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Thyroid Disease Revisited - Drs Nasr Vouyiouklis & Metzger

Online Health Chat with Christian Nasr, MD, Mary Vouyiouklis, MD, and Rosemarie Metzger, MD

April 1, 2013


Description

The thyroid gland plays a critical role in a person’s overall health. Yet many people suffering from thyroid conditions remain undiagnosed, and do not understand the serious health repercussions of untreated thyroid disorders. Diagnosis and treatment are key steps to managing a thyroid problem, and will help to control the related symptoms.

The thyroid is an endocrine gland that is responsible for controlling metabolism (the energy produced and used by the body) and regulating the body’s sensitivity to hormones. Diseases of the thyroid cause either underactivity or overactivity of this gland. Underactivity of the thyroid results in hypothyroidism (also known as Hashimoto’s thyroiditis) and goiter. Hypothyroidism can produce symptoms of weight gain, sensitivity to cold and brittle nails and hair. In Western countries, hypothyroidism is largely due to an autoimmune response, although iodine deficiency can also cause underactivity – which is largely in other parts of the world that lack iodized salt. Hypothyroidism is associated with several other diseases, including heart disease, type 1 diabetes, celiac disease and metabolic syndrome. Overactivity of the thyroid is seen in Grave’s disease, which results in bulging eyeballs, anxiety and sensitivity to heat among other symptoms. Enlargement of the thyroid can be the result of noncancerous goiter, which may or may not result in hypothyroidism or hyperthyroidism, or cancer. Radiation exposure, such as x-rays—especially in children—can affect thyroid status.

Lab tests of TSH (thyroid stimulating hormone), T3 and T4 help in the diagnosis of thyroid conditions. Recent changes in screening guidelines that have a lower threshold limit of TSH hormone affects the thyroid status of millions of adults in the U.S. This has resulted in the diagnosis of many more patients with hypothyroidism. Lab results, symptoms and physical exam help direct physicians to the proper diagnosis and treatment of the thyroid.


About the Speaker

Christian Nasr, MD is an endocrinologist in the Department of Endocrinology, Diabetes and Metabolism in Cleveland Clinic’s Endocrinology & Metabolism Institute. He is board certified in internal medicine - endocrinology, diabetes and metabolism. A medical school graduate of the Saint Joseph University Faculty of Medicine, in Beirut, Lebanon, Dr. Nasr completed his residency at Staten Island University Hospital, in New York, and his fellowship in endocrinology at Cleveland Clinic. Dr. Nasr’s specialty interests include thyroid nodules, thyroid cancers and disorders, and flushing syndromes. Dr. Nasr sees patients at Cleveland Clinic main campus and at Cleveland Clinic Lorain Family Health Center.

Mary Vouyiouklis, MD is an endocrinologist in the Department of Endocrinology, Diabetes and Metabolism in Cleveland Clinic’s Endocrinology & Metabolism Institute. She is board certified in internal medicine - endocrinology, diabetes and metabolism. A medical school graduate of the Albert Einstein College of Medicine, in New York, N.Y. she completed her residency in internal medicine and fellowship in endocrinology, diabetes and metabolism at New York University Langone Medical Center, in New York, N.Y. Dr. Vouyiouklis' specialty interests include thyroid cancer and disorders, thyroid in pregnancy, type 1 and type 2 diabetes, Turner’s syndrome and hyperparathyroidism. Dr. Vouyiouklis sees patients at Cleveland Clinic main campus, and at the Cleveland Clinic family health centers in Solon and Willoughby.

Rosemarie Metzger, MD is an endocrine surgeon in the Department of Endocrine Surgery in Cleveland Clinic’s Endocrinology & Metabolism Institute. A graduate of the University of Wisconsin Medical School, in Madison, WI., Dr. Metzger completed her residency in general surgery at the University of Virginia Medical Center, in Charlottesville, Va., and fellowship in endocrine surgery at Cleveland Clinic. Dr. Metzger’s specialty interests include thyroid cancer and nodules, parathyroid and calcium disorders, goiters, and adrenal gland disease. She performs surgery at Cleveland Clinic Center for Endocrine Surgery at the main campus.


Let’s Chat About Thyroid Disease Revisited


Effects of Thyroid Condition

emoeller: How would thyroid disorders affect the heart?

Rosemarie_Metzger_,_MD: The most common way for a thyroid disorder to affect the heart would be in the setting of hyperthyroidism. Hyperthyroidism can make the heart prone to irregular heartbeats and potentially irregular rhythms, which can be serious and increase the risk of stroke.

LucyJ: My understanding of thyroid problems is that typically you may lose weight. Is it possible to start to gain weight? And what about hair loss?

Christian_Nasr,_MD: Hypothyroidism may cause some weight gain. Hyperthyroidism may cause a lot of weight loss. They can both be associated with hair loss.

judyse74: I have a friend that is very thin despite eating a lot. He had his thyroid checked, but feels that he has a hyperactive thyroid. Could something else be wrong, or should he have other blood work done for his thyroid?

Christian_Nasr,_MD: He could have a thyroid problem. If the doctor is still suspecting hyperthyroidism (indicating an overactive thyroid) then they should do a full thyroid profile.


HYPOTHYROIDISM (HASHIMOTO DISEASE)

Hypothyroidism Diagnosis (Hashimoto disease)

bonniemyers4: How do I know if I have Hashimoto disease or am I just hypothyroid? Does it really matter? My TSH was 35.67 before medications 10 years ago.

