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Adrenal Insufficiency Testing?

Discussion in 'Adrenal Dysfunction' started by roxie60, Aug 5, 2013.

  1. Ema

    Ema Senior Member

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    Tumors on the pituitary usually overproduce hormones, not underproduce. Without any evidence of hormone overproduction, there is no need in my non-medical opinion to go through the time and expense of an MRI.

    Further there is some risk to the dye that is used to stain the gland. And since pituitary tumors are notoriously hard to see on imaging, a 3 Tesla machine is required which further increases the expense.

    All of those are worthwhile if there is evidence of hormone overproduction, of course.

    The only thing visible on a pit MRI that could cause AI would be empty sella syndrome which happens after pregnancy/labor. It's possible this is the case, but again, the treatment wouldn't change so I would skip it.
  2. roxie60

    roxie60 Senior Member

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    Ema and rlc you are both correct, I missed that first criteria. My brain has been misfiring today and I just got up from laying down 4 hours due to exhaustion, still tired but can sit up again. It seems that ACTH test is very sensitive and needs to be handled properly (chilled vile and kept chilled/frozen from the get go) I am confident that did not happen last week and now know no baseline ACTH was taken this past Thursday. I would like to have another serum ACTH and AM Cortisol mainly cause it seems these low Cortisol values are being dismissed for some reason. Maybe just a Cortisol again which doesnt require specail handling, if it is low again then it can't be ignored. If it is not, I give up understanding what is wrong with me.
  3. roxie60

    roxie60 Senior Member

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    Anyone know if there is a place online to get medical second opinions? Just a place where I can put my lab results and get a quick reply. I realize this might be fraught with issues but I think I need something to convince my GP to go against Endo and get another referral or additional blood tests.

    Found one, funny happens to be from the same city the Endo was trained at. Nevermind, cost $565.00 and requires lengthy online documentation to be filled out. I guess I should not expect it to be free but I'm just wanting a second opinion of the recent lab results - doesnt seem right to charge that much for a lab review.

    This is the link in case this can help anyone else
    http://my.clevelandclinic.org/online-services/myconsult.aspx
  4. rlc

    rlc Senior Member

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    Hi Ema re

    With respect, I think it is very important that we should not be giving non medical opinions, and only stick to what the experts say.

    Pituitary tumors can and do cause the underproduction of hormones including ACTH, growths in the brain can lead to an under production of ACTH whether they are effecting pituitary or hypothalamus. Sometimes these conditions can be corrected by surgery, secondary AI which the low ACTH indicates is possible according to the medical text books should lead to a MRI to help establish the cause of the low ACTH, failure to do this could lead to a tumor being left undiagnosed which can result in death. Which is why the qualified medical experts say a MRI should be done.

    This source says http://www.addisonssupport.com/Documentation/adrenal-insufficiency-2003.pdf

    "In secondary adrenal insufficiency of unknown origin, MRI of the hypothalamic-pituitary region is the method of choice to reveal a space-occupying lesion. Only pituitary adenomas with a diameter of greater than 1 cm will cause secondary adrenal insufficiency; smaller microadenomas are coincident. Lymphocytic hypophysitis might initially present as pituitary enlargement, sometimes leading to the misdiagnosis of a pituitary tumour, whereas the long-term course leads to pituitary atrophy and subsequent empty sella."

    All the best
    barbc56 likes this.
  5. rlc

    rlc Senior Member

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    Hi Roxie, I think repeating ACTH and Cortisol is a good idea, there is always a chance of a lab error with the ACTH test. The ACTH test is the important one, failing it shows that the problem is caused by something wrong at the level of the pituitary or hypothalamus (secondary or tertiary AI) and it rules out Addison’s (Primary AI) as the cause. I don’t know of anyone online that could give a second opinion, however the best source of information I have found regarding endocrinology is a site called endotext http://www.endotext.org/

    They’ve changed it recently so that you have to sign in, but it contains very good detailed explanations of all areas of endocrinology including the areas you need info on, many of the other articles online are simplified overviews and don’t provide the detail needed. And some are very confusingly written

    It would be a good source for you to have a look at and provide you with good info to take to other doctors.

