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Thyroid Problems

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

January 28, 2013

Introduction

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.

 

For More Information

On Cleveland Clinic
Cleveland Clinic is a national leader in caring for patients with all types of thyroid conditions, from the routine to the complex. Our patients benefit from access to a multidisciplinary staff, the most advanced technology and the latest clinical trials for thyroid conditions.

The departments and centers of the Endocrinology & Metabolism Institute at Cleveland Clinic include endocrine surgery; endocrinology, diabetes and metabolism; and the Bariatric and Metabolic Institute. We treat various disease and conditions of the endocrine system, including diabetes (types 1 and 2), obesity, hyper- and hypothyroidism, Cushing’s disease, and Addison’s disease among other illnesses.

The Endocrinology & Metabolism program at Cleveland Clinic is ranked first in Ohio and second in the nation by U.S.News and World Report.

On Your Health
MyChart®: Your Personal Health Connection, is a secure, online health management tool that connects Cleveland Clinic patients with their personalized health information. All you need is access to a computer. For more information about MyChart®, call toll-free at 866.915.3383 or send an email to: mychartsupport@ccf.org

A remote second opinion may also be requested from Cleveland Clinic through the secure Cleveland Clinic MyConsult® website. To request a remote second opinion, visit eclevelandclinic.org/myConsult


For Appointments

To make an appointment with Christian Nasr, MD, Mary Vouyiouklis, MD, Rosemarie Metzger, MD, or any of the other specialists in our Endocrinology & Metabolism Institute at Cleveland Clinic, please call 216.444.6568 or call toll-free at 800.223.2273, ext. 46568. You can also visit us online at www.clevelandclinic.org/endocrinology


About the Speakers

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’s 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, Wisc., 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 Lifestyle Choices: Root Causes of Chronic Diseases

 

Cleveland_Clinic_Host: Dr. Golubic, let’s begin with some of the questions submitted

 

Hypothyroidism vs Hyperthyroidism

Kammy: What are the symptoms of an unhealthy thyroid gland? And do patients with narcolepsy often have thyroid problems? 
Dr_ Vouyiouklis:  There are many symptoms of hypothyroidism or hyperthyroidism. With hypothyroidism, there is reduced thyroid hormone. As such, things tend to slow down. Some symptoms include: reduced mood, constipation, fatigue, slow metabolism/weight gain, dry skin and cold intolerance. With hyperthyroidism, the opposite can occur. Symptoms of hyperthyroidism include: irritability, anxiety, diarrhea, weight loss, clammy skin, heat intolerance and heart palpitations. There can be changes in menses as a result of both conditions. To my knowledge, I do not know of an association of thyroid problems and narcolepsy. Hypothyroidism if untreated can cause extreme fatigue.

 

Laboratory Ranges for Thyroid Disorders

dharral4588: What is the normal range for TSH?
Dr_Nasr: The normal range of TSH depends on the laboratory, but a typical range is about 0.4 to 4.5. The upper and lower ends of the range might be a little higher or lower depending on the lab. However, about 90 percent of individuals without thyroid problems have a TSH that falls between 0.4 and 2.5. Treatment is not indicated until the TSH gets above 4 (if symptoms of hypothyroidism are present) or above 10 (if those symptoms are not present). The lower numbers are a little trickier and require a clinical assessment.

MrsSyp: I would really like to know why so many doctors still only look at a TSH level.  AACE guidelines are wrong and this is not how thyroid disease should be treated. For 14 years I had symptoms but each doctor said your TSH is normal. It was only when I developed a tumor that something was done.  I had thyroid cancer. If the many doctors would have treated me, just maybe, I would have a thyroid today.  I am an administrator with the group, Thyroid Change™, and over 9,000 suffering with thyroid disease are asking for changes.  Our petition is international.  Maybe changes need to be made now so the new cases do not continue to grow. 
Dr_ Vouyiouklis:  Doctors should not go by lab tests alone. We strive to listen to the patient’s concerns. It is essential to do a full thyroid exam to see if there are any palpable nodules. If these are noted, further intervention with neck sonogram is then warranted at that time. In addition, if there is a family history of thyroid disease, we also take this into account. Typically, we do not only check the TSH. We also assess free thyroid hormone (FT4) and at times T3 (based on symptoms) as well as thyroid antibodies when necessary

 

