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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 knew something was wrong.

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 debilitating 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, unearthed four key factors 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 controversy surrounding specific age-appropriate TSH targets, there is a 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, 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 systemic inflammation 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 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 root causes, the following interventions were implemented:

• 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 daily.
• Encouraged her to increase exercise to the point of breaking a sweat 3x a week
• I encouraged her to cut back on 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's fatigue significantly improved, and her lab work showed notable improvements in thyroid hormones, B vitamins, and Omega-3 levels. This hypothyroidism case study is a testament to the effectiveness of using optimal reference ranges, evaluating the whole thyroid hormone panel, and addressing nutrient status, diet, and lifestyle factors to uncover and treat the root causes of hypothyroidism-related fatigue.