    Again sorry you are going through such a hard time, I hope you can find a Endo who really knows this subject inside and out soon.

    All the best
    roxie60 likes this.
  6. Ema

    Ema Senior Member

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    The "experts" disagree so I guess it is OK that we do too. :)

    For me, the risks would outweigh the benefits in most cases like this where there is no evidence of pituitary tumor (TSH is high so no panhypopit) or empty sella. A macroadenoma would most likely also produce visual symptoms. And that is the only type of adenoma they say can cause adrenal insufficiency. I'm not sure I would agree with that either.

    Ema
    alwayshopeful likes this.
  7. roxie60

    roxie60 Senior Member

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    Found this list of symps for adrenal 'fatigue' and hypothyroid. Not sure it is all that helpful since I seem to have syps from both but the Adrenal list edges out the thyroid list slightly (by 3-4 symps if counted correctly).

    Dont know anything about this guy, was looking for something on impact of treating thyroid and not adreanals and tis came up, thought it might be useful to someone.

    http://www.drlam.com/articles/adrenalfatiguevshypothyroidism.asp
  8. roxie60

    roxie60 Senior Member

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  9. roxie60

    roxie60 Senior Member

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    Anyone familiar with Dr Mike Lam, is he credible? Has anyone been his patient/client? Did you get results / answers?
  10. roxie60

    roxie60 Senior Member

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    Used the calculator at STTM to determine my FT3 RT3 ratio. My brain just cant seem to figure out the result right now to understand how it compares to their expectations (I think I know what I did wrong). http://www.stopthethyroidmadness.com/rt3-ratio/

    My numbers

    FT3 2.9 pg/dl (I think this should actually be 290 pg/dl and I converted it to 2.9 for Dr Rind's Thyroid Scale)
    RT3 11.2 ng/dl

    Ratio 0.3

    When I changed the FT3 to 290 I get a ratio of 25.9 which is in the expected result range noted at STTM site.
    Little Bluestem likes this.
  11. roxie60

    roxie60 Senior Member

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    Even Endo's still can't agree on the upper end of range for TSH test

    The sensitivity limitations of the first generation RIA methods precluded detecting the lower euthyroid reference limit (2.5 percentile) whereas upper reference limits (97.5 percentile) were reportedly to be as high as 10 mIU/L. This elevated upper limit primarily resulted from gonadotropin cross-reactivity and the failure to exclude individuals with subclinical autoimmune thyroid disease who have higher TSH values (237,286-288). Using current third generation IMA methodology, the lower TSH reference limit has now been shown to approximate 0.3 to 0.4 mIU/L (289-291). This estimate appears consistent irrespective of the population studied or the method used (289,290,292-297). In contrast, the setting of the TSH upper reference limit (97.5 percentile) has become controversial (291,298-301) with estimates ranging from 2.1 mIU/L (295,297) to 7.5 mIU/L (289,299,302). Multiple factors influence the calculation of the TSH upper reference limit for a population. These include population demographics like sex (289), ethnicity (289,303-305), iodine intake (306), BMI (307-312), smoking status (303,313,314) and age (302,304,315,316) as well as the failure to exclude the presence of subclinical autoimmune thyroid disease using the presence of TPO antibodies (287,289,317,318).
    Recent studies have suggested that TSH increases with age and that a mild TSH elevation in elderly individuals may even convey a survival benefit, although other reports dispute this (299,302,319-324). These reports have led to the suggestion that age-specific TSH reference limits should be considered (315,325). However, it appears that these mild TSH elevations may be transient (326), or in part relate to polymorphisms of the TSH receptor and cannot be interpreted to imply that subclinical hypothyroidism per se is necessarily advantageous for elderly individuals (321,327,328). Whereas there appears to be a positive correlation between age and TSH concentrations in iodine sufficient populations (289,299,329) the opposite is the case for iodine deficient populations in which there appears to be no TSH increase with age, or even a decline (286,295,296,330,331). In areas of iodine sufficiency the correlation between increasing TSH and age could represent a failure to exclude subjects with autoimmunity who may, or may not, be detected by a positive TPOAb test (317,332,333). Complicating these questions is the fact that current TSH IMAs differ in specificity for recognizing circulating TSH isoforms and that this can give rise to a full 1.0 mIU/L difference in TSH values reported by different assays – a difference that in some cases is greater than the influence of many of the other variables listed above (31,296,334,335). Because hypothalamic TRH modulates TSH molecular glycosylation and biologic activity, a rise in TSH with age could represent an increase in the secretion of biologically inactive TSH, yet immunologically detected isoforms (336,337). The blunting of the TSH response to TRH and decreased amplitude of the TSH nocturnal peak would be consistent with this premise (338,339). In contrast, in areas of iodine deficiency the inverse relationship between TSH and age could represent a failure to exclude individuals with autonomously functioning nodules (332).
    The TSH upper reference limits for non-pregnant subjects remains a contentious issue, such that it is difficult for manufacturers to cite a TSH reference range appropriate for universal adoption across different populations in different geographic areas (Figure 3). This has led to guidelines proposing the adoption of an empiric TSH upper limit of 2.5 -3.0 mIU/L, which is in accord with the TSH interval associated with the lowest prevalence of thyroid antibodies (13,37,228,317). Furthermore, a TSH upper limit between 2.0 and 3.0 mIU/L would also be appropriate for reproductive age women and pregnancy, in whom current guidelines now recommend using 2.5 mIU/L for preconception planning and the first trimester, and 3.0 mIU/L as the upper limit for the second and third trimesters (13,39,40,203,228,288,340).
    [​IMG]
    The adult TSH population reference range does not apply to neonates or children. Serum TSH values are generally higher in neonates and then gradually decline until the adult range is reached after puberty (198,296,341-346). This necessitates using age-specific TSH reference ranges for diagnosing thyroid dysfunction in these pediatric age categories.
  12. roxie60