Endocrine Disorders and Blood Pressure

boomer: Does an endocrine system disorder cause a heart murmur, high blood pressure or erratic blood sugar levels? If so, which glands are involved? Can those three problems be reversed? How do I get my doctor to listen to me about my suspicions that I have an endocrine system problem? What tests should he run and how should he interpret them?
Dr_ Vouyiouklis:  There are several endocrine issues that can cause high blood pressure and erratic blood glucose levels, although it is unlikely that these can they cause heart murmurs. I suggest you emphasize your concerns about your high blood pressure and erratic blood glucose to your doctor. Question him about other possible causes of these conditions. Hyperthyroidism can affect blood pressure. In addition, several hormones— if in excess—can affect blood pressure. (These include cortisol, aldosterone metanephrines and catecholamines.) We, as endocrinologists, tend to evaluate these hormones in patients with uncontrollable high blood pressure, or in those patients who were diagnosed with high blood pressure at a young age. Patients who have excess cortisol (Cushing’s syndrome) can have both erratic blood glucose levels and high blood pressure. If this remains a concern for you after discussion with your physician, you can always ask to see a specialist for further evaluation.

 

Symptoms of Hypothyroidism

Pmsavol: Why do I continue to have symptoms of hypothyroidism (i.e., fatigue, weight gain, sensitivity to cold, etc.) when my blood tests keep coming back in the normal range? Is there an area on the range that would possibly lower these symptoms?
Dr_Nasr: I do not expect patients to have severe symptoms of hypothyroidism when the TSH is less than 4. Some patients might continue to have milder symptoms compared to when they were initially diagnosed if their TSH was not kept below 2. I do not expect your symptoms to improve just by pushing the dose to try to further suppress the TSH. A doctor should look for other possible causes of your symptoms.

Gae: According to recent blood tests, my thyroid level is slightly below normal.  My primary care doctor and I have discussed Synthroid®.  I have researched hypothyroidism and Synthroid®.  The only symptom of the condition that I appear to have is hair loss.  My hair is quite thin.  It disturbs me to read that hair loss is one of the side effects of Synthroid®.  
Dr_ Vouyiouklis: It is unlikely that your hair loss is caused, per se, by Synthroid®. However, a change in thyroid function can cause hair loss. Therefore, if there is evidence of hypothyroidism (underactive thyroid), this likely should be treated. Remember, that hair loss may occur for some time after thyroid function is normalized as there can be a delayed response. But, typically, widespread hair loss due to thyroid dysfunction (as shown by abnormal thyroid function tests) is usually reversible.

ChrisOH: How do you know if a person with Hashimoto's disease has hypothyroidism or  hyperthyroidism? How do you test for cancer—by the thyroid number? Are selenium and zinc important for thyroid health?
Dr_ Vouyiouklis:  Hashimoto’s disease is an autoimmune thyroid issue. Most often when you hear this term it relates to a person who is hypothyroid due to an autoimmune thyroid issue. (They usually have positive thyroid antibodies, and can also have a family history of this.) Hyperthyroidism can be caused by an autoimmune condition as well. It is known as Grave’s disease.

You cannot test for cancer from thyroid function tests. A full thyroid exam is important to help evaluate this. If there is any suspicion of thyroid nodules, then a neck sonogram is needed for further evaluation.

We do not typically recommend supplements in patient with thyroid issues. Selenium, however, can sometimes be helpful in lessening some of the effects of eye changes that may occur in patients with Grave’s disease (autoimmune hyperthyroidism).

laura628: I was diagnosed with hypothyroidism and Hashimoto's disease in 1992.  I have been on thyroid medication ever since.  What is the difference between hypothyroidism and Hashimoto's disease? Since I have Hashimoto's disease, is there anything additional I should be doing besides taking my thyroid medication and having annual blood work done to test my TSH levels?
Dr_ Vouyiouklis:  Hashimoto’s disease is basically autoimmune hypothyroidism. This is one of the most common causes of hypothyroidism. Hypothyroidism is a general term that describes underactive thyroid hormone. Monitoring thyroid function regularly (yearly if there has been no significant change in your dose since diagnosis or sooner if you have new symptoms) is important to ensure that no dose adjustment is necessary.

