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What Causes Cold Hands And Feet, Fatigue And Weight Gain?

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Posted on Thu, 2 Feb 2017
Question: I am a 50-year old female. I have ongoing symptoms of cold hands/feet, fatigue, and mild weight gain (9 pounds) for over 2 years. I have been a fitness instructor for 15 years and exercise 5x a week (2x strength training and 4-5X cardio), and eat very healthy, and weighed 130 consistently for 48 years. I am baffled by this rapid weight gain. I am pre-menopausal. My TSH is always 1.5 or below. My last labs were 1.4 (TSH) (range of .45 - 4.5), Free T4 of .75 (range .82-1.7), and Free T3 of 2.4 (range 2.3-4.2). My T3 and T4 are marginal and in light of my symptoms, I would like to find out how I can resolve the problem. Over a period of a two years, I have had similar measures - TSH always low and in range, Free T3 and Free T4 always outside of range and too low. I have seen a doctor and the only way to get my T4 and T3 levels in range has been to take Synthroid which lowered my TSH to .2 which my doctor said was too low. Could it be one of other endocrine glands that is the problem and NOT the thyroid? Why is my TSH so low yet I cannot get the T3 and T4 in range to eliminate my symptoms without getting my TSH dangerously low? I am so miserable right now with my symptoms.
doctor
Answered by Dr. Binu Parameswaran Pillai (48 minutes later)
Brief Answer:
Lab errors/assay problems vs. HYPOPITUITARISM

Detailed Answer:
Good day.
Noted your question. Sorry to hear about your symptoms.
You guessed it right. If your TSH is normal or low despite your FT4 being low, you have to suspect problems outside the thyroid gland. Pituitary problems are known to cause such values. However, such readings are common due to lab errors /assay errors. But if repeat values are similar and in view if your symptoms, we have to suspect hypo pituitarism.

You need to see an endocrinologist and arrange for other pituitary functions after examination. You may also need an MRI scan of pituitary.
I must say that, in hypo pituitarism, TSH will remain low and dose titration is based on FT4 values, not TSH values.
Regards
Binu
Above answer was peer-reviewed by : Dr. Nagamani Ng
doctor
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Follow up: Dr. Binu Parameswaran Pillai (51 minutes later)
Thank you, Dr. XXXXXXX I have an appointment with an endocrinologist, but have to wait two more months for the appointment. They have asked me to gather all of my records and send them in advance, which I have. They will be able to see a steady and consistent pattern of testing with the usual in-range TSH and the borderline T3 and T4 readings.

Since you mentioned pituitary, I was "followed" for 10 years (yes, TEN years), because of what they thought was a pituitary tumor (this was in my 30's). Even though I had no symptoms, they did an MRI every other year (so 5 MRI's over a 10 year period) and the conclusion was that there was no tumor, that it was just an 'above average sized pituitary gland', especially given that there was no change in size over ten years and since I reported no symptoms.

Additional follow-up questions:
1. Could they have gotten the suspected pituitary tumor WRONG all of those years ago and it really was more than just a large-sized 'normal' pituitary gland? I will take this report to the endocrinologist at the end of February

2. I am debating on asking the holistic doctor who originally prescribed the Synthroid to try me on another brand/product to see if that might help. Maybe it is a thyroid issue and just a medication that my body isn't responding to. My T4 and T3 levels DID go up with the Synthroid as well as Cytomel that she prescribed, but again, it made my TSH go down as low as .01. Does the fact that the T4 and T3 DID go up, just with a lot of medication, give any additional clues as to whether this is a thyroid or pituitary problem? And would it be worthwhile to ask for a different thyroid medication to try?

3. Will taking a thyroid medication impact any testing they might do for pituitary if the endocrinologist does tests for that in two months? If my last dose was November 1, and I go see the endocrinologist in two more months (end of February), will that have given my body time to get all of the medication out of my system and for my thyroid and pituitary to get back to whatever their non-medicated state would be?