    roxie60 Senior Member

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    I think this paragraph from an article at Endotext is why my Endo just ignored my low serum ACTH .... it looks like this is saying low ACTH is of no dx value. By the way article also said ACTH values >=20 means no primary adrenal insufficency, secondary adrenal insufficency not even mentioned in the article. http://www.endotext.org/chapter/end...thalamic-pituitary-adrenal-axis/#toc-cortisol

    secondary is mentioned, just not found when I did search cause word broken up.
    INTERPRETATION OF RESULTS: Baseline cortisol values <5 µg/dl and ACTH concentrations >100 pg/ml are usually diagnostic of primary adrenal insufficiency. The normal peak cortisol value post stimulation should be an increment no less than 7µg/dl and a maximal level >20 µg/dl at 30′. Since 37% of subjects had a peak response to Cotrosyn at 30′ and 63% had a peak response at 60′, both time points are analyzed in all patients and if either the 30′ or 60′ sample reaches the criteria as noted above, the test is considered normal (9).
    Serum aldostserone can be measured in 0′, 30′ and 60′ blood samples as ACTH stimulation of the adrenal cortex will also stimulate aldosterone. It has been suggested that a normal aldosterone response to ACTH in the presence of a suboptimal cortisol response is diagnostic of secondary adrenal insufficiency (10). I need to look at this when less tired, my aldosterone was high after the STIM test but because my cortisol response was normal that appears to be why the Endo also ruled out secondary adrenal insufficiency. So really she did not even consider secondary AI since my cortisol response was optimal (normal, passed).

    ACTH

    ACTH ACTH measurements, while subject to the same circadian variability as cortisol (actually it is the variability of the ACTH that is directly responsible for the variability of the cortisol), are not subject to the effects of CBG. Values of ACTH > 100 pg/ml in the setting of possible adrenal insufficiency are usually suggestive of primary adrenal insufficiency, while values >500 pg/ml are diagnostic. Low concentrations of plasma ACTH are not diagnostic, except for the undetectable levels observed in patients with cortisol producing adrenal adenomas. Plasma ACTH concentration is also low in patients taking exogenous steroids.
  13. roxie60

    roxie60 Senior Member

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    So why are LOW serum ACTH levels flagged??????
  14. Little Bluestem