Myadvocate: I have a chronic cold body temperature. Typically, it is  96.5 degrees Fahrenheit,  but it has been as low as 93 degrees. It has never been up to 98.6 degrees in the last five years, yet my TSH level is usually in the normal range. Only once was it slightly low.  What else should I have checked, as I really dislike my constantly cold hands and feet?  Even moving to South Carolina did not help.  Are there additional tests or different studies that might be useful?
Dr_Nasr: This cannot be explained by hypothyroidism. Coldness in the extremities is typically due to ‘cold sensitivity’, which is a spasm of the small arteries to the fingers and toes (and sometimes to the ears and the tip of the nose). An extreme case of this is Raynaud's phenomenon.  You should keep your body warm including in the summer when you enter an air conditioned area.

Pas: I am suspecting a sluggish thyroid because of fatigue, fibromyalgia (diagnosed in 1989 at The Ohio State University Hospitals Department of Rheumatology and Immunology with 13 of 18 trigger points affected) and headaches (which I have experienced the majority of my life). Could this be related to thyroid or parathyroid problems?  Also, all of the routine tests say no, but no one ever scrutinizes my T3 and T4 levels.
Dr_ Vouyiouklis: Sluggishness can be seen in patients with hypothyroidism (underactive thyroid). If the TSH is in the normal range of 0.4-4.5 (depending on the laboratory), it is less likely that your symptoms are a result of this. TSH is a very sensitive marker for thyroid function, so while a free T4 may be additional useful information, a TSH should be able to indicate if there is thyroid dysfunction.

If you have a parathyroid issue, sluggishness can sometimes be seen— typically if the blood calcium levels are very high. Normal serum calcium will most likely rule out this condition.

Judy: I have been on thyroid medications for 20 some years. I was just wondering whether thyroid issues can cause depression or anxiety issues.
Dr_ Vouyiouklis:  If the thyroid function tests are abnormal while being on the thyroid medication, you can certainly feel symptoms of anxiety (if your dose if too high causing hyperthyroidism) or depression (if your dose if too low suggesting hypothyroidism). But when the thyroid function is normal, the medication itself does not actually cause these conditions.

 

Immunosuppression and Hypothyroidism

RRH: Have any of the physicians participating in the web chat seen patients that also have other autoimmune disorders? If so, how does immunosuppression play a role in Hashimoto's disease? Will it alter my TSH lab results? I'm curious because I still have monstrous fatigue (taking 1/2 of 0.125 mg of Synthroid®), but I also inject methotrexate (.60 cc). My throat also feels like it swollen on the inside—either when I’m swallowing or not. I also have scleroderma.
Dr_Nasr: Physicians who deal with non-endocrine autoimmune disorders are rheumatologists and not endocrinologists. I suspect you are seeing one.  If you are already hypothyroid, I do not expect immunosuppression to modify the course of Hashimoto's disease. Medications other than glucocorticoids, such as prednisone and the like, should not affect your TSH, T4 or T3 levels. Your throat symptoms could be related to the scleroderma. You should have that investigated by a doctor though to make sure there is nothing else going on in that area.

 

Hypothyroidism and Diabetes

duffer50: I am 63 years old and have been taking Synthroid® 100 mg for hypothyroidism for six years. I just had two fasting glucose levels taken this month, which were 106 and 107. I also have moderate mitral valve regurgitation, atrial fibrillation and moderate pulmonary hypertension. I take Pulmicort Flexhaler® (budesonide) two puffs daily and Proair® HFA two puffs daily, plus blood pressure medications and warfarin. My foods are all fresh. I plug in everything I eat and drink to My Fitness Pal mobile phone app, and average about 28 g of sugar per day. Could any of the above be influencing my glucose?
Dr_ Vouyiouklis: Steroids can affect blood sugar, especially if you have a predisposition for diabetes or a family history of diabetes. Steroid effects are usually more pronounced if they are taken orally or if given intravenously. Steroid inhalers (like Symbicort® [budesonide]) are less likely to affect blood glucose although this could happen.

 

Treatment for Hypothyroidism

Nance107: What causes Hashimoto's thyroiditis and what is the best method of treatment? Can getting intravenous immunoglobulin (IVIG) cause this condition? Can iodine help this condition?
Dr_ Vouyiouklis: Hashimoto's thyroiditis is a type of autoimmune thyroid disease in which the immune system attacks and changes the texture of the thyroid gland. Hashimoto's thyroiditis stops the gland from making enough thyroid hormones for the body to work the way it should. Therefore often people will need thyroid hormone replacement. Levothyroxine replacement (T4) is used to treat Hashimoto’s thyroiditis, although there are other formulations such as Armour thyroid (which contain both T3 and T4), which is also sometimes used.