You have been so very helpful. I am suffering and I think the worst is the freezing cold all of the time. I have to wear a winter coat in my house and we keep the thermostat at 78 degrees. And the fatigue. I am doing my best to hold out until the February appointment but need some hope and direction right now. Thank you for providing BOTH! :)))))))))))))))
doctor
Answered by Dr. Binu Parameswaran Pillai (39 minutes later)
Brief Answer:
Follow up

Detailed Answer:
Thank you for the reply. Noted the questions and MRI findings. I am glad that you had MRI done in the past and yoyr doctors were thinking in right direction. However, please understad that pituitary problems are not always due to a tumour. Sometimes your TSH producing cells in thyroid ( Thyrotrophs) can fail to produce enough TSH without having a tumor. In short, there can be hypopituitarism due to causes other than tumors. However this is more common in younger ages, but not impossible at your age. Problems of hypothlamus gland also can cause pituitary to fail.

To answer your questions,
1. Could they have gotten the suspected pituitary tumor WRONG all of those years ago and it really was more than just a large-sized 'normal' pituitary gland? I will take this report to the endocrinologist at the end of February?
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If serial monitoring was done and excluded a tumor, then there is unlikely to have a tumor. Hypophysitis ( inflammation of pituitary gland) can give an imoression of a large gland, but has typical features on MRI scan. And it is not possible for hypophysitis to exist for 10 years.
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2) I am debating on asking the holistic doctor who originally prescribed the Synthroid to try me on another brand/product to see if that might help. Maybe it is a thyroid issue and just a medication that my body isn't responding to. My T4 and T3 levels DID go up with the Synthroid as well as Cytomel that she prescribed, but again, it made my TSH go down as low as .01. Does the fact that the T4 and T3 DID go up, just with a lot of medication, give any additional clues as to whether this is a thyroid or pituitary problem? And would it be worthwhile to ask for a different thyroid medication to try?
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As i previously mentioned, in hypo PITUITARISISM, we do not titrate the dose of medicine based on TSH levels. ( IN HYPO THYROIDISM, yes, we do titrate based on TSH levels) The drug dose is titrated based on Free T4 levels. Hence, an endocrinnologist is a better person than other doctors in this situation. Ft4/Ft3 changes with thyoid hormone replacement can not differentiae between problems of thyroid and pituitary. A different thyroid medication is not likely to change the situation.
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3. Will taking a thyroid medication impact any testing they might do for pituitary if the endocrinologist does tests for that in two months? If my last dose was November 1, and I go see the endocrinologist in two more months (end of February), will that have given my body time to get all of the medication out of my system and for my thyroid and pituitary to get back to whatever their non-medicated state would be?
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Not to worry. Three month period is good enough for medication effects to wean off. Sometimes, drug induced TSH changes may take a bit longer to normalise. However, a trained and experienced endocrinologist will understand the situation well.
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It may be worthwhile to get your 8 AM serum cortisol levels ( fasting) and ACTH levels done in addition to Thyroid tests. Thyroid related issues tend to worsen during winter and it is good to avoid exposure to cold.

Happy to help further if you have any more questions.

Kind regards
Binu

Above answer was peer-reviewed by : Dr. Remy Koshy
doctor
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Follow up: Dr. Binu Parameswaran Pillai (6 hours later)
Thank you Dr. XXXXXXX SO much. This helps me tremendously as I prepare for my appointment. I will get the additional test you suggested as well.

If my T4 and T3 remain 'borderline' and/or at the very, very bottom of 'normal', should I go back on medication OR is that really only for patients who are obviously out of normal range? It seems like I am in a gray area and wonder if I should just try and deal with the symptoms since it is only borderline and I know there are risks with any medication.

doctor
Answered by Dr. Binu Parameswaran Pillai (9 hours later)
Brief Answer:
Avoid Biotin prior to your next thyroid test

Detailed Answer:
My pleasure.

In clinical medicine, we look at the patients and their symptoms rather than just the numbers. If you have hypothyroidism related symptoms and If your T4 and T3 remains low, and once if we find that your cortisol levels are good, there is no harm taking a small dose thyroxine in an attempt to keep T4 above mid normal range and observe of the symptoms improve.

Indeed, in your case, it looks like as if there are gray areas which need to be worked out completely to find a solution. I hope since you are off any kind of medications for now, a fresh test done in Feb may reveal things in a better way. Try not to take any supplements containing Biotin in large dose few days before you do thyroid tests.

