There’s a big gap in medicine – I call it the gray area. Oftentimes, the medical world depends heavily on labs. People either have a condition or they don’t. The gray area or the middle area is often overlooked. Primarily, because it’s difficult to measure. This gray area is very important for women with PCOS or hypothyroidism.

The Gray Area of PCOS

In 2003, a gray area for diabetes was created, called “prediabetes.” For a long time, there was no “prediabetes.” You either had diabetes or you didn’t. The category of prediabetes is very important for individuals with PCOS, because insulin resistance is a root cause of PCOS. 

Pre-diabetes and diabetes are assessed using a lab measure called hemoglobin A1c (HgbA1c). Hemoglobin A1c measures how much glucose is attached to red blood cells over a 2-3 month period.

The ranges used for HgbA1c are:

Normal – Below 5.7%

Prediabetes – 5.7% – 6.4%

Diabetes – 6.5% or above

Up until 5.7%, A1c is considered normal. However, symptoms of insulin resistance can show up before a diagnosis of prediabetes.

Labs are a great objective tool to check for insulin resistance. However, it’s also important to look for physical and physiological signs that might show insulin resistance if your A1c is below 5.7%.  

This is what I like to call the gray area. In this area, there’s no objective, quantitative measure classifying someone with “pre-diabetes,” but there’s plenty of signs to look out for. Signs that women with PCOS experience before they hit a 5.7% A1c. 

These signs include: 

• Skin tags (small, soft skin growth that show up on the neck, upper chest, underarms, and eyelids)⁣
• Acanthosis Nigricans (dark skin patches in crevices, on the back of the neck, finger/toe knuckles, chin, forehead, etc.) 
• Inability to lose weight, despite eating well and exercising 
• Dark coarse facial hair in women 
• Can’t maintain a weight⁣
• Pee more frequently⁣
• Thirsty all the time⁣
• Have sugar cravings that don’t go away with eating carbs⁣
• Low blood sugar in between meals⁣
• High inflammation (body pain, chronic fatigue, insomnia, depression, mood disorders, gut issues, frequent infections, weight gain or loss, high C-Reactive Protein). ⁣

Paying attention to the gray area is an important strategy to ensure we get the help we need BEFORE symptoms worsen and become more difficult to address. By looking out for these signs, you can assess whether you have insulin resistance or not. And once you know, you can start working on improving your insulin sensitivity. Check out my blog “Diabetes: 5 Habits that Increase Your Risk” learn more about habits you can change to reduce insulin resistance.

The Gray Area of Hypothyroidism

If I got paid for the number of times I’ve seen someone with a higher TSH, but still within the “normal” range, who had multiple symptoms of hypothyroidism…I’d be RICH! 

TSH, or Thyroid Stimulating Hormone, is usually the first blood test checked to assess for thyroid dysfunction. The current normal range for TSH is 0.45-4.12 mIU/L. However, some physicians use an upper limit of 5.0 mIU/L. 

Although a TSH of 4 is considered “within range” based on the current medical standard, it doesn’t mean it’s optimal or that you can’t have hypothyroid symptoms.

The range is based on a large sample size from a population of people who were considered free of thyroid disease (2002 NHANES). People with risk factors and family history of thyroid dysfunction, self-reported thyroid disease or goiter, and thyroid autoimmunity were excluded from this study. The study concluded that 95% of the US thyroid-disease-free population had a TSH range between 0.45 and 4.12 mIU/L. And this is where the TSH range comes from. 

However, the National Academy of Clinical Biochemistry (NACB) has recommended that the upper limit for TSH be 2.5. And, “in fact, about 20–26% of the population would be hypothyroid if the upper limit of the normal range is lowered to 2.5–3.0 mIU/L.” (Biondi, B 2013).

So, if the normal range is based on a population that is considered free of thyroid disease, but shifting the range would make more people hypothyroid, how should we really be assessing for hypothyroidism? We’re playing a chicken and egg game here. 

Individuals can sit in the gray area of hypothyroidism, when they are experiencing symptoms of hypothyroidism and have a TSH on the upper level of the range. Sometimes, you can have symptoms even without an elevated TSH. 

Results from a 20-year follow-up study (Whickham Study) showed that a TSH higher than 2 mIU/L increased risk for hypothyroidism (Surks et al., 2005).

In 2003, the American Association of Clinical Endocrinologists encouraged doctors to use a narrow TSH range of 0.3-3.0 mIU/L and to treat patients who are outside of this range; others have suggested the upper limit be 2.5 mIU/L. 

Your symptoms aren’t just in your head, even if your labs are “within range.” A TSH higher than 2.5 mIU/L, combined with symptoms of hypothyroidism, should be taken seriously. 

Oftentimes, this means advocating for yourself until you get the support you need. You are not a nuisance if you request a referral endocrinologist; no matter how rude or condescending your provider might be. Ask for the referral anyway. If you have an endocrinologist who is not taking your symptoms seriously, find a new endocrinologist who will. 

And don’t sleep on how much of an impact nutrition has on thyroid function. Schedule a free information call to learn more about how I can help!