Christian_Nasr,_MD: If you have been living in the U.S. since you were little, then you have Hashimoto disease. Nothing else would give that high TSH. Hashimoto could be confirmed by having the microsomal antibodies measured—although it would not change the management.

judyse74: Why would living in the U.S. since we were little cause Hashimoto disease?

Christian_Nasr,_MD: Because we are in an area of iodine sufficiency and iodine (even normal levels) could trigger an immune reaction.


Autoimmune Diseases: Hashimoto Disease and Celiac Disease

rebeccalydia: Can you talk about the correlation between gluten allergies and thyroid disease? I was recently diagnosed with both Hashimoto thyroiditis as well as multiple food allergies. I am wondering how they affect each other and are related.

Christian_Nasr,_MD: They are both autoimmune disorders and they can be seen in the same patient. Other than gluten allergy I am not aware of any other associations between food allergies and Hashimoto disease.

Esjay22: Are you saying that celiac disease and Hashimoto thyroiditis go hand-in-hand?

Rosemarie_Metzger_,_MD: Both are autoimmune disease processes. However, people with celiac disease don't necessarily also have Hashimoto thyroiditis and vice versa—people with Hashimoto disease don't necessarily have celiac disease. The similarity is just that they are both mediated by our bodies own autoimmune response. People with one type of autoimmune disease are typically at higher risk than someone without an autoimmune process to have another autoimmune disease.

Esjay22: I have been diagnosed with Hashimoto thyroiditis. I was on birth control for many years. About six months ago I discontinued the birth control and ever since my thyroid is not stable. Initially, it went hyperthyroid to 1.1 and now it is hypothyroid around 5. They decreased my levothyroxine sodium (Synthroid®) after getting off birth control, and now they increased the Synthroid® dose since my last blood work was above 5. I recheck my thyroid in two weeks. I also have a very small microadenoma with a prolactin level in the 50s, which is the lowest it's been. This has been lower and appears stable since getting of birth control.

Mary_Vouyiouklis,_MD: Birth control pills which contain estrogen and progesterone can affect thyroid-binding proteins. When on birth control, there is usually an elevation in thyroid-binding proteins. Therefore, a person with hypothyroidism on thyroid hormone replacement will likely need a higher dose of their medication when they are on birth control. Therefore, once you come off the birth control, you will likely need this thyroid hormone replacement dose reduced.

Hashimoto thyroiditis is a very common autoimmune disease. Sometimes those with one autoimmune disorder may have others. However, patients may have positive antibodies for a disease but not have clinically significant disease. Therefore, we usually do not check for other diseases unless there are specific symptoms related to these.

Checking T cells in this situation is not useful as it does not change management of Hashimoto thyroiditis. If you are on thyroid hormone replacement for Hashimoto disease and your thyroid function is normal, this should suffice!


Neurological Symptoms and the Thyroid

rebeccalydia: What is the connection with neurological symptoms and thyroid disease? Ever since I started feeling unwell and was diagnosed with hypothyroidism, I have noticed that my memory and coordination have changed slightly. Although I have started taking supplemental thyroid hormone, these symptoms have not improved back to my normal functioning before I started having hypothyroid symptoms. Is this common?

Mary_Vouyiouklis,_MD: What is your TSH? If you supplement thyroid hormone and the thyroid function normalizes and you are still having these symptoms, then it is less likely that they are related to your thyroid. I would recommend you see a neurologist for further evaluation. However, if your TSH is still abnormal or if you most recently started on thyroid hormone (less than six weeks from start of treatment), it can sometimes take time to see a response.


Central Hypothyroid Diagnosis

loveitaly: My daughter is 31 years old. She has developmental disabilities with cerebral palsy, seizure disorder and intellectually challenged. She also has hypothyroidism since 2006.The symptoms she presented were episodes of hypothermia. She has a wonderful endocrinologist and she is on levothyroxine .88 and .1 on alternate days. My father has had hypothyroidism for over 22 years. Her endocrinologist says that her hypothyroidism is not totally hereditary, but also due to her neurological condition. Her levels are perfect, (T3,T4, etc.), except the TSH, which he says in her is always going to be low. I like your input in this.

Christian_Nasr,_MD: She probably has central hypothyroidism, which means that her TSH does not really reflect her thyroid levels—probably because of a pituitary problem associated with her neurological problems. When we look at the TSH to judge the adequacy of the levothyroxine dose, we have to trust the pituitary gland—otherwise the TSH could not relied on.

loveitaly: Following my previous question, every now and then, my daughter gets cold in the evening although it could be 96 degrees Fahrenheit. We warm her up, even inside the house. We put her in a pair of gloves, double socks, a little hat, and so on. In the morning sometimes she is very warm and we have to give her a sponge bath. This happens sporadically. When we test the levels, the doctor says, "optimum results, they could not get any better than that." Her pituitary has been checked, and a recent CT scan from last year was fine. Of course it always shows her severe brain damage from birth, but no changes are shown.

Christian_Nasr,_MD: Thyroid levels do not vary significantly during the day or night. Your daughter's pituitary gland does not have a tumor on it, but it was probably affected by her brain damage.


