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General metabolic breakdown
I have hypothyroidism; I take 37.5 mcg of Levothyroxine and my TSH is now at 2.97.

For years I have struggled with sudden pangs of hunger resulting in sweating, confusion, migraines, etc. I regularly wake up in the middle of the night shaking with hunger. Over the years I've significantly reduced carbs in my diet in response. My diet consists almost entirely of vegetables, beans, fruits, nuts, cheese, eggs, with a slice of high-fiber bread on certain days. And yet the symptoms have remained, no matter what I do. Did pinprick blood glucose test when I have the symptoms, and it always came out normal. Fasting glucose levels were normal until recently. I'm not overweight (male, 44 yrs, 5'8" and 146 lbs), but I have added inches to my abdomen. I also don't exercise regularly, which I know I have to rectify.

I've been to many doctors, including endos. Nobody has been able to diagnose the issue, and they're often very flippant: 'just manage it with dietary changes' (what else can I eliminate from my already spartan diet?), or 'go to a psychiatrist for stress/depression'. Nobody was/is willing to administer the 24-hour saliva test to figure out if I have adrenal insufficiency/fatigue.

However, I recently got a few tests done and the results are as follows:
Fasting glucose: 99 (the highest I've seen)
triglycerides: 190 (cholesterol is fine, LDL/HDL balance is fine)
sodium, potassium, calcium, bicarbonate, etc., all normal
fasting insulin: 20 (reference rangs <17)
fasting c-peptide: 3.7 (reference range: 0.8 - 3.1)
A1C: 5.9 (range: 4.8-5.6%) and average glucose: 123
morning ACTH: 50 (reference range: 6-50)

So triglycerides, insulin, c-peptide, A1C and ACTH are higher than normal. I've strongly suspected adrenal insufficiency/fatigue. But my current endo has asked me to take the cortisol stimulation test and is refusing to administer a 24-hr saliva test. I think the key here is to measure cortisol (either after stimulation) or over a 24 hr period.

Based on the test results I've gathered so far, what are my choices for further diagnostic steps? Any ideas on what might be going on? Is adrenal insufficiency the cause of high ACTH, and also my body's inability to metabolize carbohydrates and fat? Do I already have insulin insensitivity?
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657231 tn?1453836403
If your sodium and potassium are fine then AI is usually not on the table.

ACTH can be elevated for Cushing's as well. That would fit with elevated insulin etc.

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Based on ACTH data, is it better to test cortisol levels with a cortrosyn injection + 30/60 min blood draw or a 24-hour saliva test?
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657231 tn?1453836403
Cushing's testing is 24 hour urine testing, 8 am blood testing, midnight blood or midnight saliva.
Some will do 10 hour urine tests.

Blood testing has to be extensive and cover ACTH and pretty much a ton of hormones. Elevated cortisol messes with a lot.
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