What are you getting IVIG for? Is it for an autoimmune issue? If yes, sometimes people with one autoimmune issue can have other autoimmune diseases as well. Autoimmune thyroid disease (i.e., Hashimoto’s thyroiditis) is one of the most common autoimmune diseases. 

One should avoid taking iodine in this situation. If you have evidence of underactive thyroid and are symptomatic, the treatment of choice would be thyroid hormone replacement (T4 replacement).

Babi: I was diagnosed with Hashimoto’s thyroiditis two years ago.  After treatment with Synthroid® 75 mcg, my lab numbers were normal with a TSH level between 1 and 2. My free T3 is 2.94, and has always been under 3.0). However, I was mildly depressed even after a psychiatrist put me on Zoloft® 50 mg. My doctor added compounded T3 10.3 mcg one year ago and started me on a progesterone cream (estradiol was 192.10 and progesterone 7.92 in the luteal phase). Even though the mild depression decreased in intensity, I still get it every two or three months. It lasts about 35 days, regardless of the psychiatrist adjusting the dose. (I am now on Zoloft® 150 mg). The psychologist who evaluated me believes that the cause of my depression is not psychological. Should I try raising my compounded free T3 level and lowering the Synthroid® dosage? My latest laboratory test results show free T3 is 3.14 pg/mL. My free T4 is .81 ng/dL and  TSH is .33. My estradiol is 212.55 and progesterone is 12.62 in the luteal phase. 

I lose hair every time I wash it and I have broken nails, along with the on-and-off mild depression. One doctor told me I was over-medicated and should stop taking the compounded T3 because it doesn't do anything (since my TSH is .33). Another doctor told me TSH fluctuates constantly, and I should just repeat the test in a month to see if it is over .50  Since T3 levels are related to mood and feelings, I am afraid to stop taking the compounded T3. In your opinion, considering my mild depression problem, should I stop taking the compounded T3 and stay with the Synthroid®  75 only Or should I adjust my Synthroid®  dose and continue taking the compounded T3 to raise the TSH level? Although my TSH was .33, other times it has been.66 or .54.

Would having the free T3 level between the 4.0 and 5.0 range improve my mood?  (It is currently 3.14 with the help of the compounded T3 10.3 mcg and Synthroid®  75 mg)

Could a TSH third generation of 4.49 and T3 total of 1.34 when I was at 36 years old (which was four years before I was diagnosed) have caused a depression episode I had that lasted two months?  At the time I was not taking any thyroid medication and had started taking Paxil®.
Dr_ Vouyiouklis: Your TSH level is too low, which means you are on too much thyroid medication and this will need to be adjusted. While we typically treat with levothyroxine (Synthroid®) alone, sometimes we do add T3 to help with mood. There are some studies that have suggested that the addition of T3 may help, but we use the combination with a goal of keeping your thyroid function within normal range. At this time, your TSH level is lower than normal as stated above. You should not make any changes to your medication on your own. This should be done by your endocrinologist.

A TSH level of 4.49 is not a mid-normal level, but for some laboratories it may be considered within normal range. It is theoretically possible that you may have had somewhat of a decreased mood with this TSH level, although it is doubtful that it would result in a two-month depressive episode.

 

Symptoms Following Hypothyroidism Treatment

anjalique: I have had hypothyroidism for four years now, and I am taking Levoxyl® 125 mcg. However, I still do not feel normal. I have no energy although I am active. I've got brain fog and other symptoms.  I get regular blood tests and my doctor says they are O.K. I watch what I eat, which is mostly a vegetarian diet. I eat like a bird and can’t lose a pound. I have never been heavy my entire life. Would seeing a thyroid specialist benefit me? I'm at my wits end and very frustrated.
Dr_Nasr: A bird eats the equivalent of its weight every day, so I am not sure you are eating like a bird. I am not sure whether you had these symptoms when you were first diagnosed with hypothyroidism, and whether the magnitude of the symptoms improved somewhat after treatment was started. If your TSH is in the normal range, I would expect you to feel like you have no energy. Sometimes patients will feel their energy is not that good when the TSH is in the upper half of the normal range. Sometimes fine tuning the medication dose will help. When I read about these severe symptoms, I suspect other things could be happening. Seeing a thyroid specialist or even an endocrinologist might help. However, a specialist might concur with your physician. I should say though that if low energy and brain fog were the only significant symptoms, then giving you a low dose of T3 might help you.  

rnk01: I am really looking forward to getting more information on thyroid issues. I have been struggling with this for years. One and one half years ago my TSH number was 35.64. That was when they first discovered I had a problem. Medication has brought it down to 5.14, but I still do not feel any better. I have extreme sensitivity to cold, weight gain that will not go away no matter how much I diet and exercise, fatigue and sleeplessness—plus many other issues. All of this is combined with menopause and extreme hot flashes and night sweats.