Hypothyroidism and Men’s Health: Association and Treatment

jamesditto: Does hypothyroidism treated with 175 mcg levothyroxine sodium (Synthroid®) contribute to erectile dysfunction? I have no other medical problem that requires prescription drugs and have been taking this medication since 1982. I have been bouncing back and forth between 150 and 175 mcg.

Christian_Nasr,_MD: Untreated hypothyroidism may lead to erectile dysfunction and even low testosterone. If the cause of the hypothyroidism was the pituitary gland, that could be associated with low testosterone as well. Once thyroid hormones are normalized the erectile dysfunction should improve if it was directly related to the hypothyroidism. (It might take a few weeks.)

tnb65: Is low testosterone (low-T) sometimes associated with thyroid problems or Hashimoto disease? Or, is it likely coincidental? I'm a 47-year-old male, and have been tested for low-T since getting Hashimoto thyroiditis. My symptoms were not typical for hypothyroid. I had tinnitus, night-time headaches, blood pressure spikes, and generally feeling ill. I also had low energy and was gaining some weight. My TSH was normal at 3.58. I was diagnosed with Hashimoto disease with anti-thyroid peroxidase (TPO) autoantibodies test. Now, most of those symptoms are gone, but the tinnitus remains. When I have a day of exertion, however, the night-time headaches and sometimes blood pressure spikes return until I take my medicine the next day. Why might that be? Because my body is asking my thyroid to do more hormone generation? Is there anything I can do about it?

Christian_Nasr,_MD: Tinnitus, headaches and slightly elevated blood pressure could be seen with untreated significant hypothyroidism, and they improve with thyroid hormone treatment. A TSH of 3.58 is not too normal and in the presence of anti-TPO antibodies tells me that your risk of progressing into overt hypothyroidism with a TSH higher than 10 is about two to four percent per year, so that will need to be monitored.


Thyroid Profile

Patty: Why would a thyroid have both a low TSH and a low free T4?

Christian_Nasr,_MD: If it was persistent, then a doctor would suspect a pituitary cause. More commonly it is due to a transition from hyperthyroidism after thyroiditis. Rarely do we see a hot nodule secreting mostly T3 which could give that picture.

Carie: I have Hashimoto disease, which is treated by my primary care physician. Last year my T3 total was low (66 ng/dL) but the T4 and TSH were normal. I felt fine and still do. I will be having it rechecked in the very near future. If it is still low, is this any cause for concern with the other numbers being normal?

Christian_Nasr,_MD: Your doctor should stop measuring the T3 level. It is useless for the diagnosis of hypothyroidism. Only TSH (maybe also free T4) should be followed yearly. You should have those checked sooner if you start having symptoms of hypothyroidism or if you are of a childbearing age, you should be monitored more closely.

chambiges: I am a 53-year-old female. I have hair loss and great difficulty losing weight despite two hours per day of vigorous exercise with a 160 to170 heart rate. My caloric intake is approximately 1000 calories per day. My body temperature upon awakening in the morning is between 96.5 and 97.5 degrees Fahrenheit over the last year. In 2012 my TSH test was 5.9 on my annual physical by my internal medicine physician. For the next year, I ate Brazil nuts daily for the selenium. My 2012 TSH test was in the normal range. Despite the normal TSH, could my symptoms be thyroid related? Besides TSH, are there other tests to pinpoint thyroid issues?

Christian_Nasr,_MD: With these symptoms, I would check free T4 along with the TSH. If your TSH was still elevated and you were having symptoms, then consideration should be given to a trial of thyroid hormone. Your metabolism must be terrible to have this weight problem, but I do not expect it to improve much by trying thyroid hormone.

dsm08: I have symptoms of extreme fatigue, hair loss, brittle nails, dry skin, weight gain, brain fog and chills. I have tried to get an appointment to see if I have a thyroid problem, and I was told that endocrinologists only treat and not diagnose problems. The average wait to see an endocrinologist is six months. My primary care physician and gynecologist say it is just menopause, so they won't refer me. I cannot do hormone replacement therapy treatment. This has been going on for four years now. The only test results I have are from February 2012, when my TSH was 4.315 and T4 was 1.2. In October 2012, my TSH was 2.2 and my T4 was 1.3.

Christian_Nasr,_MD: These symptoms suggest hypothyroidism, but your thyroid profile from October was normal, actually more normal than back in February 2012. Even the profile from February would not explain all the symptoms that you have been having. You should have your TSH measured periodically though because TSH of 4.3 was not too normal.

adreed: I have had Hashimoto thyroiditis for years, and I'm still clinically hypothyroid despite a normal TSH, free T4 and free T3. No matter how much levothyroxine I take, my free T3 and T4 will not stay elevated. I responded well at first to an increase in levothyroxine. (For the first time in my life I took off weight and had energy.) However, it always wears off and I end up hypothyroid again. It is impossible to make me swing hyperthyroid. Adding T3 makes me worse. Is this thyroid hormone resistance? If so, how do you diagnose it? Do you have physicians who can diagnose resistance to thyroid hormone?

Mary_Vouyiouklis,_MD: The TSH is the most sensitive marker of the thyroid. What was your TSH? What was your free T4? Are you on other medications? Sometimes other medications can interfere with these levels. Have you had a TBG (thyroid binding globulin) test done?

Nisaiah: Why is T3 measurement useless? I've heard from several sources that the TSH measurement is useless.

