What should I ask my doctor?
March 9, 2010 10:27 PM   Subscribe

Years of fatigue and related symptoms. YANAD but what questions should I ask my doctor? What tests should I ask for?

For the past several years, I have been consistently fatigued and have had various other symptoms that could indicate anything from Chronic Fatigue Syndrome to thyroid issues to adrenal issues to anemia to a sleep disorder to depression. Assuming it is depression, I have spent years trying many different therapists and kinds of therapy, and several different antidepressants (prozac, wellbutrin, celexa, cymbalta). I am more than willing to keep trying different therapists and medications until I find a combo that works for me, but I want to unequivocally rule out all the other possible causes for my symptoms first.

Over the past few years, I have had bloodwork done several times and nothing abnormal has turned up. However, I just realized that I have only ever had my TSH levels tested, and not T3, T4, thyroid antibodies, etc - all the things that I am seeing recommended on various thyroid disorder forums. I haven't even had a chance to look up the recommended tests for the various other possible disorders. I have an appointment with my PCP tomorrow and want to be a strong advocate for myself. What should I make sure I ask my doctor about? What tests should I ask be performed? (I know YANAD, YANMD, etc, etc)

My symptoms include:
Fatigue (most deliberating, every minute of every day is an effort)
Difficulty focusing/concentrating
Feeling disassociated or foggy
Extremely poor memory (to the point where it is a running joke among my family)
Apathy / lack of interest in everything (even things I used to enjoy)
Weight gain (only over last 6 months, all other symptoms have been present for years)
Anxiety / panic attacks (possibly related?)
Sensitivity to heat and cold
Dry skin
Decreased sex drive and difficulty achieving orgasm
posted by Nickel to Health & Fitness (13 answers total) 11 users marked this as a favorite
I have MS and struggle with extreme fatigue. Sometimes I wake up and am so achingly tired that moving my arms, competing a sentence, or even reaching a conclusion feels like way too much effort. Which is really the most brutal thing when you're type A a million times over. This is a serious thing, and believe me I feel you. So given that my experiences and symptoms are not at all yours, I will share that what sometimes works for me is Provigil, although I do still feel the fatigue behind the rush that the med gives me (which is why I often resist taking it).

Funny to see this question because I just met with my neurologist today to discuss managing my fatigue and he recommended that I up my dosage of Provigil and even sometimes add Ritalin to the mix. This is a very specific cocktail obviously designed for me (and my very low blood pressure) but just thought I'd throw it out there. The Epstein Bar virus is thought to have some relation to MS, for what it's worth.

Anyway, point being that fatigue sometimes is a symptom of a more serious neurological issue. Have you met with a neurologist? I also often find that once I knock out the fatigue any sense of depression or helplessness completely melts away.

Good luck!
posted by ohyouknow at 10:41 PM on March 9, 2010

You may want to take a very close look at your diet, just to be sure. I am pretty healthy but I've noticed that taking in a high ratio of carbohydrates to protein/fat, taking in too many calories in a day, or drinking lots of other beverages besides water causes me to get tired, a little irritable, and foggy in the head; the effect is rather marked and lasts for a day or so. Some people seem to get similar symptoms from gluten (breads and processed foods). I'm not trying to downplay systemic causes and the value of following through with medical tests, but this should be very easy to check in the meantime by modifying your diet temporarily and seeing whether there's any improvement... same goes for if you consume a lot of processed food or artificial sweeteners.
posted by crapmatic at 11:05 PM on March 9, 2010

Tilt Test!
Er, that is - consider dysautonomia - a malfunction of the autonomic nervous system - and its many variants. When the voluntary and autonomic nervous systems don't work in sync, things can go screwy. Symptoms mimic chronic fatigue (the syndrome falls under the CFS umbrella) - and can have funny manifestations - like short term blood pressure drops. (A tilt test checks for these BP wiggles.) These can be treated.
Potassium levels - there is a variant of CFS/Dysauto that is related to an extreme potassium deficiency - and which can be somewhat alleviated with regular supplements.

Blood tests for vitamin deficiency? A B12 deficiency can do really wierd things to your energy levels, memory and attention span.