Can you give me any suggestions on how to get relief from some of this?  I am absolutely miserable and the menopause has been going on for about four years now. I am just wondering whether these two issues are working together somehow.  I just want to get my life back.
Dr_ Vouyiouklis:  You may be still feeling symptoms because you are still hypothyroid. Your TSH at 5.1 remains slightly elevated, so you should probably have your dose adjusted. Please note that the TSH range is wide. Also, it can take up to six weeks to three months to see changes in thyroid function, and it can sometimes take time to see a complete response to the medication. I would suggest you talk to your doctor about your symptoms of cold sensitivity, fatigue and weight gain and discuss possibly increasing your thyroid hormone replacement dose to see if your symptoms improve.

Harris: I have been taking thyroid medication for over 50 years. I presently take one Synthroid® 0.075 mg and two liothyronine tablets 5 mcg daily. My recent blood test results showed  TSH 0.93   with a flagged reference range of 0.34 to 5.60. My free T3 was 2.84 with a flagged reference range of 2.50-3.90. My free T4 was .067 with a flagged reference range of 0.58 to 1.64. I have been told these are normal! During the past two years my energy level has dropped and  I believe I should have more energy than what I am experiencing.  Do you have any suggestions?
Dr_ Vouyiouklis:  Do you mean your free T4 is 0.67 or 0.067? If 0.67, then yes, your thyroid tests are within normal range. Perhaps your decreased energy may be from some other issue not related to your thyroid, which should be evaluated. When was your last ‘well’ visit with your primary care physician? A yearly blood work screening may sometimes show other causes that may cause reduced energy.

KDow: I have had hypothyroidism for 10 years and take 125 mcg of levothyroxine. I have a history of superficial blood clots. I have been having chest pain and pressure for several months. I have had an EKG, ultrasound and chest CT scan, which are all normal. Could this chest pain be related to the hypothyroidism or possibly blood circulation?
Dr_ Vouyiouklis:  Is your thyroid function normal at this time? Chest pain is unlikely related to your history of hypothyroidism. Further evaluation should be done by your primary care physician, a cardiologist or pulmonologist.

deband: What causes the heart to flutter when you take Synthroid®, or do nodules on the thyroid cause heart fluttering? I am a 56-year-old female and have hypothyroidism. I am on Synthroid® .75 mcg. My numbers are T4 1.5 and TSH 2.42. When I started in 2011, I was on Synthroid® .25 mcg and my numbers were T4 1.15 and TSH 7.53. The nodules that were found in October measured3 mm. Also, is there really a difference between Synthroid® and the generic brand? I usually wake up and take my Synthroid® and lie back down for an hour. My sister said lying back down could cause stomach problems. Is that true? Should I stay up once I have taken it? Does orange juice interfere with the medicine—particularly if there is calcium in the orange juice? I feel pretty good except for the heart flutters and sometimes I have to burp, which I never did before.
Dr_ Vouyiouklis: Heart fluttering can be from taking too much Synthroid®—although your recent TSH level of 2.42 is within range. Perhaps the fluttering is from some other cause. You may want to talk to your doctor about this. They can further evaluate you with an EKG or Holter monitor to see if there is any change in your heart rhythm, etc.

Your question about brand-name medication vs. generic is a common one. We usually like to use brand-name medication (regardless of the brand) because we know that the dose will be consistent each and every time. Occasionally, generics that are sold to pharmacies change. Some studies have shown that a change in the type of thyroid hormone replacement even though the dose on the pill may be the same, may actually have different effects on the patient. So, we like to stick to a brand of thyroid hormone replacement to ensure consistency. This is especially important in patient on medication during pregnancy or if they have a history of thyroid cancer.

You do not have to stay up after you take Synthroid® as long as you take it with water and wait before eating or drinking anything else. Yes, orange juice has been found to possibly interfere with its absorption, so it’s best to take it with water.

