Thyroid Dysfunction in Sarah’s StoUnraveling the Discordant Symphony

January 9, 2024by Dr. S. F. Czar0

Case Study:

Patient: Sarah, a 35-year-old woman

Chief Complaint: Fatigue, weight gain, difficulty concentrating, and hair loss for the past year.

Medical History: Sarah has no significant medical history.

Examination: She appears tired and has slightly puffy eyelids. Her body mass index (BMI) is 28.5, suggesting overweight. Blood pressure and heart rate are within normal limits.

Laboratory Findings:

  • Thyroid-stimulating hormone (TSH): 7.5 mIU/L (elevated, indicating hypothyroidism)
  • Free T4: 0.8 pg/dL (low, confirming hypothyroidism)
  • IGF-1: 75 ng/mL (low, disproportionately low for elevated TSH)

Diagnosis: Hypothyroidism with low IGF-1 levels


  • The low IGF-1 level is unusual in hypothyroidism, suggesting a more complex metabolic picture.
  • Sarah’s symptoms are not fully explained by hypothyroidism alone.

Further Investigation:

  • Ultrasound of the thyroid shows no abnormalities.
  • Autoimmune markers for thyroiditis (TPOAb and TgAb) are negative.
  • Additional blood tests reveal mild insulin resistance and elevated prolactin levels.

Diagnosis Revised: Subclinical hypothyroidism with secondary IGF-1 deficiency due to combined insulin resistance and hyperprolactinemia.

Treatment Plan:

  • Levothyroxine therapy for subclinical hypothyroidism.

  • Metformin to address insulin resistance and potentially optimize IGF-1 production.

  • Investigation and management of the cause of elevated prolactin, potentially impacting IGF-1 and metabolic function.

  • After 3 months on levothyroxine, Sarah’s TSH normalizes, but her fatigue and weight remain largely unchanged. IGF-1 levels remain low despite improved thyroid function.

  • Metformin improves insulin sensitivity but doesn’t significantly impact weight or fatigue.

  • Further investigations reveal a prolactinoma (non-cancerous pituitary tumor) as the cause of elevated prolactin. Treatment with dopamine agonists successfully lowers prolactin levels.


  • After 6 months of combined levothyroxine, metformin, and dopamine agonist therapy, Sarah’s fatigue and weight improve significantly. Her hair loss stabilizes. Her IGF-1 levels rise to within normal range.
  • Sarah continues to be monitored for thyroid function, insulin resistance, and prolactin levels to ensure optimal long-term management.


This case study illustrates the complex interplay between IGF-1 and thyroid dysfunction. Sarah’s discordant presentation highlights the importance of considering:

  • Beyond TSH: Measuring IGF-1 levels can provide valuable insights in atypical cases of thyroid dysfunction.
  • Holistic Approach: Underlying conditions like insulin resistance or hormonal imbalances can contribute to symptoms and impact IGF-1 levels, requiring comprehensive management.
  • Personalized Medicine: Tailoring treatment based on individual factors like thyroid function, metabolic profile, and underlying hormonal imbalances leads to better outcomes.


Sarah’s case demonstrates the critical role of understanding the intricate tango between IGF-1 and thyroid dysfunction in optimizing patient care. By delving deeper than a single hormonal marker, healthcare professionals can unravel the discordant symphony, compose a personalized treatment melody, and ultimately restore the harmonious symphony of health for individuals with complex metabolic disturbances.

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