You may have depression - as WELL. Depression as a response to illness is not particularly rare. More than a few doctors will imply - or insist - otherwise. Insist that your doctor focuses on the whole picture and consider the possible depression a plausible side issue, rather than the primary problem. If they don't, dump them.
Ditto the insomnia - if your quality of life is as rocky as it sounds at the moment - who WOULDN'T be having some problems dealing with it?

Visit your GP, have a COMPLETE blood workup and go from there. The Blood workup may be perfect. Don't let that stop anyone.

Consider Shy-Dragger Syndrome

Before you go to your doctor, I would seriously suggest having a read around the Dysautonomia Information Network or the NDRF. You may not fall under their umbrella, but they're a good starting point for the symptoms you describe, and they're an awfully good resources for preparing to navigate the medical profession with a fatigue-related complaint. Unfortunately, familiarity with the Great Fatigue Umbrella is not enormous, and most people, at one point or another, face some seriously colossal bull and it is more common than it should be for otherwise sensible and empathetic specialists to refer patients to psychiatrists because - regardless of verifiable symptoms - said patients don't fall into their specific field.

Keep your BS filters WIDE open - there are more than a few quacks and snake-oil peddlers operating in the field (their fee scale is a good giveaway. Desperate people are desperate.), and more than a few have M.Ds.
posted by tabubilgirl at 11:10 PM on March 9, 2010

Definitely get your iron levels checked. And find out not only are your anemic yes/no but what percentile are you? Because if you're at the low end of normal when you test, you may be below the threshhold at other times.
posted by Jacqueline at 2:39 AM on March 10, 2010

I hate being the sleep apnea broken record, but consider asking for a sleep study if all your other tests come back normal.
posted by elsietheeel at 4:47 AM on March 10, 2010

I'm with crapmatic - there's a blood test for gluten sensitivity/intolerance or you could try changing your diet. Of course a number of issues fit those symptoms, but you sound alot like me before I changed my diet.
posted by quodlibet at 5:15 AM on March 10, 2010

Have you ever had your Vitamin D checked during previous blood tests?

I was really exhausted and only able to barely make it through my day before crashing. I attributed it to having an infant who decided to walk early, but it turns out I was Vitamin D deficient. And not just normal deficient --- severely deficient, like I'd be the new poster child for Rickets deficient if I didn't get it upped. I started a vitamin supplement of 1000 I.U./day at my medical practitioner's recommendation, and within a month I started to feel less tired, and nearly four months later, my Vitamin D is in the normal range and I'm normally tired instead of all-the-freaking-time-exhausted-can-barely-make-it-through-the-day. Not only that, but I've also found myself sleeping better (waking baby factor aside) at night, too, since taking it.

This doesn't sound like it would be your problem by itself, but it could be a contributing factor. Finding out is easy --- just a blood test, so if you're going to have blood drawn for other tests, you might as well as ask about this one, too.
posted by zizzle at 6:08 AM on March 10, 2010

I agree with elsietheeel; a sleep study may be a good idea, as apnea could explain some of your symptoms (but not all).
posted by desjardins at 6:45 AM on March 10, 2010

All of these suggestions are real possibilities and certainly worth testing, but I think the thyroid problem might be the most likely one, if only because it's so common. Don't let the doctor tell you that you don't have thyroid disease just because your TSH is normal, as too many doctors will do. My TSH was normal even when I was severely hypothyroid. Find out what your previous TSH test results were, and see if your current TSH number is higher than it was before, and of course get the free-T3 and free-T4 tests that you've read about elsewhere.

If you get tested for celiac, be sure to east plenty of wheat before the test. If you avoid wheat beforehand, the test doesn't work.

Get your B12 levels and your iron levels checked, as well. It's not uncommon to lose the ability to absorb B12 even at normal adequate intake levels. Both low levels of iron (anemia) and high levels (hemochromatosis) can cause fatigue.