Wondering: I just started treatment for hypothyroidism about seven weeks ago and slightly prior to treatment noticed some blurring of vision. Are the two related and should I see my eye doctor?
Dr_ Vouyiouklis: Yes, you should see your eye doctor about this, although it is less likely related to your thyroid. How high was your TSH level? Have you had your recent yearly physical and blood work to ensure that nothing else may be causing these symptoms of blurry vision?

IslandGirl12: I am a 64-year-old female diagnosed with hypothyroidism many years ago and take 0.125 mg of Synthroid® daily. I have many of the symptoms of low thyroid, including brittle fingernails that peel and sensitivity to cold. However, but I also have extreme heat sensitivity and profuse sweating constantly—even in air conditioning. I had a hysterectomy and oophorectomy when I was 42 years old. I don't take estrogen for this. Could this sweating and heat sensitivity be related to the thyroid, or is it possible that I don't know what sensitivity means. No one likes extreme cold or heat, but what is meant by sensitivity? I've told my family doctor about the sweating many times, but he just ignores me. 
Dr_ Vouyiouklis:  What is your current TSH level? It sounds like some of the symptoms you describe may be hot flashes, but it could be related to the thyroid if your TSH level is lower than normal. This may be a sign of too much thyroid hormone on board.

AGUS: Five years ago I went to my primary care doctor complaining of never feeling rested. I would go to bed around 10:00 or 11:00 p.m., and wake up to my alarm the next morning around 7:30 a.m. or 8:00 a.m. I felt like I had to drag myself out of bed, and I was always tired during wake time. Other symptoms I had or currently have are very emotional, constant highs and lows.  My primary care doctor instantly put me on Zoloft® for depression. I told her I didn't think I was depressed and begged her to do blood work. I thought maybe I was going into menopause. I was 42 years old at the time. It turned out that I have hypothyroidism, and the doctor put me on .75 mg of Synthroid®. I felt better a few weeks later, but never felt 100 percent.  Two years later I went in for a blood test, and I told the doctor that I thought my medications were going to need tweaked because I was having all of the same symptoms again. The doctor said my blood work was in the correct levels for the amount of medicine I was on, and if she were to increase it I could have a stroke.  This did not sit well with me.

I took matters into my own hands, and found Dr. S. Sethu Reddy at Cleveland Clinic. He did more extensive blood work and it turned out that either my T4 or my T3was still off.  He adjusted the medicine, and I am feeling pretty good now. However, I won’t go back to my primary care doctor now, Dr. Reddy does not need to see me anymore and I need to find a good primary care doctor. Also, is my medicine always something that will need to be changed over the years?
Dr_ Vouyiouklis: Sometimes the dose may need to be changed. If you have any changes in gut absorption and/or if you take vitamins and iron, the medication may not be absorbed as well. You should wait three to four hours after taking the thyroid hormone replacement before taking any vitamins or iron.

You can still see an endocrinologist for a follow-up visit, even though your thyroid levels may be normal now or you can follow-up with your primary care physician, whomever you prefer

Jlhoule: Just was wondering why Armour Thyroid is not prescribed very often? I am on Levoxyl®, and although my levels are so-called normal, I am still symptomatic—constipated, fatigued, etc. I have Hashimoto's disease. My endocrinologist has also tried adding Cytomel®, but I had a bad reaction to it. I eat right, exercise and take vitamins. My biggest complaint is that even though I regularly get eight to nine hours of sleep per night, I still feel like I have to take a nap in the afternoon, which of course is impossible since I have two children.
Dr_Nasr: Armour Thyroid is still prescribed. However, just for the purpose of helping with the energy, I have to tell you that only some patients will benefit from that intervention—so I would not put a lot of hope on that. If your levels are normal by the endocrinologist's interpretation, then you should not be having severe symptoms. The symptoms that you describe are those of hypothyroidism, but they should have disappeared or at least improved if the thyroid was causing them. Constipation has many causes. Sleep apnea can cause more fatigue than hypothyroidism and having both is a double whammy! Enjoy your children.