Christian_Nasr,_MD: T3 measurement is useless to diagnose hypothyroidism. It is very helpful for the follow up of hyperthyroidism. TSH is more reliable because it reflects your pituitary function. If I have a reason not to trust your pituitary, then I will not trust your TSH.

Carie: Does the TSH third generation test measure TSH only, or does it include T3 andT4?

Christian_Nasr,_MD: A third generation TSH test indicates that the test is very sensitive and detects three positions after the decimal point.


Synthroid: Long-term Use

emoeller: Upon being diagnosed as hypothyroid, how long can one expect to be on Synthroid®?

Christian_Nasr,_MD: If it was not improving then once you started on Synthroid® you would need to stay on it.


Levothyroxine Sodium with Other Medications

BTroyer: Does the use of lansoprazole (Prevacid®) interfere with the effectiveness of levothyroxine sodium (Synthroid®)? If so, would there be a span of time after stopping the use of Prevacid® that it would take for the Synthroid® to begin its effectiveness again?

Rosemarie_Metzger_,_MD: Prevacid®—which is a proton pump inhibitor (PPI)—works to decrease the acidity of the stomach. Gastric acid is thought to be a necessary factor in levothyroxine absorption and, therefore, PPIs can interfere with levothyroxine absorption. This means that less of the thyroid hormone is absorbed. Within a week or two of stopping PPIs the gastric acid level should be back to normal. That said, there are other things that can interfere with levothyroxine absorption including eating or drinking coffee within 60 minutes of taking the medicine. A high fiber diet, calcium supplements, iron, sucralfate (for ulcer treatment), bile-binding agents (used in those patients with irritable bowel syndrome [IBS], high cholesterol or after gallbladder removal) and antacids can also interfere with the absorption of levothyroxine. It is important to separate taking levothyroxine and these other medications by at least four hours.

khaki: What are your thoughts on liothyronine sodium (Cytomel®) suppressing TSH and free T4? I have taken Cytomel® with my levothyroxine sodium (Levoxyl®) for the last 12 years. Currently I am on 175 mcg Levoxyl®), and 5 mcg Cytomel®). My TSH suppresses on Cytomel®), while my free T4 remains barely within or just below normal range. There is no pituitary issue. I was diagnosed with Hashimoto thyroiditis 18 years ago with a TSH of 13. Recently, after mistakenly ingesting soy over a period of time, my TSH increased again to 10. Currently it is .02, while my free T4 is .7 (ranging from .6 to 1.6). My free T3 was not tested because my doctor will not test for it.

Christian_Nasr,_MD: Cytomel® may suppress TSH intermittently because of the drug profile of Cytomel®, which peaks a couple of hours after taking it and then the level goes down several hours later. I do not think you have a pituitary issue because your TSH was up to 10. You seem to be on a good dose of levothyroxine. Make sure your doctor checks your TSH before you take the Cytomel® dose, which would more accurately reflect your levels. When you are on the combination, your T4 will always be a little low because it is the T3 that suppresses the TSH. There is no benefit from testing the T3 because it will vary during the day from the profile of T3 that I described above.

janiceasad: My T3 was in the high 50s and I’m on Cytomel®. What does that mean and will it get better? Do I have to take the medicine along with my Synthroid® 100 mg.

Christian_Nasr,_MD: It depends on the dose of Cytomel® that you are on and when the T3 was measured in relationship to your intake of Cytomel®. The T3 level would be elevated if checked soon after taking Cytomel® and low just before your next dose. You have to generally take Cytomel® at the same time as Synthroid®, but sometimes you might need to take another dose during the day.


Side Effects of Synthroid

finnishgirl: If a person has to have thyroid removed surgically or chooses radiation, then lifelong thyroid replacement is necessary. Why do people say taking levothyroxine sodium (Synthroid®) makes them gain weight? Is taking Synthroid® a better choice than Armour® Thyroid?

Mary_Vouyiouklis,_MD: Replacing thyroid hormone with either Synthroid® or Armour® Thyroid and achieving good hormone levels in the blood would lead to normal metabolism and, therefore, should not affect the weight.

ruth.lee47: I have a hypothyroid condition for which I'm taking the smallest dose of levothyroxine sodium (Synthroid®). Does that make me anymore likely to get osteoporosis than someone without this condition? How often should I get bone scans if I'm more likely to get osteoporosis than someone who doesn't have a thyroid condition?

Christian_Nasr,_MD: Being on thyroid hormone does not increase your risk of bone problems. Being on excessive doses of thyroid hormone if you are postmenopausal may cause osteoporosis.


Synthroid Effect on TSH

GeorgeBMac: Do the thyroid hormones TSH, T3 and T4 vary based on exercise? Can exercising say, increase TSH levels and decrease the T3 or T4? Additionally, I have heard that it takes several weeks when one first starts taking it to feel the effects of thyroid medication. Is this true? And, if so, do we know why?

Mary_Vouyiouklis,_MD: Yes, it can take time for the TSH level to respond to changes in thyroid hormone. It can take from six weeks to three months. This is why it is best to wait this time before adjusting or making changes.


Synthroid vs. Armour Thyroid

Janerww: Why do so many physicians seem to have patients supplement with levothyroxine sodium (Synthroid®) or other T4 medications only? Why supplement a malfunctioning gland with only one of its hormones? I have been on Armour® Thyroid for about 40 years. There was one time a physician was going to "bring me into the 21st century" and put me on Synthroid®), but this was a big mistake. I had 18 symptoms of hypothyroidism despite having a normal TSH. I spent years recovering from this medication change.

