The best teaching comes from experienced mentors. We publish case studies from veteran functional medicine practitioners to help educate the community on how testing relates to root-cause medicine. To order any of the tests from this case study, sign up for Rupa below.

[signup]

Hypothyroidism Case Study: Fatigue, Hashimoto's, and a Functional Medicine Approach

The Patient's Symptoms and History

Alexandra, a 34-year-old female, presented with significant fatigue despite being on levothyroxine for hypothyroidism and Hashimoto's thyroiditis. Her symptoms included difficulty exercising, constipation, inability to lose weight, dry skin, and a constant feeling of exhaustion. Although her thyroid labs fell within the standard reference range, she felt something was not quite right.

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

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.

Despite her efforts to maintain a healthy lifestyle, Alexandra continued to experience significant fatigue, indicating that there might be underlying factors beyond her hypothyroidism diagnosis contributing to her symptoms.

Lab Analysis and Root Causes

A comprehensive lab analysis, a hallmark of functional medicine, identified four key factors that may be contributing to Alexandra's fatigue:

1. Above Target Thyroid-Stimulating Hormone(TSH): Although her TSH and Free T4 fall within the standard reference range, they are not optimal. TSH levels can vary widely by age. Although there continues to be discussion surrounding specific age-appropriate TSH targets, there is a consensus that a young female may benefit from 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 might 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, a reverse T3 test could have been obtained to see how much of her available T4 was being converted to the inactive reverse T3. She has evidence of inflammation and deficiencies in B vitamins, which can affect the 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 may suggest systemic inflammation associated with cardiovascular health and other wellness concerns (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. A copy of the lab work from her physical just a month prior showed 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 health (3) (4). Her diet is low 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 levels (6), was elevated. Blood levels of B12 can vary significantly based on recent ingestion of B12 supplements or foods containing B12. Methylmalonic acid is a compound whose degradation depends 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. 

Functional Medicine Interventions

To address the potential root causes, the following interventions were considered:

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

Outcomes and Follow-Up

Three months later, Alexandra reported improvements in her fatigue, and her lab work showed notable changes in thyroid hormones, B vitamins, and Omega-3 levels. This hypothyroidism case study highlights the potential benefits of using optimal reference ranges, evaluating the whole thyroid hormone panel, and addressing nutrient status, diet, and lifestyle factors to explore and manage hypothyroidism-related fatigue.