In midlife, it is common to see gut symptoms, overlooked thyroid irregularities, and chronic low grade inflammation occur concurrently. This case highlights a 57 year old woman with a cluster of concerns that many patients bring to functional medicine clinics. She presented with persistent constipation, post meal fullness, inability to tolerate most grains, low energy, difficulty losing weight, and worsening rosacea. Her primary goal was to reduce gut symptoms, improve energy for exercise, and lose fifteen to twenty pounds in a sustainable manner.
She also carried a past diagnosis of Hashimoto thyroiditis. Her antibodies were now normal, which is a reminder that autoimmune antibody production fluctuates significantly. The absence of antibodies does not eliminate a history of autoimmunity, but it offers an opportunity to reduce immune activation through targeted lifestyle and gut focused interventions.
Initial Laboratory Evaluation
A comprehensive panel allowed us to identify several physiologic patterns that were contributing to her symptoms.
Metabolic and nutrient markers
- Mostly stable blood sugar markers with high/normal fasting glucose and normal insulin.
- Glucose 97, A1c 5.2, insulin 3.5
- Kidney and electrolyte markers were normal. Notable findings included a functionally low magnesium level and low total protein.
- BUN 17, Cr 0.71, Na 141, K 3.9, Cl 102, CO2 26, Ca 9.3, Phos 4.1, Mg 1.9 low, Protein 6.6 low, Albumin 4.6, Globulin 2.0 low, A to G ratio 2.3
- Liver function was optimal.
- AST 15, ALT 13, Alk Phos 56, GGT 11, Bilirubin 0.3, LDH 144
- Iron studies revealed an elevated ferritin with high iron abnormal iron saturation. In women with chronic constipation, high ferritin sometimes reflects inflammation or unrecognized supplemental iron intake.
- Iron 75 high, Iron saturation 28, TIBC 267, Ferritin 177 high
- Lipid markers showed mildly elevated total and LDL cholesterol.
- Total cholesterol 230 high, triglycerides 91, HDL 71, LDL 141 high, total cholesterol to HDL ratio 3.2
- Inflammation and methylation markers showed mild elevation of high sensitivity CRP and elevated homocysteine with low normal B12.
- CRP hs 1.23 high, Homocysteine 12.1 high, B12 374 low, MMA 160
- Blood counts were normal and vitamin D was sufficient at 47.3.
Thyroid Evaluation
Her thyroid panel was the key clinical finding.
TSH 6.060 high
Total T4 6.2
Free T4 1.06
Free T3 3.1
Total T3 94
Thyroid peroxidase antibody less than 6
Thyroglobulin antibody less than 1.0
This pattern is consistent with subclinical hypothyroidism. TSH is elevated while circulating thyroid hormone remains within range. Subclinical hypothyroidism is common. Prevalence increases with age and reaches about ten percent in women older than sixty. Although debated, the literature shows associations with higher LDL, higher CRP, increased risk of cardiovascular disease, and impaired quality of life. Several trials have demonstrated improvement in carotid intima media thickness and lipid markers with appropriate thyroid hormone replacement.
Decisions about treatment require context. This patient had symptoms that overlapped with thyroid dysfunction such as fatigue, constipation, weight gain, and cold intolerance. Addressing root causes that can influence TSH was the first step, before committing to lifelong thyroid replacement.
Breath Testing and Diagnosis of Methane Dominant SIBO
She completed a Small Intestinal Bacterial Overgrowth (SIBO) breath test which demonstrated elevated methane with normal hydrogen and hydrogen sulfide. Methane levels above ten parts per million at any point are associated with intestinal methanogen overgrowth. This pattern could explain chronic constipation, slow motility, gas retention, and the sensation of fullness even with small meals.Methane dominant SIBO also reduces absorption of nutrients such as B12, iron, folate, and fat soluble vitamins. Her low normal B12, elevated homocysteine, and mild protein deficiency fit this pattern.
Lifestyle and Dietary Contributors
A diet and nutrition log revealed low intake of iodine and zinc rich foods. Both minerals are essential for thyroid hormone production, thyroid hormone conversion, and immune regulation. We increased her intake of seafood, sea vegetables, pastured eggs, and pumpkin seeds. Her caloric intake was also below what she required given her activity level and work demands. Undereating can increase cortisol output and compound thyroid dysfunction. Increasing consistent protein intake and improving meal timing became an early priority.
Her stress load was significant. She worked more than fifty hours each week with a lengthy commute and was supporting children transitioning into and out of college. She performed cardiovascular exercise five days each week without sufficient recovery. This combination can suppress thyroid conversion, elevate reverse T3, and worsen fatigue and constipation.
We worked with a monthly focus method. Each month she selected one implementable behavioral target, such as:
- Shifting breakfast to a higher protein template.
- Replacing two cardio sessions with strength based sessions to support metabolic rate.
- Adding a nightly ten minute wind down routine with nasal breathing.
- Blocking two evenings per week where no additional work projects were permitted.
This approach decreased overwhelm and allowed measurable improvement without relying solely on supplements or protocols.
Treatment Strategy
Treatment targeted the gut, nutrient deficiencies, stress physiology, and overall thyroid signaling.
Antimicrobial protocol for methane SIBO
- Targeted herbal antimicrobials selected for methanogen reduction
- A biofilm disruptor to improve efficacy
- SCFA support to stabilize the gut mucosa
- Motility support to improve migrating motor complex function
Nutrient and metabolic support
- Magnesium for motility and mitochondrial function
- B12 and methylation support to lower homocysteine
- Discontinuation of an unneeded iron supplement discovered during intake review
- Repletion of dietary iodine and zinc
- Increased total caloric intake with emphasis on protein and fiber
Stress and recovery interventions
- Structured strength training
- Reduction of excessive cardio
- Monthly stress reduction goals
- Sleep hygiene optimization
Post Treatment Outcomes
Her response to treatment was significant.
Symptom improvements
- Constipation improved from one bowel movement every two to three days to daily regularity
- Post meal fullness decreased, suggesting reduction in fermentative gas load
- Rosacea improved with decreased systemic inflammation
- Energy increased, which allowed greater participation in strength training
- Weight began to trend downward with improved caloric balance and thyroid support
Laboratory improvements
- Vitamin D increased from 47 to mid 50s through sunlight and dietary strategies.
- Homocysteine normalized due to improved B12 absorption and supplementation with a homocysteine level of 7.6 and B12 level of 1100.
- Ferritin decreased after discontinuation of iron supplementation and resolution of constipation.
