High fasting blood glucose, normal OGTT, hypoglycemia

Patient

Q: 41 year old active female, NOT overweight ( 5'10, 130Ibs), on no medications, good BP & Cholesterol, no other medical problems, eat a very healthy diet with no processed foods and very little sugar, plenty of whole foods, veggies, nuts, seeds, lean meats, healthy grains.

Have had 2 high fasting blood glucose tests in the last month (101 mcg/dL, and 105 mcg/dL with normal range being 70-100), but a normal Oral Glucose Tolerance Test (GLU GTT-FAST: 99 mg/dL, GLU GTT - 2HR: 84 mg/dL). Also normal Insulin of 7.6 uIU/mL (range 2.6 - 24.9). Microsomal Antibodies

Symptoms:  Undiagnosed hypoglycemia spells that have increased in frequency lately to several times per day (shaking, sweating, nausea, heart palpitations, light headed, resolves upon eating something with sugar). Also extreme fatigue, tingly/numb hands, restless at night, sometimes insomnia, multiple cataracts, retinal hemorrhages, spells of double vision, damaged blood vessels in eyes seen during dilated eye exam, floaters, dry eyes and nose, frequent infections, occasional headaches, frequent urination.
Doctor

A:   Thank you for writing to Ask The Doctor

I have gone through your query and I do not think that you have a problem with glucose. There is a chance that you have some disease or a pre-disease which can be controlled by certain steps. Hypoglycemia is common in people who do not consume long term release sugars. If you are not taking things like oats or rice which are released slowly to the body, then there is a chance of low sugar.

Based on your weight, I also think that you do not have excess fat or too much of glycogen stores. This can cause the hypoglycemia you had.

Coming to the increased level of glucose in the blood. The levels are raised by less than 5 mcg and this can happen if you did a sudden run to the test centre or if there was a release in adrenaline which caused the glucose levels to go up. Combined with the normal GTT, I do not think that this is anything to worry about.

I am worried about the fatigue that you are having. There is a chance that this is a migraine or there is a chance that you are more predisposed to blood clots. I recommend that you get checked for a HbA1c and a D-dimer assay. This can help get to the cause.

I also recommend that you see a Neurologist to check your double vision. There is a chance that this is just a migraine that is causing problems but I would want to confirm the cause.

All the best and do follow up after you get the reports. Wish you the best of health.

Comments / Follow Ups

Patient: Thank you for your response.

I do eat organic oats with a bit of honey every morning for breakfast, but perhaps that is not enough slow release sugar for the day?

I do not have much body fat, and it is true that on the rare occasions when I am able to gain a few pounds, I seem to have the hypoglycemia less often.

Would you still feel it a good idea to track blood glucose levels at home with a glucometer, or do you think this would be a waste of time and there is no chance of an issue with my glucose, pre-diabetes, etc?

I have seen a neurologist and have 2 normal brain MRI's to rule out any neurological cause of the double vision spells. In fact, after much testing, it was assumed that the double vision spells must be due to hypoglycemia.

What makes you suspect a predisposition to blood clots?

I have also had autoimmune blood work done to look for other causes of fatigue, but all was normal.

Is there any chance I am having the hypoglycemia spells at night while I am sleeping, and that could be causing insomnia, sweats, restlessness, fast heartbeat, etc.? If this was the case, then is it possible my body is trying to compensate for the low blood sugar levels at night, and therefore my morning fasting glucose is increased?
Doctor: Thank you for the follow up.

I was only suspecting clots because of your age and the symptoms of hemorrhage in retina and the damage to blood vessels in the eye. It is just a hunch and you can get the test done when you are getting regular phsyical examinations and blood tests done.

In 40s, there is a slight change in the body chemistry and the fast heartbeat with the headache made me feel that an arrhythmia is possible.

The symptoms can be explained with hypoglycemia and you should keep glucose levels high. You can try eating 7 times a day and consume snacks like fruits and honey tea in between. Eating 7 times will boost your metabolism.

Also, taking coffee and tea will force the body to convert gycogen to glucose and keep your glucose levels in a good range.

