Brief Answer:
A detailed explanation of the test results and recommendations.

Detailed Answer:
Hello and welcome to 'Ask a Doctor' service,

I carefully read your query and also checked the uploaded report and pictures.

As for the lab results:

1. You clearly have very low thyroid function: your TSH is almost 20 times the upper norm. Sometimes, patients may develop severe symptoms and even a medical emergency called "myxedema coma" if this is not treated properly and quickly.

You may choose to increase the dose of levothyroxine as it is obvious that 50mcg is not sufficient for you. In mild to moderate hypothyroidism patients need to take 100-125 mcg of Levothyroxine a day so in your case, I think higher doses are needed. You can start so far to take 100 mcg and in a week go to 125-150 mcg a day till you see your doctor.

Your doctor may decide to further increase the dose. The TSH has to be measured every 4-6 weeks to determine if the dose of Levothyroxine you are taking is appropriate or you need to change it.

When TSH reaches 5 or less then you can stay with that dose and check your TSH every 3 months and then every 6 months.

It is important to have regular checks of the TSH, at least every 1-2 years after it has been stable and within the normal range for 2 years.

Please be aware that if confusion and disorientation last, you may need an urgent visit with the doctor to make sure you are not developing myxedema coma (this may also cause low body temperature, low blood pressure, seizures, altered mental status).

2. You have increased prolactin levels. This is a common finding in patients with low thyroid function. So, after treating the hypothyroidism and TSH has reached normal level, you may check again prolactin levels to see if they go back to the norm.

3. Your testosterone levels are too high. This may be due to the injections you are taking. High testosterone may also cause problems such as mood swings, euphoria, impaired judgment, irritability, heart problems, increased risk for clotting, impaired sperm count, liver problems, enlarged prostate, etc. You may need to address this with your doctor and decide on the dose you use.

4. FSH and LH are hormones that the brain produces to stimulate the sexual organs and sexual hormone production. They are low in your case and this is normal as testosterone injections do suppress these hormones.

As for the skin rash:

I think this seems like a fungal infection. I would advise you to use a combination of an antifungal and a mild steroid (Miconazole or Clotrimazole combined with Hydrocortisone or Betamethasone). You may use the steroid first as a thin layer (hydrocortisone or betamethasone) over the rash and then the antifungal (miconazole or clotrimazole) over the steroid, twice a day for 7-10 days.

Normally, it should fade within a week or so. If you do not notice any improvement in the first 5 days or the rash gets any worse you will need to stop the treatment and see a doctor.

I hope this answers your query. I remain at your disposal in case further medical assistance is needed.

Regards,
Dr. Antoneta Zotaj
General and Family Physician

---

Brief Answer:
A detailed explanation of the test results and recommendations.

Detailed Answer:
Hello and welcome to 'Ask a Doctor' service,

I carefully read your query and also checked the uploaded report and pictures.

As for the lab results:

1. You clearly have very low thyroid function: your TSH is almost 20 times the upper norm. Sometimes, patients may develop severe symptoms and even a medical emergency called "myxedema coma" if this is not treated properly and quickly.

You may choose to increase the dose of levothyroxine as it is obvious that 50mcg is not sufficient for you. In mild to moderate hypothyroidism patients need to take 100-125 mcg of Levothyroxine a day so in your case, I think higher doses are needed. You can start so far to take 100 mcg and in a week go to 125-150 mcg a day till you see your doctor.

Your doctor may decide to further increase the dose. The TSH has to be measured every 4-6 weeks to determine if the dose of Levothyroxine you are taking is appropriate or you need to change it.

When TSH reaches 5 or less then you can stay with that dose and check your TSH every 3 months and then every 6 months.

It is important to have regular checks of the TSH, at least every 1-2 years after it has been stable and within the normal range for 2 years.

Please be aware that if confusion and disorientation last, you may need an urgent visit with the doctor to make sure you are not developing myxedema coma (this may also cause low body temperature, low blood pressure, seizures, altered mental status).

2. You have increased prolactin levels. This is a common finding in patients with low thyroid function. So, after treating the hypothyroidism and TSH has reached normal level, you may check again prolactin levels to see if they go back to the norm.

3. Your testosterone levels are too high. This may be due to the injections you are taking. High testosterone may also cause problems such as mood swings, euphoria, impaired judgment, irritability, heart problems, increased risk for clotting, impaired sperm count, liver problems, enlarged prostate, etc. You may need to address this with your doctor and decide on the dose you use.

4. FSH and LH are hormones that the brain produces to stimulate the sexual organs and sexual hormone production. They are low in your case and this is normal as testosterone injections do suppress these hormones.

As for the skin rash:

I think this seems like a fungal infection. I would advise you to use a combination of an antifungal and a mild steroid (Miconazole or Clotrimazole combined with Hydrocortisone or Betamethasone). You may use the steroid first as a thin layer (hydrocortisone or betamethasone) over the rash and then the antifungal (miconazole or clotrimazole) over the steroid, twice a day for 7-10 days.

Normally, it should fade within a week or so. If you do not notice any improvement in the first 5 days or the rash gets any worse you will need to stop the treatment and see a doctor.

I hope this answers your query. I remain at your disposal in case further medical assistance is needed.

Regards,
Dr. Antoneta Zotaj
General and Family Physician

---

Brief Answer:
Detailed answer below

Detailed Answer:
Hello and welcome back,

It is a pleasure to assist you, so feel free to ask anytime you have a medical concern.

Hallucinations may happen with high testosterone levels and in both low and high thyroid function. It is very difficult in your case to know for sure which is really causing them.