Regards
Binu
Above answer was peer-reviewed by : Dr. Arnab Banerjee
doctor
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Follow up: Dr. Binu Parameswaran Pillai (5 hours later)
This is SO helpful to me and will allow me to go to my appointment better prepared. Thank you for being SO thorough and prompt, Dr. XXXXXXX Pillai! :) I will submit my review per the site's request and have no further questions at this time. Thank you again and Happy New Year!
doctor
Answered by Dr. Binu Parameswaran Pillai (2 hours later)
Brief Answer:
Best wishes

Detailed Answer:
My pleasure. Happy to help. Happy new year.
Regards
Binu
Above answer was peer-reviewed by : Dr. Nagamani Ng
doctor
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Follow up: Dr. Binu Parameswaran Pillai (6 days later)
Hi, Dr. XXXXXXX - I paid for additional follow-up with you, as you were so helpful before. My appointment is still weeks away yet my symptoms are getting worse - and honestly, creating a lot of anxiety to the point I can not focus on my work and family.

I went through an online lab and re-tested my thyroid levels myself before the late February appointment just to see what my labs have done instead of having to wait and let the doctor do it in a month only to have a wait another month to get the results back (I'm sure she will test again anyways, but I wanted to go ahead and check and see what was going on). After being off the Synthroid and the Cytomel for 10 weeks, I had a TSH of 2.93 (range 0.4 - 4.5) Free T3 of 2.8 (range 2.3 - 4.2),and Free T-4 0.9 (range .8-1.8). I had nothing else other than some mildly elevated cholesterol levels that looked out of the ordinary.

I realize I need some additional reassurance and/or answers on some of this to be able to make it until I can see this doctor in another month:

1. With these numbers ALL within the normal range, is it unusual that I am having these symptoms (COLD hands and feet and overall coldness to the point of wearing a coat in a house that is 78 degrees with the heater on, weight gain of 7-9 pounds over a year, and fatigue despite adequate rest). What would YOU recommend to your patient who had labs like these as far as whether or not you would recommend they start medication?

2. When I was on the Synthroid and Cytomel, the only way I could get my T4 and T3 higher was to take so much Synthroid (next dose up from 88, I believe it was 112?) that it put my TSH down to .01 which I know is not good. Is it healthy to go on THAT much medication if my labs are just 'borderline'? I am wondering if I just need to learn to live with this.

3. If the T3 is really the active hormone, why can't i just take Cytomel? I never really improved on the Synthroid until the doctor added Cytomel about 6 months into the initial treatment plan, and then I got better. I just wondered if the Synthroid ever really did anything and if it was the Cytomel that made me feel better, if it would have been better off just to start with that. It was a low dosage (20 mcg a day). I know the risks and that it isn't ideal, but why would this not be a good option for me?

4. Have I "messed up" my thyroid by taking Synthroid and Cytomel for two years - even if under direction and supervision of an MD? Will the only way to get my numbers more in the higher ends of the range to relieve symptoms be to get and stay on these medications for life?

I am sooo tempted to start back on my 88 mcg. of Synthroid and 20 mcg. of Cytomel before that February appointment. I feel THAT bad. I certainly don't want to make myself WORSE so I keep refraining and trying to wait it out. Can you offer insight on my additional questions?
doctor
Answered by Dr. Binu Parameswaran Pillai (14 hours later)
Brief Answer:
Folow up

Detailed Answer:
Good day,

Thank you for the question. Happy to help. Noted your questions ,concerns and the thyroid blood reports:

Let me answer your questions one by one.

