 6 months ago.

If your 24 hour urine for free cortisol is normal, it is NOT an adrenal problem, and as I stated you would not need further testing.

Sorry about any confusion.

It is completely incorrect that TSH alone will not show hypothyroid> It will as long as one uses the correct parameters which are .3 to 2.5 ad a normal range. Above 2.5 is hypothyroid.

Please click a positive rating on the rating scale [we are paid on the basis of positive ratings] and be sure to let me know if you have not finished with any questions.

Customer: replied 6 months ago.
How do you explain a normal TSH level and a below range FT4 along with my hair falling out? Central hypothyroidism has to be treated by keeping the TSH very low. I did have a 24 hour urine cortisol test done, and it was low, while blood tests were showing high. I did not realize that they were testing two different things. Are you a Board certified Endocrinologist? I will see if I can find my records.
Expert:  DrRussMd replied 6 months ago.

Your free T4 was normal.

Even if it were slightly below normal, that would be within lab error ranges with a normal TSH.

Hypothyroid would have a TSH over 2.5.

For a pituitary problem, TSH would be below normal with a clearly low T4, which is not what you had.

In addition, you would have to have something like a pituitary tumor to cause that, which would show up on a brain MRI.

But to sort this out, you need a doctor who can examine you, run the tests, and re check everything.

Please click a positive rating on the rating scale [we are paid on the basis of positive ratings] and be sure to let me know if you have not finished with any questions.

Customer: replied 6 months ago.
can you tell me the normal ranges of FT3 and FT4 with the new parameters?
Customer: replied 6 months ago.
3/8/2010 cortisol 7.3, range 2 - 23.........DHEA sulfate serum 11, range 56 -283....FT4 0.67 range 0.71 - 1.85.......FT3 4.0, range 2.4 - 4.2...........TSH less than 0.06, range 0.45 - 4.67..........4/29/2010 I have a test showing FT4 0.52 and TSH at 0.19 6/16/2010 shows FT4 less than 0.68, range 0.71 -1.85, and TSH 1.05, range .45 - 4.67. By this time my hair was falling out, but my TSH was normal. I had been on levothyroxine and cytomel. after first test, levothyroxine was dropped to .025.....after second test, levothyroxine was stopped, and cytomel dropped to 30 mgs 2x daily. After last test, the other doctor in the office said my thyroid was too low and he put me on 60 mgs of armour. The first 2 tests show low TSH and low FT4. The last showed normal TSH and low FT4....and regardless of what the paramenters were.....My hair been falling out.12/02/2010 DHEA was in normal range........FT4 0.80, range 0.71 - 1.85........TSH 0.20 FT3 4.6, range 2.4 - 4.2....ACTH les than 2, range 6 - 8.......I asked endo if she was concerned about the slightly high FT3, she said she was not.Before I got the shots in my heels, my cortisol was 6.3, range 5.0 - 25............ACTH 9, range 6 - 58. Is there anything else that could drop my cortisol and ACTH so close to the bottom of the range? Those thyroid tests show my TSH low, even with the new parameters.Do you still feel that I do not have hypthyroidism.? If not, what would cause my hair to fall out when the doctor normalized my TSH, but my FT4 was still low?18 days from getting a kenalog shot in each heel, my cortisol dropped from 6.3 to 2.4...........range of 5.0 - 25.0
My ACTH dropped from 9 (range 6 - 58) to 5 ( range 5 - 27) These were both 8am draws. The original draws were cortisol at 10:25, and ACTH at 11:51.I just really want to know if these tests really don't mean anything because of the shots, and if you still don't think I have hypothyroidism.
My ACTH stim test was low dose stim test. my highest draw, was 11.6, The test was looking for a peak value of 20.Would this stim test be inaccurate becaus of the kenalog shots.The testing above shows low FT4 along with low TSH....even using the new parameters.
Customer: replied 6 months ago.
Customer: replied 6 months ago.
My last two questions were not answered by Dr Russ....Then I got an email asking me to rate Dr. Thomas...Who is Dor Thomas, and why am I asking to rate someone I didn't even talk to???
Customer: replied 6 months ago.
I will not pay for two different doctors, especially when I never talked to one of them, and the other did not reply to my last messages. I have used this sight before and been happy...not this time. I think maybe the doctor just got tired of me. I didn't choose to have a difficult condition.
Expert:  DrRussMd replied 6 months ago.

Your most recent thryoid tests indicate normal ranges.

But you are talking about very old tests in any case.

You need a whole new set now, since you have not been on any medications.

If both T4 ant TSH are actually low, and if Acth is low, you should have an MRI of the brain to look at the pituitary.

I don't know why you are getting two doctors names. That is a site glitch that I will report.