It is a bit strange the T4 came out normal but you have to consider that this is only one measurement (there is a chance of if being unreal) and also T4 shows the hormone at a point in time. On the other hand, TSH is checked at least twice and both times it comes out very high result so it is for sure you TSH is very high.

TSH can be very high when the thyroid is not working properly (the pituitary gland that produces TSH tries to stimulate the thyroid to produce T3 and T4) and this is the case in more than 95% of the cases and is called peripheral hypothyroidism. Rarely, a primary tumor in the pituitary gland may cause overproduction of the TSH and in this case, the thyroid gland produces a lot of T3 and T4 (there would be very high levels of these as well). This is called central hyperthyroidism and happens very rarely.

I think in your case because the T4 is not too high, it is more likely you have the common form of hypothyroidism, due to the low function of the thyroid gland and in this case you should increase the dose of levothyroxine and it should not cause you any problems.
The dose of 100 mcg of Levothyroxine is a dose that is used in mild forms of hypothyroidism so I do not think it is causing you any problems. It takes a while for the patients to feel better after they start Levothyroxine and in your case very likely you need a higher dose of it to have normal levels so I am not surprised you do not notice much difference as yet.

As for myxedema coma, this is more common in elderly patients that have chronic conditions or it can be aggravated during an acute infection. So, the risk in your case is small but should be considered if you notice any worsening.

To conclude:
- both high doses of testosterone and low thyroid function can affect the brain and cause hallucinations. It is difficult to know in your case which is the exact cause.
- The dose of Levothyroxine you are using is not too high and I do not think that the increase of Levothyroxine is the cause of the hallucinations (unless you have the central form of hyperthyroidism, which is not very likely in your case)
- The T4 you recently checked is a measurement in a point of time, so it coming out almost normal can be explained with a not so accurate result as in the previous check it was low (completely justifying the high TSH and the diagnosis of peripheral hypothyroidism).
- The doctor may check anti-TPO to make sure if you have Hashimoto, which is the most common cause of peripheral hypothyroidism and confirms the diagnosis (no doubts if the TSH is high due to low thyroid function or a mass producing TSH in the pituitary gland)
- Myxedema coma is very rare in your age but I mentioned it so you are aware of it and see your doctor soon if you notice any of the symptoms mentioned. The increase in the dose of Levothyroxine does make it even more unlikely but I think it will come a time soon that you will need to increase the TSH again (increases are done not earlier than in a week's time, so you should not rush now).

I hope this answers your query. I remain at your disposal in case further medical assistance is needed.

Regards,
Dr. Antoneta Zotaj
General and Family Physician

---

Brief Answer:
Detailed answer below

Detailed Answer:
Hello and welcome back,

It is a pleasure to assist you, so feel free to ask anytime you have a medical concern.

Hallucinations may happen with high testosterone levels and in both low and high thyroid function. It is very difficult in your case to know for sure which is really causing them.

It is a bit strange the T4 came out normal but you have to consider that this is only one measurement (there is a chance of if being unreal) and also T4 shows the hormone at a point in time. On the other hand, TSH is checked at least twice and both times it comes out very high result so it is for sure you TSH is very high.

TSH can be very high when the thyroid is not working properly (the pituitary gland that produces TSH tries to stimulate the thyroid to produce T3 and T4) and this is the case in more than 95% of the cases and is called peripheral hypothyroidism. Rarely, a primary tumor in the pituitary gland may cause overproduction of the TSH and in this case, the thyroid gland produces a lot of T3 and T4 (there would be very high levels of these as well). This is called central hyperthyroidism and happens very rarely.

I think in your case because the T4 is not too high, it is more likely you have the common form of hypothyroidism, due to the low function of the thyroid gland and in this case you should increase the dose of levothyroxine and it should not cause you any problems.
The dose of 100 mcg of Levothyroxine is a dose that is used in mild forms of hypothyroidism so I do not think it is causing you any problems. It takes a while for the patients to feel better after they start Levothyroxine and in your case very likely you need a higher dose of it to have normal levels so I am not surprised you do not notice much difference as yet.

As for myxedema coma, this is more common in elderly patients that have chronic conditions or it can be aggravated during an acute infection. So, the risk in your case is small but should be considered if you notice any worsening.

To conclude:
- both high doses of testosterone and low thyroid function can affect the brain and cause hallucinations. It is difficult to know in your case which is the exact cause.
- The dose of Levothyroxine you are using is not too high and I do not think that the increase of Levothyroxine is the cause of the hallucinations (unless you have the central form of hyperthyroidism, which is not very likely in your case)
- The T4 you recently checked is a measurement in a point of time, so it coming out almost normal can be explained with a not so accurate result as in the previous check it was low (completely justifying the high TSH and the diagnosis of peripheral hypothyroidism).
- The doctor may check anti-TPO to make sure if you have Hashimoto, which is the most common cause of peripheral hypothyroidism and confirms the diagnosis (no doubts if the TSH is high due to low thyroid function or a mass producing TSH in the pituitary gland)
- Myxedema coma is very rare in your age but I mentioned it so you are aware of it and see your doctor soon if you notice any of the symptoms mentioned. The increase in the dose of Levothyroxine does make it even more unlikely but I think it will come a time soon that you will need to increase the TSH again (increases are done not earlier than in a week's time, so you should not rush now).

I hope this answers your query. I remain at your disposal in case further medical assistance is needed.

Regards,
Dr. Antoneta Zotaj
General and Family Physician

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