    Little Bluestem Senescent on the Illinois prairie, USA

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    Since STTM has you enter the unit of measure, I think you should enter the number exactly as given.
    Are you sure that you have the correct unit?
  15. roxie60

    roxie60 Senior Member

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    It was given as 290 and I had changed it to fit Dr Rinds Thyroid Scale, so putting in 290 pg automatically picks the unit for RT3. Not entirely sure they are correct.
  16. Little Bluestem

    Little Bluestem Senescent on the Illinois prairie, USA

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    It did not automatically pick the RT3 unit for me. Was the unit it picked for RT3 for you the same unit that was on your lab results?
  17. invisiblejungle

    invisiblejungle Senior Member

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    I don't consider Dr. Lam to be credible at all. I remember 3 years ago, he was all the rage on Curezone, but very few people actually got better with him.

    He actually treated people without doing any testing, so he had no idea if patients had high cortisol or low cortisol. And he put everyone on an identical protocol: ridiculously large doses of liposomal vitamin C and pantethine. Some people still have permanent sensitivities from the supplements he prescribed. In my opinion, Lam is the worst kind of "integrative" doctor.

    Not only that, but he lied about his financial interests. He claimed that he didn't sell supplements but recommended that his patients buy their stuff from Supplement Clinic. Well it turned out that Supplement Clinic was owned by his son. I would stay away from that whole operation.
    roxie60 likes this.
  18. roxie60

    roxie60 Senior Member

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    I keep all my lab results in a WORD table and I forgot to put the unit down for RT3. If I find that lab again I will update this post.
    Little Bluestem likes this.
  19. roxie60

    roxie60 Senior Member

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    Dr wants me to now add Metagenics Adrenogen. Anyone use this? Postive affects? I really dont want to but another supplement that doesnt help. How long have to take for benefit or see results?

    Metagenics Adrenogen®: 90 Tablet Bottle or 270 Bottle

    Adrenal Nutrition for Functional Support.

    Metagenics Adrenogen helps regulate hormones by providing high quality nutrition to the adrenal galnds. The adrenal glands are responsible for producing the adrenaline hormones epinephrine and norepinephrine. When these become unbalanced, a myriad of symptoms can ensue. Some of which are unregulated blood pressure, chronic fatigue, muscle weakness and irritability. To ensure your adrenal glands are getting all of the proper nutrients they need to remain balanced and healthy, Adrenogen is a great product.
    Adrenogen Recommendations:
    • One tablet three times daily or as directed by your healthcare practitioner.
    • Keep out of reach of children.
    • If pregnant or nursing, please consult your healthcare physician.
    What is Adrenogen?
    Adrenogen provides nutritional support for adrenal function by combining high-quality nutrients that are involved in hormone regulation. The body's adrenal glands produce stress hormones, steroid hormones, and blood pressure-regulating hormones.
    • Delivers a select blend of B vitamins involved in adrenal hormone production.
    • Provides adrenal concentrate† that is guaranteed raw (processed below 37°C) so the natural constituents remain intact.
    [​IMG]
    [​IMG]
    Metagenics Adrenogen® Ingredients:

    Riboflavin
    10 mg
    Vitamin B6 (as pyridoxine HCl)
    25 mg
    Pantothenic Acid (as D-calcium pantothenate)
    50 mg
    Raw Adrenal Concentrate (bovine†)
    80 mg
    para-Aminobenzoic acid (PABA)
    25 mg

    Other Ingredients:
    Microcrystalline cellulose, cellulose, calcium silicate, croscarmellose sodium, stearic acid, silica, magnesium stearate.
    †All bovine glandulars found in Metagenics products are imported from New Zealand.
    New Zealand has an active government-monitored BSE (Bovine Spongiform Encephalopathy) surveillance program and no known cases of BSE.
  20. roxie60

    roxie60 Senior Member

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    decided to go ahead and try it. just took one. I have had something going on with myhead today, like the feelinf of being sedated. all i have taken so far today is synthroid, lithium orotate and now adrenogen. this happened yesterday also. I added sudefed for the last few days due to having caught a cold and tired of blowing nose.

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