who should I see first?

[Aggie1]

Dear Dr. Lupo, I would appreciate your input as  I do not know which MD to see first.  I have had these symptoms occurr about four  times in the last 16 years and this last bout has lasted, instead of two to three weeks, two and a half months now.  I have muscle fatigue, pain in legs and arms with muscle spasms at times that are severe and  wake me up.  I have shortness of breath ( about a year now going up stairs) Raynauds started about  five years ago and I will wake up with both hands asleep.  I will also experience flushing with some anxiety, mainly over whether I will have to live like this working full time much longer!.  I became hypo 10 years ago and assume it is Hashi's as my boys ( age 14 and 11 now have Hashi's, my oldest's antibodies were high).  Looking over my blood work over the past five years though I see that my  TSH has hovered no lower than 2.3 and over the last year has been 4.3.  ANA test came back very high 1:1230 with centromere pattern. My GP feels it is limited scleroderma?  Do you know if this ANA can be due to Hashi's and Raynaud's alone or should I be seeing a Rhemutologist before endo and I also understand this TSH level is not theraputic and I am hoping some of these symptoms will subside with maybe T3 added or armour.  I am currently on 100mcg  of levo. Thank you,  I am hoping for some insight for my children's sake as well.

[Mark Lupo, M.D.]

ANA this high is usually not due to Hashi and Raynaud's alone -- would see a Rheumatologist for complete evaluation.  There is debate about the target TSH range, but I would usually attempt to increase the dose to get the TSH to around 1.0 then re-evaluate.  Adding T3 helps some, but not most/all patients.  Armour 60mg once a day (or 30mg 2x/day) or a combo of Cytomel 5mcg (2x/day) and Synthroid (about 75mcg) would be a starting place if your tsh is >2 on 100mcg T4.

[Aggie1]

I also forgot to mention this muscle pain/fatigue comes and goes mysteriously with some days also negligible and others making it difficult to function.  I do not have any other esophageal symptoms or skin symptoms as of now to point towards CREST or limited scleraderma.  If synthroid is increased.  What would the next dose level be to try and how would that be converted to Synthroid/cytomel combo or Armour.  I am more inclined to try Armour I think.  Bless you for your input.  Wish you were in my area!