Christian_Nasr,_MD: You like T3. Most patients do not care about T3, and do very well on just T4. Occasionally we encounter a patient like you who has a lot of symptoms when they take T4 alone.

Nisaiah: Many doctors look down their noses at Armour® Thyroid, but I know someone who took Synthroid®, and the lowest dose made her feel terrible. Her doctor let her try Armour® Thyroid, and she felt back to normal again. What are pros and cons of Armour® Thyroid vs. Synthroid®, and which types of patients do better on each?

Christian_Nasr,_MD: Before 1970, the only thyroid hormone medication available was Armour® Thyroid. Since then multiple preparations have been available. Most patients feel fine on levothyroxine (Synthroid® ), but some swear they feel much better on Armour® Thyroid compared to levothyroxine. The main disadvantage of any thyroid hormone is giving too much of it. If not given enough, the patient will continue to feel hypothyroid until the dose is adjusted. For Armour® Thyroid, one has to be careful with the T3 content, which might give heart arrhythmia in older people.


Continued Symptoms Despite Synthroid®

chris22: I’ve had Hashimoto thyroiditis for over 10 years and I am 32 years old. Even when my TSH is within normal limits on Synthroid®, I still have symptoms, including hair falling out, dry skin, very low energy and exercise tolerance, and so on. Is there anything else that can be done for symptoms when doctors insist TSH is normal and you are fine? I have been on both Armour® Thyroid and an herbal thyroid helper supplement, with really bad reactions to both. (I experienced terrible joint pain, fuzzy head feeling, worse energy and other symptoms.) My rheumatoid test was negative and I had to go off Armour® Thyroid. I have almost every clinical sign of fatigued adrenals. What can be done to improve adrenal function? My doctor will not address it because one 8 a.m. cortisol saliva test was normal, but I have read you need more than one.

Christian_Nasr,_MD: I am not sure what your TSH, was but if it was in the lower end of normal you should not have all those symptoms. Your TSH is normal, but I am not sure you are fine because there could be something else causing your symptoms. I am glad you considered rheumatoid arthritis, but fibromyalgia is another possibility. One 8 a.m. cortisol salivary test does not rule out anything. If the question of adrenal insufficiency was raised, then you should have a more accurate testing of the adrenal function.

em0406: I had a partial thyroidectomy about 17 years ago as treatment for goiter. A little over one year ago I had the remainder removed due to fluid-filled nodules that needed to be continuously drained and biopsied. (They were all benign.) Since the last surgery we have not been able to get my Synthroid® dosing leveled out. When the dosage is too high, I end up with panic attack- type symptoms and gastrointestinal issues, which have landed me in the ER at least once and at my primary care physician a couple times. When it’s too low, I have zero energy. I recently changed endocrinologists to see if a fresh look may help since it’s been over a year and I have never had any issues prior to the second surgery. Are there any recommendations you can offer that may help?

Christian_Nasr,_MD: One factor is the prescribing doctor; the other one is the patient herself. Please make sure you take your medication regularly and by itself—with no food for an hour, and no iron or calcium for 3 hours after you take your levothyroxine. You probably have to be on the same brand name to eliminate any fluctuation.


Hypothyroidism Disease Reversal and Prevention

duffer50: I have been hypothyroid and on levothyroxine sodium (Synthroid®) for seven years. Is it ever possible to wean off medications or even better, have my thyroid be healthy enough for no medications again?

Christian_Nasr,_MD: If you were significantly hypothyroid when Synthroid® was initiated, then I would recommend not going that route. If on the other hand, your TSH was only slightly abnormal, you could cautiously try to wean yourself off. Most likely though you would need to go back on Synthroid® down the road.

annebring: I have hypothyroidism ever since the birth of my child in late 2011. I was wondering if there is any chance of the disease reversing itself while on medication? If so, how would I be able to tell?

Mary_Vouyiouklis,_MD: Are you on thyroid hormone replacement? If you are, it is unlikely that the disease will reverse itself while on medication. Thyroid hormone supplementation provides an appropriate amount of replacement to keep your thyroid blood tests in the normal range. Your thyroid hormone replacement dose may, however, change over time.

StayWell123: Is there anything that one can do to heal the thyroid gland, to get it to produce the correct amount of hormone if you are currently taking medication to make up for low thyroid production?

Christian_Nasr,_MD: If the thyroid has already failed, it is usually impossible to heal it. In some cases of thyroiditis, the hypothyroidism may be transient and the thyroid could heal itself, but this is usually within a few weeks of the attack. After many years of hypothyroidism you cannot get the thyroid to work again.


Effect of Diet and Exercise on Thyroid

GeorgeBMac: Can exercise deplete the body’s store of thyroid hormones? And if so, should dosing be adjusted in any way for strenuous exercise?

Mary_Vouyiouklis,_MD: No. Exercise should not deplete the body's stores of thyroid hormone.

annebring: I would like to know if there are any dietary recommendations for hypothyroidism? I have seen things on the Internet regarding gluten free, coconut oil and so on.