Please click a positive rating on the rating scale [we are paid on the basis of positive ratings] and be sure to let me know if you have not finished with any questions.

Customer: replied 6 months ago.
I guess I really came on here to ask about whether or not my adrenals could have almost stopped functioning, and my ACTH levels have dropped, only 18 days after getting a kenalog shot in each heel?Is there anything else that could have made my ACTH and cortisol levels so close to the bottom of the range before getting the shots?This is probably why I failed to mention that I am on thyroid medication. I am being tested regularly and my dose gets adjusted when it needs it.It has been 3 years since my cortisol was tested.I asked you if the FT4 and FT3 levels have been changed any with the new parameters, and you did not answer my question. Have they been changed?You only mentionTSH testing and FT4 testing. Why do you feel that it is not important to get a FT3 test, since FT3 is the active hormone that FT4 must be converted to?I realize those were old tests, but they also showed my FT4 and my TSH low at the same time. I do not take thyroid medications that have T3 in them on the day of testing, so they should not affect the test restults. Two of the test results showed low TSH along with low FT4. The test that had normal TSH still showed a low FT4, with the added symptom of losing a lot of hair. Less than .68 is not a normal range, when I can run my fingers though my hair and have hair come out with them, and when there are little globs of hair on the shower floor when I am done showering. This is when I was put on 60 mgs of armour. I have never had this happen before thyroid medication, and I have never had it happen after being dosed to keep my TSH level very low, and my FT4 in middle range and FT3 in upper range.I asked 4 very specific questions, they each have a question mark at the end. Could you please answer them?
Customer: replied 6 months ago.
I ran across some information about long term use of narcotics. It sounds like they can mess with your HPA axis. I started taking darvocet in the about November of 1999. I was switched to norco 10/325s about the same time of year in 2005, after a hysterectomy made my fibromyalgia flare unbearably. I weaned almost completely off of the narcotics in August of 2016. I sometimes take a 5/325 norco, but not every day. I also took soma with the darvocet and the norco. I know all my medications were listed in my paperwork when I saw the first endocrinologist. After those kenalog shots in my heels, I have since had a steroid shot in my shoulder, (Date ?) a steroid shot in my knee, summer of 2015, also a cyst on my ankle drained and given some steroid with the injection, twice during the next year. I was given steroid shots in the back of my head in August of 2016, and in September I was given steroid shots in my neck for headaches. I was given a bolus of steroids when I had a knee replacement October 2016, and also when I had reflux surgery December 2016. Could the narcotics have caused my cortisol levels and my ACTH levels to be so low in their ranges, which promted my doctor to order an ACTH stim test? Would I be likely to have lowe adrenals now because of the steroid injections? I know I had normal thyroid function when I was put on thyroid suppression was the way they treated multiple thyroid nodules 19 yrs ago. A psychiatrist wanted me to go off thyroid medication to see what my thyroid would do on it's own. I had been off for about a year, when I was going to have carpal tunnel surgery. Even though my TSH and FT4 were within "range" they were both at the low end of their ranges. He felt like my thyroid was too low, being at the low end of the range. I was sent to an endocrinologist, who tested everything, and tested my FT3 for the first time. It was one number above the bottom of the range. She is the one who put me back on thyroid medication after 10 yrs of being off of thyroid meds. She obviously felt that my thyroid was not working very well. I have been told I probably never needed thyroid treatment, but having my hair falling out when I was lowered to 30 mgs of cytomel 2x daily, which put my TSH in the normal range, but kept my FT4 flagged as low, sounds like I definitely became hypothyroid at some point, and makes me not trust that TSH levels are giving the right picture of my own thyroid levels, when my thyroid is tested.
Customer: replied 6 months ago.
It has been longer than 24 hours. I am truly disappointed with "just answer" this time. I have asked quesions before and been given advice that was helpful to me. I assume there will not be a charge on my credit card, since my questions have never been answered I will go back to the difficult task of trying to find a competent endocrinlogist.
Customer: replied 6 months ago.
I was told I would get a response within 24 hours several days ago.....what gives? Is there someone that is an actual board certified, up to date endocrinologist that can give me some direction, or are you just going to keep telling me i have been referrred to a new endocrinologist, and that I should get a response within 24 hours? All that has been done, is that the green bar telling me I have been referred to someone else has been moved down two spaces, so that it looks like I just got told I was being referred to someone else. I was told this sometime between January 30 and january 31. I f no one wants to deal with this, just tell me, so I can try and get some direction somewhere else.
Customer: replied 6 months ago.
Expert:  Chris Wyatt replied 6 months ago.

I referred your question to the moderators for assistance. I apologize that we haven't been able to provide you a good answer. I am not a specialist in this area. Hopefully staff can assist you soon.