I would not recommend buying a glucometer yet. It is a hassle to maintain a glucose reading chart and will be a problem. If eating well solves the problem, then you should stick to that only. I am not too worried about the test. I feel that the test range is too narrow and in reality should be a bit wider. And the GTT is a much more accurate test. If the GTT is normal, I would not worry.

The HbA1c will measure long term glucose status of the body and can help you know how glucose has been in the long term. If that is also normal, then you do not have diabetes for sure.

Hope this helps you. All the best.
Patient: Wanted to provide you results of tests from 2011 (the time the retinal hemorrhages and damaged blood vessels in eyes were found) to see if these results change your mind about my blood clots/arrhythmia risks (also note the hemorrhages and damage was not seen this year in eye exam, all looked ok).
EKG & Cardiac Ultrasound both normal, Normal CBC w diff, HA1C 5.3, Sed Rate 4, Homocysteine Plasma 4.2 umol/L (3.2 - 10.4 is normal range), Factor 5 Leiden: negative, CRP 1.4 mg/L (0.0-4.9 is range), Anticardiolipin Ab IgG/M Qn:
Patient: Anticardiolipin Ab IgG/M Qn:
Patient: Anticardiolipin Ab IgG/M Qn:
Patient: won't let me finish!
Patient: Wanted to provide you results of tests from 2011 (the time the retinal hemorrhages and damaged blood vessels in eyes were found) to see if these results change your mind about my blood clots/arrhythmia risks (also note the hemorrhages and damage was not seen this year in eye exam, all looked ok).
EKG & Cardiac Ultrasound both normal, Normal CBC w diff, HA1C 5.3, Sed Rate 4, Homocysteine Plasma 4.2 umol/L (3.2 - 10.4 is normal range), Factor 5 Leiden: negative, CRP 1.4 mg/L (0.0-4.9 is range), Anticardiolipin Ab IgG/M Qn:
Patient: Anticardiolipin Ab IgG/M Qn:
Patient: Also, would that normal HA1C of 5.3 back in 2011 rule out Diabetes for me, or do I need to have that again to be sure? Thanks so much.
Patient: Also, I had a low Estradiol (E2) blood test last year of 12 pg/mL during Follicular phase, 0-266 is the range for Follicular phase. (FSH was 9.7 mIU/mL, Luteinizing Hormone was 8.7 mIU/mL, Growth Hormone HGH was 0.3 ng/mL, and Prolactin was 10.2 ng/mL), normal thyroid tests, normal iron & ferritin, & negative for celiac & autoimmune. I have heard low estrogen can cause some of my symptoms too (insomnia, night sweats, fatigue, hair loss, heart palpitations). Do you think the low estrogen could be my problem? My Ob/Gyn's answer to the low estrogen is for me to get on the birth control pill until I am 55 or so, when she suspects I will be through menopause. But I know the pill can increase risk of blood clots, so I don't really want to do that if I am at increased risk of clots already??? Would another form or hormone replacement be better than the pill, or do all forms carry the increased risk of blood clots? I am desperate to get rid of this fatigue & other symptoms, but 14 years on the pill worries me a bit?
Patient: ..... Anticardiolipin Ab IgG/M Qn:
Patient: Grrrrr!
Patient: Protein S-functional 81% (60-145 is range), Protein C-Functional 79% (74 - 151 is range), Antinuclear Antibodies: negative, .Would you still recommend D-dimer assay, or do the above results by any chance indicate blood clots were not the issue?
Doctor: The HbA1c was to check the long term status of glucose to confirm that the glucose level hasn't been high in the last 6 months.

Since everything else is normal, I still want to understand the cause for the retinal hemorrhages. Based on the description you have given in the follow up, I do not see anything indicating a blood clot. There are 2 common types of retinal damage causes. One is a hypertensive issue and one is a diabetic issue.

One of the best ways to get checked would be see a Eye Doctor. If you have already seen one, then see another eye Doctor for a second opinion. Retinal Hemorrhages and Multiple cataracts cannot be ignored.

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