Mary_Vouyiouklis,_MD: If you are on thyroid hormone replacement, you do not really have to make any changes to your diet. If you have subclinical (borderline) hypothyroidism, then you could consider avoiding high soy or iodine, which may affect thyroid function in those with autoimmune thyroid disorders. To my knowledge, there is no good evidence to suggest that going on a gluten-free diet will improve thyroid function especially if you do not have celiac disease (gluten intolerance).

pilatesgirl: I have lower levels but abnormal levels of autoantibodies for thyroid. The doctors say it is too early to do anything to change this. I have celiac disease, and follow a gluten-free diet. I do not use the substitutes though, and eat a real food diet. What do you believe I might be doing to nip this problem before it blooms larger into a more severe situation? Also, I have high blood levels of iodine and don't take it in supplement form. I did take chlorella for awhile, but have stopped. Do you think chlorella could have caused this? Is it unhealthy to have high blood iodine?

Christian_Nasr,_MD: I am not sure what you meant by ‘lower but abnormal levels of autoantibodies.’ If those were abnormally elevated—even slightly—that would indicate Hashimoto thyroiditis. That could be associated with celiac disease. Nothing would prevent progression into hypothyroidism. Some recommend eating Brazil nuts (two or three per day) for their content of selenium, but nobody knows whether that really prevents hypothyroidism. Blood level of iodine is never accurate. Urine iodine is a better indicator of body iodine, but I am not sure chlorella did that.


HYPERTHYROIDISM

Diagnosis of Hyperthyroidism

nutzy: What are the signs of hyperthyroidism?

Rosemarie_Metzger_,_MD: Typical symptoms of hyperthyroidism include:

  • Heat intolerance—always feeling hot despite the surrounding temperature
  • Palpitations—or being aware of your heartbeat or feeling like it is 'beating outside of your chest'
  • Poor sleep—inability to sleep
  • Fatigue
  • Weight loss
  • Nail changes
  • Eye symptoms—Depending on the cause of your hyperthyroidism, you may also have eye symptoms, including dry eye or bulging of the eyes

While all of these are symptoms of hyperthyroidism, not everyone who is hyperthyroid will have these symptoms—nor do you need to have all of them to be hyperthyroid.


Grave’s Ophthalmopathy

ktower: I was diagnosed with Grave disease this past August. My thyroid was destroyed after radioactive iodine treatment. Since then my endocrinologist has regulated my medication. I take 125 mcg of levothyroxine sodium (Synthroid®). At the end of November I began developing Graves’s ophthalmopathy (thyroid eye disease). An eye specialist placed me on prednisone (40 mg) for a month due to my age (29 years old). The swelling around my eyes decreased and the irritation to my eyes disappeared. As I weaned off the prednisone the swelling and irritation returned, but not as severe as before. I have read that there is a chance this will regress with time. Should I wait this out?

Christian_Nasr,_MD: I am in favor of waiting it out. I strongly recommend avoiding prednisone or any high-dose steroid especially if given for more than one to two weeks without a clear endpoint. If the irritation is not as severe as you describe, I recommend just monitoring the symptoms. Your doctor should intervene (medically or surgically) only if you cannot take the symptoms anymore, or if by the doctor's judgment, your vision is threatened.


Hyperthyroidism Treatment

sugarcookie: I was diagnosed with hyperthyroidism a few months ago with a TSH of 0.07. as well as testing of free T4 and free T3. I was put on methimazole (Tapazole®). Three and one half weeks later, my TSH had risen to 22.3. My free T4 was 0.5, and I had a total T3 of 1.1. I was taken off methimazole and will have a repeat TSH after six weeks. Is it unusual for the TSH to rise that quickly? I also had periorbital edema (not exophthalmos) on methimazole. Is that unusual?

Christian_Nasr,_MD: I have to say this is a very short time for TSH to rise from 0.07 to 22.3 which tells me that you had not been too hyperthyroid for too long before you started methimazole. Hopefully, you will not bounce back into hyperthyroidism. Periorbital edema may be seen during hypothyroidism or just from palpebral inflammation (of the eyelid) with Grave disease. It may happen from drug reactions of any kind.


THYROID NODULES AND TUMORS

Prognosis of Nodules and Tumors

IrishGram: Is what I am experiencing a usual course for long-term nodules? I am 64 years old. I have had thyroid nodules for nearly 20 years which have gone from functioning to cold over the past two decades. Several biopsies have all been benign. These solid nodules are heterogeneous; have irregular margins; are hypoechoic with calcifications and have significant blood flow with Doppler ultrasound. I was given levothyroxine sodium (Synthroid®) years ago to suppress growth, but the nodules grew anyway. The dominant nodule is 4.0 x 1.6 x 1.4 cm. We do have a family history of thyroid cancer (my brother's son) as well as thyroid nodules.

Rosemarie_Metzger_,_MD: You need to continue to have regular follow up for your nodules. Even benign nodules have up to a five percent risk of containing a cancer. Continued nodule growth despite hormone supplementation warrants investigation. At the very least you should get yearly ultrasound evaluations. Many nodules never change in size, while some grow and some shrink. We are most concerned with those that grow and this is often an indication for repeat biopsy. Also, given the size of your nodule you may have compressive symptoms that would warrant surgical evaluation even though your biopsies have been benign.

bonde: Can benign tumors of the thyroid turn cancerous? What are the triggers, and what are the signs?

