Blood lab results-help for interpretation

[Miss_Nestor]

Hi,

I had recently a short synacthen test done. The NHS scheduled it because I have a diagnosis of adrenal fatigue (4 points saliva cortisol test), and they don't believe in adrenal fatigue. The doctors said my results are normal, but when I look at the NHS guidelines, it's not.

9 am cortisol: 639

30 minutes after synacthen injection: 771

I had this test done the day after I had a bike accident. I was in pain all night, so it might be why my morning cortisol is a bit high.

In the NHS guidlines, they say that to exclude adrenal insufficiency, we have to observe a incremental rise in cortisol > 200 nmol/L AND a 30 min value > 600 nmol/L

So I don't understand why the NHS endocrino said that my test is normal.

I also have new thyroid and iron results. Could you please comment on it. I was on 60 mg of NDT. I have now added 6.25 mcg of T3, but I still don't feel great.

RT3: 0.07 mcg/L (0.09-0.35)

T3 libre 4,02 pmol/L 3,1 - 6,8

T4 libre 6,87 pmol/L 12,00 -22,00

VS (erythrocyte sedimentation rate) 1ère heure 7 mm (<10 )

VS 2ème heure 18 mm (< 20)

Iron 102 µg/dL 37 à 145

Transferrine 2,65 g/L 2,00 à 3,60

Capacité totale 370 µg/dL 250 à 350

Capacité latente 268 µg/dL

Saturation 27,6 % 25,0 à 40,0

Ferritine 58 ng/mL 15 à 150

[Hidden]

Did they do an ACTH blood test at the same time as the SST? This helps to determine whether this is a pituitary or adrenal issues. However your cortisol level is slightly above the normal range for that time of day. I don't think that the accident would elevate your cortisol results as both pain & an accident will deplete your cortisol levels not elevate it. With a result like that would exclude adrenal insufficiency but would lend itself to Cushing's syndrome. Although your cortisol did not rise according to the guidelines it was rather high to start off with so I wouldn't have wanted to see an even higher rise. I have secondary adrenal insufficiency due to a tumour which caused Cushing's so have a bit of experience of them both. Hope that helps?

[Miss_Nestor in reply to Hidden]

Cushing's was ruled out a while ago. They made me do the tests 8 times though!

[MaisieGray]

It was unhelpful to have the test whilst in pain and having had an accident - it was unlikely to return results reflective of your normal status, which in a calmer state "might" be lower. However, I believe you are misinterpreting your results and the NHS guidance. The guidance says that results in excess of 200nmol/L & 600 nmol/L rule out adrenal insufficiency ie are normal. Your results were 639 & 771 respectively and, as they stand, are therefore normal as the Dr said ie no adrenal insufficiency. Did you mention the accident to him?

Your thyroid results show you to be under-medicated, and on only 1 grain NDT that is unsurprising. Why did you not increase the NDT, rather than adding in mono-T3?

[Miss_Nestor in reply to MaisieGray]

Thank you for your reply. I really think the NHS guideline says that cortisol has to increase by more than 200 because I have read it in 3 different websites from different countries.

I have added more T3 because last summer I was on 90 and then 75 mg of NDT and my RT3 was too high. Do you think it’s not a good idea?

[MaisieGray in reply to Miss_Nestor]

Do you have the link to the source document from which you took the quote "to exclude adrenal insufficiency, we have to observe a incremental rise in cortisol > 200 nmol/L AND a 30 min value > 600 nmol/L" because as written, the preposition is missing. I inferred it to mean "incremental rise in cortisol" to >200 nmol/L; whereas you have read it to mean "incremental rise in cortisol by > 200 nmol/L. The latter makes seems less likely; not least because another online NHS document states "Further blood samples will be taken to measure cortisol after 30 minutes and after 60 minutes" ie measure the level, not the increase.

Reverse T3 can be elevated in a number of conditions associated with a reduction in the metabolic rate, notably starvation/calorie restriction, extreme carbohydrate restriction, chronic heart failure, and alsonon-thyroidal illness syndrome (aka “low T3 syndrome”) seen in critical illness, very elderly patients, chronic stress, myocardial infarction, and chronic inflammatory states etc. In these cases, the rise in rT3 is a consequence, not a cause, of the alterations in intracellular thyroid hormone metabolism directed by the deiodinase enzymes, the relative activities of which are affected by the condition itself. Any interpretation of the relative levels of T3 and rT3 must take into account all the factors that affect the activity of all three deiodinases - reactivation of the D3 deiodinase and down-regulation of the D1 deiodinase contribute to both increased rT3 formation and to reduced rT3 clearance, while at the same time reducing T3 synthesis from T4; so conditions affecting the expression of D1 and D3 in this way have a profound impact on circulating levels of T3 and rT3 and the T3/rT3 ratio. So its more important perhaps, to address what's driving the increase in rT3 than simply adding more T3.

[Miss_Nestor in reply to MaisieGray]

Thank you for your very detailled answer. I don't know whqt is driving my rT3 high.

About the synacthen test, the link is here: homerton.nhs.uk/our-service...

English is not my first language; so I'm probably wrong!

[MaisieGray in reply to Miss_Nestor]

Thank you for posting the link.

The NHS wrote:

"All patients should have had a 9am cortisol taken before the test is arranged. If the level is above 500nmol/L or below 100nmol/L the test is generally unnecessary ...... Adrenal insufficiency is excluded by an incremental rise in cortisol of >200 nmol/L and a 30 min value >550 nmol/L. The baseline cortisol should exceed 190 nmol/L."

So your test going ahead with a 9 am sample of cortisol = 639, fits with the baseline requirement of min. 190 nmol/L but seems contradictory to the 500 nmol/L upper limit (or perhaps they were taking account of your bike accident pain/stress & factoring in a possible false high - you didn't confirm if you had mentioned it to the Dr). But importantly, the NHS text provides the preposition "incremental rise in cortisol of >200 nmol/L"; and I agree with you, that at 771 it seems to indicate that your +30 minutes result did not show a rise in cortisol of >200 nmol/L.

[Miss_Nestor in reply to MaisieGray]

Sorry, I forgot to answer. I didn't see a doctor, but I mentioned it to the nurse. I even asked if we should reschedule the test and she said no.