1. With these numbers ALL within the normal range, is it unusual that I am having these symptoms (COLD hands and feet and overall coldness to the point of wearing a coat in a house that is 78 degrees with the heater on, weight gain of 7-9 pounds over a year, and fatigue despite adequate rest). What would YOU recommend to your patient who had labs like these as far as whether or not you would recommend they start medication?
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Most symptoms of hypothyroidism are nonspecific. Which means, these symptoms can exist in other diseases as well. With a normal thyroid function test like in yours, I will never recommend starting thyroxine or Cytomel to my patients. I am sorry to say, but we may need to search for another causes for your symptoms.
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2. When I was on the Synthroid and Cytomel, the only way I could get my T4 and T3 higher was to take so much Synthroid (next dose up from 88, I believe it was 112?) that it put my TSH down to .01 which I know is not good. Is it healthy to go on THAT much medication if my labs are just 'borderline'? I am wondering if I just need to learn to live with this.
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With the current levels of your thyroid hormones, it is not recommended to start medications now. However, I do understand that some people may have "tissue level hypothyroxinemia" where they have symptoms despite having normal thyroid blood levels. However, endocrine society has not recommended to treat anyone if blood levels are normal. It can suppress TSH and also there are chances of osteoporosis and irregular heart beats in such cases.
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3. If the T3 is really the active hormone, why can't i just take Cytomel? I never really improved on the Synthroid until the doctor added Cytomel about 6 months into the initial treatment plan, and then I got better. I just wondered if the Synthroid ever really did anything and if it was the Cytomel that made me feel better, if it would have been better off just to start with that. It was a low dosage (20 mcg a day). I know the risks and that it isn't ideal, but why would this not be a good option for me?
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Cytomel is pure T3 preparation and it is used only when we withdraw synthroid in certain patients. ( examples in the treatment of thyroid cancer patients and while preparing them for radio iodine treatment). Some doctors do add Cytomel along with Synthroid and I agree that many patients do very well on it. However, doctors do have to work with in the approved rules of " guidelines:.

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4. Have I "messed up" my thyroid by taking Synthroid and Cytomel for two years - even if under direction and supervision of an MD? Will the only way to get my numbers more in the higher ends of the range to relieve symptoms be to get and stay on these medications for life?
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I would say that taking Synthroid and Cytomel doesn't damage your thyroid. The TSH may go down, but it will recover in few months. I would advice not to start medicines now and recheck the whole thyroid blood works after few months to see the trend.

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As I mentioned earlier, we may have to look for reasons beyond/other than thyroid. Depression is a common cause of such symptoms. Do you think that you have any symptoms of depression ? Please feel free to discuss further,

regards
Binu

Above answer was peer-reviewed by : Dr. Prasad
doctor
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Follow up: Dr. Binu Parameswaran Pillai (8 hours later)
Dr. XXXXXXX I tried to follow-up and I cant see where it took my follow-up questions. I am going to try again and HOPE to remember all of what I wrote earlier. My apologies if you receive this twice!

1. Thank you for clarifying that it is your professional recommendation that a patient you would see with my current blood work that you would NOT recommend medication. I have had one other MD two years ago tell me the same thing. The alternative medicine doctor I had been seeing is who suggested it and started me on the Synthroid and Cytomel a year ago. Her diagnosis was "suboptimal thyroid." Do the two types of practitioners simply follow different guidelines? I get what you are saying that your guidelines (I assume guidelines for endocrinologists) do not warrant medication for someone with my blood work. I did feel better for a while -almost a year - but then it stopped working which is why I questioned if I needed it in the first place and have that late-February appointment with an endocrinologist. Just wondering if alternative medicine docs have different guidelines (she is a D.O.).

2. Would your recommendations change even if my problem was determined to be hypopituitary? I know you mentioned that is a possibility and what I am planning on talking to the endocrinologist about in February. I know you said the medication used to treat a patient with that diagnosis might be the same as for a thyroid patient, only t3 and t4 are what is looked at and NOT the TSH. Would your recommendations for no medication for a patient with my readings but with symptoms be the same if my problem was determined to be hypopituitary problems?

3. Just curious what SYnthroid is supposed to do for T-4 levels. Mine were the same on 88 mcg. of Synthroid as when I was on NO medication. I understand Synthroid lowers TSH, but what is it supposed to do to T4 levels? And if those levels are the same with or without hte medication, what exactly does that mean? That the medication isn't working? That someone didn't need it to begin with? None of the above?

4. I am a fitness enthusiast and while not a body builder, am on a couple of online forums where some of the bodybuilders talk about getting their own Cytomel and using it for periodic "treatments" to gain energy, increase metabolism, etc. as a competitive measure. That really scares me, but I am also so desperate to get my energy levels back as well as a normal metabolism, I almost think I would try it if I knew it wouldn't do something totally crazy to my body. What COULD happen to someone who put themselves on a low-dose treatment like they say that they do before competitions? I understand those with heart conditions don't need to mess around with meds like Cytomel and I also understand long-term use and bone issues, but what risks do these people have by doing short (4-6 weeks) treatments to help their body with energy and metabolism?

