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Have hypoglycemia. Feeling fatigue, headache and lightheaded. Cortisol stimulation test done. Suggestion

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Practicing since : 2001
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I would like help understanding my labs. I have been very fatigued with headaches and lightheadedness. I also experience hypoglycemia. My B/P can get very low. I had a Cortisol Stimulation test ordered by a hematologist. During that particular test, they forgot to take my ACTH level but my b/p before the test was 84/42 and cortisol was 9.1. After the injection the cortisol went to 23.1 and my b/p went to a normal range. I also felt great for a few hours. The Dr. called me back in to get the ACTH (that was forgotten) another morning. That particular test showed that my ACTH was 8.0 and my cortisol was 3.7. Please help me understand these low normals and if it could be causing my fatigue, h/a's and low b/p. Side note: My b/p can be within a normal range, but I still feel horrible so I don't think the low b/p is the only reason for feeling sick. Also, I'm not a runner which I know can contribute to lower b/p.
Posted Wed, 24 Apr 2013 in Thyroid Problem and Hormonal Problems
Answered by Dr. Shehzad Topiwala 16 hours later
Yes you are absolutely right in understanding the need to see an endocrinologist, in order to comprehensively assess these complex hormone test results. In addition to an array of more endocrine related tests such as cbc, cmp, prolactin, IGF1, FSH, LH, estradiol, TSH, Total T4, free T4 , Total T3, T3 resin uptake (to name a few), the endocrinologist will perform a thorough clinical exam to corroborate lab findings. Then based upon the results of preliminary hormonal assessments, he or she may order dynamic tests such as the one you underwent. It is called the ACTH stimulation test. There is a systematic way to go about performing these complicated tests. It requires the expertise and experience of an endocrinologist to interpret test results in the light of clinical symptoms.The greatest value of an 8 am cortisol is when it is drawn at that time, provided you have a conventional sleep wake cycle like most people. But if you work night shifts then the test may need to be performed closer to waking hours. A value above 15 to 18 is reassuringly good. A value below 6 is concerning and less than 3.5 or so is worrisome and highly suggestive of adrenal insufficiency. Anything between 6 and 15 is in the grey zone and merits dynamic procedural testing based on the discretion of the treating endocrine physician. For more information, peruse WWW.WWWW.WW
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Follow-up: Have hypoglycemia. Feeling fatigue, headache and lightheaded. Cortisol stimulation test done. Suggestion 4 hours later
Thank you so much Dr. Shehzad. Just wanted to make sure that you understood correctly that I already had the ACTH stimulation test. In that particular 8:00 am test, my cortisol level was 8 prior to the ACTH stimulation. After the injection it went to 23.1. Because they forgot to draw my ACTH level during that procedure, I went back a few days later at which point they drew my cortisol and ACTH. The level of cortisol on that day was 3.7 & ACTH was 8.

So would this be suggestive of secondary adrenal sufficiency?
Thank you so much for your thorough response.
Answered by Dr. Shehzad Topiwala 14 hours later
I see. When you went back a few days later, did you have the blood sample drawn around 8 am ?
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Follow-up: Have hypoglycemia. Feeling fatigue, headache and lightheaded. Cortisol stimulation test done. Suggestion 5 hours later
It was around 10:00 am
Answered by Dr. Shehzad Topiwala 8 hours later
Since you had the sample taken couple hours after the ideal time, it is expected to be lower. Going back to your ACTH stimulation test result, even though the ACTH level was inadvertently omitted it is not absolutely necessary to have drawn it. It is notable that if the ensuing blood sample after the ACTH injection showed a cortisol of 23.1 which is considered a pass ie normal. But it is important that this sample was drawn either at 30 minutes or 60 minutes after the ACTH injection.
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