42 year-old woman presenting with fatigue. 42 year-old woman presenting with fatigue.42 yo female presents with history of progressive fatigue. She first noted the fatigue about 6 months ago when she was having trouble keeping up with her calendar of activities at home and at work. She has been quick to dismiss the difficulty attributing it to the increased amount of work with her job and driving the kids to their sports practices and maintaining the household. She denies any significant weight changes or temperature sensitivities. She describes a persistent lack of energy and an increase in the fatigue. There is no change in concentration or cognition. She further denies any increase in sleep despite the fatigue. She does not snore, and her husband notes no apnea. Daytime naps are not helpful. Her diet is “normal”, usually 3 meals a day with balanced fruits and vegetables but a large portion of prepared meals. She does not smoke and has an occasional glass of white wine. She has 2 children, both in high school. Her menses is regular, her mother experienced menopause early and her first period was at age 13. 42FemaleAs above. Additionally, she denies any recent illnesses, sick contacts, fevers or rashes. She denies any myalgias or arthralgias. She denies any depression. She denies any tremors, headaches, visual changes or numbness or tingling in the extremities. She denies any family history of endocrine, neurologic or psychiatric disorders. Her physical exam is noteworthy for normal vital signs, normal HEENT exam, no thyromegaly, no lympadenopathy. No skin discoloration. Cardiac, pulmonary, abdominal, neurologic exam all wnl. Labwork with a normal CBC and BMP. Vitamin D 25OH is 34. TSH 6.1 with a normal Free T4. A PTH, FSH and LH were all as expected.She is very against the idea of hormone supplementation and would like to pursue other integrative therapies in the hope to avoid “converting” to hypothyroidism. She feels that though she is fatigued that it is likely compounded by her concurrent increased work and home stress. I’ve recommeded various relaxation techniques and stress reduction methods including tai chi and meditation and will repeat the TFTs in 6 months or earlier is symptoms change. We discussed the annual risk of conversion to hypothyroidism to be about 10-15% from subclinical hypothyroidism. w/u and history are negative for direct reversible cause (except for increased stress). What else can I offer her to improve her thyroid?