Rosemarie_Metzger_,_MD: Benign biopsies have an approximate three to five percent false negative rate. This means that there is a low chance that there are actually cancer cells in the nodule that was biopsied, but that they weren't captured by the needle as it passed through the nodule. Because of that, we always recommend that benign nodules be followed and monitored for any change in size, which would indicate a need for re-biopsy. There are no triggers per se for cancer, but there are risk factors, including family history of thyroid cancer and exposure to external beam radiation in the head or neck (like the kind used to treat lymphoma, not dental x-rays). There are no specific signs for thyroid cancer, which is why follow up is so important.


Medications for Nodules

armintajl2: I have hypothyroidism, and I’m taking a half pill of .125 mg levothyroxine sodium daily. Both of my daughters have thyroid nodules. Their TSH levels are in the low normal range. They have never been put on medications. Should they be on medications and should these nodules be tested routinely?? Both were found on CT scans that were taken for other issues.

Rosemarie_Metzger_,_MD: If their thyroid function is already normal, they do not need to be placed on thyroid hormone. They should have an ultrasound evaluation of their thyroid glands, however, for further characterization of the nodules. Typically, all nodules bigger than 1 cm require biopsy to make sure there is no evidence of cancer. Even benign nodules require yearly follow up.


Treatment of Thyroid Nodules and Tumors

brivera: I was recently diagnosed with hyperthyroidism and proceeded to elect to have the right side of my thyroid removed (due to three nodules) two weeks ago. In your opinion, what are the chances that I will return to a hormonally balanced state and, therefore, not require the use of lifelong synthetic hormone supplements?

Rosemarie_Metzger_,_MD: I will assume that your hyperthyroidism was due to the nodules and not a more global thyroid process. If your hyperthyroidism was due to a toxic nodule, then removal of the nodule is likely to return you to a euthyroid state (hormonally balanced). Some of that will depend on the remaining thyroid tissue you have. On average, 75 percent of people who have only one side of the thyroid removed are able to make enough thyroid hormone so that they don't need additional thyroid hormone supplementation.

rasato: I have thyroid nodules which I have had biopsied and were negative and I also take levothyroxine sodium (Synthroid®). I have been treated for Cushing disease, which is under control. My doctor told me the reason I need to take Synthroid® is because my pituitary is not telling my thyroid to make hormone. Do you think my thyroid will ever begin making hormone again? Can this lack of pituitary communication with my thyroid be causing these nodules? Also, at what size is it important for these nodules to be removed? They are large enough to be seen when I swallow, but are not affecting my swallowing.

Christian_Nasr,_MD: Visually bothersome or cosmetically unacceptable nodules or goiter might need to be removed. Compressive nodules should be considered for removal. Your pituitary will not recover if the initial surgery disturbed it years ago. TSH is unreliable to tell what the level of thyroid hormone is, so you have to rely on symptoms and T4.

bonde: Regarding benign tumors of the thyroid, what is the best way of monitoring them? How often should they be measured? When and why should they be biopsied? When and why should they be excised?

Rosemarie_Metzger_,_MD: The best way to monitor a thyroid nodule is with ultrasound. They should be measured at least every year. If you have several years in a row where the size is unchanged, then monitoring can be spread out a bit. Any nodule bigger than 1 cm in size is typically biopsied. Also, if there is growth in a nodule that is being followed, it should be biopsied. Occasionally nodules that are smaller than 1 cm will be biopsied if they have suspicious characteristics on ultrasound. Any nodule that is confirmed to be cancer on biopsy requires surgery. There are several other biopsy results that are in the suspicious category, and these often require surgery as well. Some people undergo thyroid surgery for benign nodules if the nodules are big enough to be causing symptoms because the nodule is large.


Cold Nodule Treatment

happiness1: I have a large cold nodule with atypical cells on cytology. I have trachea deviation due to the large size of my thyroid. What is the recommended treatment?

Christian_Nasr,_MD: Atypical cells do not confer a high risk of cancer although that depends on the type of atypia that was noted. If the cold nodule was a solid nodule, it would need to come out. If cancer was found, then removing the remainder of the thyroid would be indicated.


Radioactive Iodine Treatment

Lin62: I have a hyperactive thyroid (with T4 of 1.2, T3 of 3.7, TSH of 0.01 and FSH of 70.0). In November, I had a thyroid scan and uptake performed. I had increased uptake on the left lobe and faint uptake within the right lobe. I had a thyroid fine needle aspiration on the right nodule, and it is benign. I’m trying to decide whether to have radioactive iodine therapy. Is it necessary since the nodules are benign on the right side? I’m pretty sure that the nodules on the left side are also benign, since they took up most of the iodine. It was not suggested that I need a fine needle aspiration on the left nodules. Is it possible that thyroid levels may improve without doing anything further?

Christian_Nasr,_MD: You are correct that the risk of cancer is very low in hot nodules (your left nodule). If the nodule was not bigger than one inch, you were not symptomatic and the thyroid levels were stable with a detectable TSH, then you could have your levels monitored every six months and avoid surgery. If any of the other conditions were met, then you should consider having surgery to have the right side removed. Radioactive iodine is an option.

Lin62: If I have radioactive iodine therapy, I was told I probably would become hypothyroid. Then I would need to be on medicine rest of life, possibly levothyroxine sodium (Synthroid®). I have heard that being hypothyroid makes you feel really tired. I also heard Synthroid® makes you gain weight and you cannot lose the weight. Is this the one used by most people?