Don't dismiss the idea of sleep apnea just because you don't snore (if you don't); my own diagnosis of sleep apnea was delayed by over a year because I didn't snore. Ask for the blood tests before the sleep study or the tilt table test, simply because blood tests are a lot cheaper and less trouble.
posted by Ery at 7:12 AM on March 10, 2010 [1 favorite]

Diet, exercise, allergies are all things to consider, especially diet and allergies, because those can really wear on you without your realizing there is even an issue. Also, 8 hours of solid sleep a night can make a huge difference. All that said, it sounds to me like a low-functioning thyroid is the most likely culprit. I am not a doctor, so everything that follows is my own basic knowledge and personal experience.

Thyroid levels are notoriously difficult to categorize as abnormal or normal. Not that there isn't an established range, there is, but what is "normal" for one person, could actually be low or high for another. A lot of times, people are borderline and treated as normal for years, but in fact, could really benefit from thyroid medication. You should definitely have the complete thyroid blood workup, and possibly the iodine uptake test, but you might also ask your doctor to consider trying you on a low dose with regular blood workups to see if that helps.

Hypo-thyroidism runs in my family, and I seemed to exhibit symptoms since adolescence, but always tested "normal." Finally, a good 15 years or so of symptoms later, I was actually prescribed synthroid to address not only a possible underactive thyroid, but also symptoms of depression. Three years later, and it has made a HUGE difference. I also suffer from clinical depression, but addressing the thyroid was the first big step, and as long as you monitor it closely for adverse reactions, a trial run is a fairly benign thing to do, in my (non-medical professional) opinion.

My family members have also had a similar experience of having symptoms, testing "normal" into their 20s-30s, and then showing significant improvement when given synthroid. Doctors seem to be really resistant to prescribing synthroid without the lab test to back it up because hyperthyroidism is a serious condition that could be triggered if you are given too much, but I think that if you start with a low dose, have regular blood workups to monitor things, and pay close attention to any possible adverse reactions, it's worth a shot (and I was lucky enough to find a doctor who agreed). Since it is also used to treat depression, I think that establishes enough precedence that it's not highly dangerous to try a low dose with proper monitoring, but many doctors might disagree.

One last thing, I started out on the generic of synthroid (and I happily take the generic form of several prescriptions), but eventually they switched me to the same dose but the brand name, and it was far more effective. It's fairly common that happens, and maybe it won't matter at all for you, but it's something to consider if you are trying out different doses and feel like you should be receiving more benefit. Sorry this is so long and good luck!
posted by katemcd at 7:48 AM on March 10, 2010 [1 favorite]

Another thing that helps me is taking a 20 minute semi-nap at around 2pm (I use Pzizz for that and to fall asleep). My neurologist has also recommended acupuncture once a week (and yoga has always been helpful).
posted by ohyouknow at 8:45 AM on March 10, 2010

I have similar issues. For a variety of reasons, including health insurance and doctors moving away, I've had multiple docs. One doc was great at believing it was serious and getting me tested for stuff. Next doc was also a good listener and great at fine-tuning meds. Another doc prescribed thyroid meds, even though I tested in the normal range, which helped a lot.

Currently, looking for a new doc, as the last one basically told me that it's either not real, or "just depression." Being so tired that it affects my work, and limits my ability to have a life is, in fact, depressing. If the depression causes the fatigue, or the fatigue causes the depression, doesn't matter; feeling better matters.

Some SSRIs, esp. Prozac, gave me panic attacks. SSRIs are also known to affect sex drive and ability to reach orgasm. A doctor who will really review your meds is a huge help. A therapist taught me that a cold wet washcloth on the face can stop a panic attack. (mammalian dive reflex)

I've learned that exercise, sunshine and being outdoors are critical to my health. A minimum of 8 hours sleep/night, good nutrition, and a multivitamin also help. When I'm exhausted, insisting on being heard and taken seriously is really difficult, but I keep trying. You deserve good care.
posted by theora55 at 8:59 AM on March 10, 2010 [1 favorite]

You should ask for detailed copies of previous lab results. I've started doing this for everything. I recently got a copy of my results from a year ago and the lab had the normal range for TSH at .47-5.01 even though the American Association of Clinical Endocrinologists lowered that range 7 years ago. My results were still under 3, but I could have been at 4.9 and the doc would have just told me everything was normal.
posted by ghostmanonsecond at 6:33 PM on March 10, 2010 [1 favorite]

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