Thank you again for clarifying and my apologies if this came through twice.
doctor
Answered by Dr. Binu Parameswaran Pillai (27 hours later)
Brief Answer:
Hypothyroidism

Detailed Answer:
Good day,
Sorry for the delay.
Noted your questions.

1) Alternative medicine practioners do not follow Modern medicine guidelines. Modern medicine guidelines are evidence based professional recommendations. Sub optimal thyroid function is called hypothyroidism and in that, Free T4 and Free t3 will be low and TSH will be high. However, in hypopituitarism, Free T4, Free T3 will be low and TSH will be low or low normal. There is one more variey called Sub clinical hypothyroidism, where only TSH will be high and Free T4 and Freee t3 renains in the low normal range.

2) Yes, my opinion would change in hypopituitrism. However, in hypopituitarism, Free T4 and Free T3 levels will be low ( lower than normal range) and TSH will be either lower than normal or in low normal range. A repeat thyroid function test ( after a longer duration of stoppping medication) will help further to determine your baseline thyroid hormone status.
As i mentioned earlier, symptoms of hypothyroidism are non specefic. There are specefic symptoms like thyroid swelling. In the absence of that, with a normal Thyroid blood profile, it is not good to start treatmemt if Free T4 and Free T3 are normal.

3) Synthroid is nothing but T4 itself ( levothyroxine). It will rise Free T4/T4 levels. And if the dose is in excess, it will cause TSH to go low.

4) If you use a medicine for non recommended causes, it is called abuse. I can not justify using a hormone just to boost metabolism ( if the hormone blood levels are normal). Metabolism may increse when you take thyroxine. But as for now, there are no recommendations to take synthroid/cytomel just to boost metabolism if your blood levels are normal. Even for short while if you use these medicines, the hypothalamo-pituitary-thyroid axis get disturbed and it will take long time for the body's own system to recover.

My recommendation would be to kindly avoid taking synthroid/cytomel until you see an endocrinologist so that a more realistic baseline thyroid blood values can be obtained. Otherwise, the lab results will even confuse the doctor,

Above answer was peer-reviewed by : Dr. Nagamani Ng
doctor
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Follow up: Dr. Binu Parameswaran Pillai (14 hours later)
Thank you for all of this great information. I am going to continue as is with no medication and let my blood levels stabilize so the doctor will have a good baseline. It is so hard to wait and not do something when the symptoms seem to get worse, but I want a good long-term solution and not a quick fix so I will continue to do the hard part of just waiting and letting things stabilize so the doctor can make an accurate assessment. I think now I realize that the issue could be one of many things - which is different than before when I felt sure I knew it could only be one thing. Thank you for opening my eyes to that! If doctor determines medication would truly not be helpful, I am going to ask about various supplements and/or foods that would help my body not feel so cold and tired all of the time. She may have thoughts on that as well (I don't care if it is a medicine or a supplement or a food - whatever will help me and is safe, I am open to trying). Thank you again for your expertise and thorough answers!!

doctor
Answered by Dr. Binu Parameswaran Pillai (33 hours later)
Brief Answer:
Right decision

Detailed Answer:
Thank you.
I think your decision not to take synthroid or cytomel until medical review in February is a right one. May I request you to stop vitamin supplements containing Biotin a week before your next blood tests to minimize the interference with the tests. While you wait for the medical review, it may be good to start an exercise regimen and include yoga in it. Many of my patients benefit from it.
Wish you good health in the new year.
Regards
Binu
Above answer was peer-reviewed by : Dr. Nagamani Ng
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Dr. Binu Parameswaran Pillai

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What Causes Cold Hands And Feet, Fatigue And Weight Gain?

Brief Answer: Lab errors/assay problems vs. HYPOPITUITARISM Detailed Answer: Good day. Noted your question. Sorry to hear about your symptoms. You guessed it right. If your TSH is normal or low despite your FT4 being low, you have to suspect problems outside the thyroid gland. Pituitary problems are known to cause such values. However, such readings are common due to lab errors /assay errors. But if repeat values are similar and in view if your symptoms, we have to suspect hypo pituitarism. You need to see an endocrinologist and arrange for other pituitary functions after examination. You may also need an MRI scan of pituitary. I must say that, in hypo pituitarism, TSH will remain low and dose titration is based on FT4 values, not TSH values. Regards Binu