Christian_Nasr,_MD: You will become hypothyroid for life if you are given the correct dose of radioiodine. You will most probably be offered Synthroid® to correct hypothyroidism, but you could discuss other options. Synthroid® is the medication that is used the most.

Synthroid® does not make anybody gain weight, but being on nothing will make you gain a lot of weight.

jkole: I have a hyperactive thyroid with Grave’s disease. I had radioactive iodine in February 2012, and my thyroid is still overactive. The symptoms I was having did not return though. My endocrinologist has now recommended radioactive iodine again, and I have concerns with the risks. How common is this, and what other options are there? Are there any common dietary changes that might be helpful?

Christian_Nasr,_MD: It’s not too common. About 10 percent of patients treated with radioactive iodine will experience this. Most patients will become hypothyroid down the road. If you are not too hyperthyroid, you could be treated with a low dose of methimazole (Tapazole®) and monitored for the onset of hypothyroidism. Since it has been over a year, another dose of radioactive iodine is justified.


Thyroidectomy

judyse74: Since I had my thyroid removed, should I stay away from iodine or continue using salt, etc., with iodine?

Rosemarie_Metzger_,_MD: You can use iodized salt.

nharward: If you have to have thyroid removed, how long will you be in the hospital, and how long before you can eat or talk?

Rosemarie_Metzger_,_MD: Thyroid surgery typically requires an overnight stay in the hospital. There are some centers where patients are discharged on the same day as the surgery is performed, but this is not typically the norm. It also depends on the type of thyroid surgery being done. You will be allowed to eat and drink as soon as you are awake enough from the anesthesia to do so safely, i.e. you can eat and drink later in the day on the same day as your surgery.

cmazey: After a total thyroidectomy due to a follicular variant of papillary carcinoma and diagnosis of Hashimoto disease, will I always have Hashimoto thyroiditis or since the thyroid is gone, I no longer have it?

Christian_Nasr,_MD: Hashimoto disease implies damage to the thyroid gland. One of the indicators of Hashimoto disease is the presence of microsomal antibodies in the blood. After removal of the thyroid gland, the microsomal antibodies will decline over time because your immune cell memory will decline since there is no more thyroid antigen to trigger the immune response.


ENLARGED THYROID

Diagnosis

tracy483: During a routine physical, my doctor found that my thyroid felt enlarged and nodular and ordered blood work. My TSH level was 1.050. My free T4 was 1.0 and T3 was 84. The T3 level was flagged on the results as low, but I was told the levels were normal. No discrete nodules were found in the ultrasound. However, I am still concerned that my T3 was low. Should I be concerned? Also, should I have my thyroid levels checked at certain intervals to see if anything has changed?

Christian_Nasr,_MD: T3 levels are only useful in the diagnosis of hyperthyroidism. Serum T3 levels vary depending on the non-thyroidal clinical situation. For example, if one was sick, dieting or losing weight, the serum T3 level will be low. When someone is critically ill, the T3 will be undetectable. In those situations, one cannot diagnose hypothyroidism. TSH remains the best test to gage the thyroid state. It has to be taken into context. T4 might be needed in conjunction with TSH sometimes to be able to make a diagnosis. In your case, the T3 level was not normal but it did not reflect an illness or a thyroid abnormality. Because of nodular thyroid disease, you should have your TSH measured once a year or more often should the clinical situation warrants it.

countrygirl44062: Three years ago, my doctor told me my thyroid was enlarged and she sent me for an uptake scan and ultrasound. The results were concerning enough for her to refer me to an endocrinologist. I am concerned as I have a niece and first cousin that have had thyroid cancer. All of the women on my father’s side of the family have some sort of thyroid issue. The doctor I am seeing now only sees me once a year and has never ordered blood work. When I tell him that my neck hurts and is swollen, he tell me that I should talk to a surgeon and have it removed. Should I be concerned and get a second opinion? What causes a thyroid to become enlarged? Is there any treatment for it?

Rosemarie_Metzger_,_MD: Yes, you should seek a second opinion. There are many reasons that your thyroid might become enlarged. One of those reasons is a thyroid nodule. Given your family history of thyroid cancer, I think it's important that you be seen to see if your thyroid enlargement is related to a nodule. If it is, you may require a biopsy to rule out cancer. Thyroid nodules occasionally require surgery for treatment, but not always.

chihuahua3mama: If my biopsy was negative and my thyroid is still enlarged, but not painful, should I just let it be?

Rosemarie_Metzger_,_MD: That depends on whether you have other symptoms. Nodules themselves are rarely painful. They can, however, cause other compressive types of symptoms like difficulty breathing (feeling a strangling sensation, especially when lying flat), difficulty swallowing or occasionally voice changes. Sometimes these symptoms alone are bothersome enough to people that they want thyroid surgery even though their biopsy is normal. Even if you do not have symptoms and your biopsy was negative, it is important to continue routine yearly follow up of your thyroid to make sure it is not continuing to grow significantly.


Closing

Moderator: I'm sorry to say that our time is now over. Thank you again Dr. Nasr, Dr. Vouyiouklis and Dr. Metzger, for taking the time to answer our questions today about Thyroid Disease.

Christian_Nasr,_MD: Thank you for all of your questions.

Rosemarie_Metzger_,_MD: Yes, thank you for the interesting questions.

Mary_Vouyiouklis,_MD: Thank you, and we hope you will follow up on your thyroid health.


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