 

Nutrition and Hypothyroidism

Wondering: Are there any supplements or dietary issues you should be aware of with hypothyroidism? Should mustard be avoided?
Dr_ Vouyiouklis:  If you are hypothyroid and on thyroid hormone replacement, we don’t usually recommend any dietary changes or restrictions. If you are borderline hypothyroid without symptoms and do not wish to start medication, you should be careful with eating too many soy products. Soy may result in noticeable hypothyroidism which would require treatment. I am unaware of any association of mustard and thyroid issues.

aka9hh: I have hypothyroidism, and did not find out until after I had my daughter. I am having a hard time losing weight and not sure if there is a right diet for me. I also have heard not to eat certain foods because it cancels out my medicine. Is this true? I am so blind when it comes to hypothyroidism, i.e.  when it comes to how I should live my life to be a healthier me. Can you please give me advice on these matters?
Dr_Nasr: First make sure your thyroid level is good. You should work on reducing your calories regardless of the thyroid state if you are trying to lose some weight. There is no ‘thyroid diet’—except if you have hypothyroidism, you will have to make sure you do not consume kelp or a lot of seaweed. Do not take high amounts of iodine (but do not worry about the usual iodide content of foods). Soy-containing food if consumed in large amounts may affect the absorption of your thyroid medication

Zeberk: I have been newly diagnosed with hypothyroidism. My TSH levels had been checked for years and they were low, but never to the point that anyone felt I should be on medication. All of my life I have struggled with my weight. Now that I am in my 40s, I was able to lose a great deal of weight. However, if I am not almost perfect about what I eat and exercise two hours each day, I can gain it back very easily. I have found a web site that focuses on the right foods to eat with hypothyroidism—and that seems to be very key. What do you tell patients on the nutritional side for eating to improve thyroid?
Due to some other issues beyond just weigh, including extreme coldness, skin issues, dry hair, brittle nails, etc., a new doctor checked my free T4 and T3 levels. It was determined that I have a very low T4. I have been on 100 mg of Synthroid® for about six weeks now. I am experiencing great changes and it seems it gets better almost daily.
Dr_Nasr: Other than excess iodine and excess soy, I am not aware of any foods in the Western diet that would affect thyroid function.  I am concerned that your doctor diagnosed your hypothyroidism based on a very low T4 level.  I am glad you are feeling better, but the issue of low T4 in the setting of normal TSH might need to be investigated further. Please discuss this with your doctor.

salvuccima: My main concern with my thyroid issue is weight gain. What we can do to lose weight while on medication and dealing with a thyroid problem?
Dr_Nasr: Untreated hypothyroidism can cause some weight gain. Once the hypothyroidism is treated though, the weight should start coming down to baseline with the appropriate efforts.  You should be able to lose weight regardless of the medication as long as you are on the correct dose.

 

Pregnancy and Hypothyroidism

sarika2012: I am suffering from autoimmune hypothyroid disease with severe muscle and joint pains and constipation. I take a very high dose of Synthroid® (250 mcg) to keep my pain level down. This means my TSH is suppressed; my free T3 is 5.6; and my T4 is 3.6 times higher than the normal maximum limit. I am very thirsty and experience frequent urination. Is this related to thyroid disease or due to something else? I am planning to conceive with this condition, so what precautions should I take? Which Cleveland Clinic doctor should I see who is experienced to treat my thyroid condition and support my plans to conceive and give birth to a healthy baby?
Dr_Nasr: I am concerned that you are being placed in a not so healthy thyroid hormone range. This might prevent you from conceiving and also threaten pregnancies.  We have several experienced thyroidologists who can help you. Your symptoms are not expected when your levels are in that range. I am suspecting other causes. 

 

Fluctuating Hypothyroidism and Hyperthyroidism

WN: I was treated for hypothyroidism, which has been stable for 12 years.  Then suddenly I became hyperthyroid, leading to atrial fibrillation.  For the past two years my TSH levels have been fluctuating between hypothyroidism and hyperthyroidism.  Adjustments to the dosage levels of my levothyroxine adjustments are being done about every seven to eight weeks based on my TSH levels.  Atrial fibrillation seems to be related to hyperthyroidism.  Why after so many years of being stable, did things change?  Do you see a strong correlation between atrial fibrillation and hyperthyroidism?  I am seeing an endocrinologist who can’t explain why my thyroid suddenly became unstable. 
Dr_ Vouyiouklis: What is your thyroid hormone dose? Was it too high and that is why you became hyperthyroid? Sometimes our absorption of the medication can change, requiring dose adjustments even after being on it for many years. Did you have your TSI antibodies checked? Sometimes we can see fluctuations in levels in patients who have autoimmune disease. These patients may appear to have overactive thyroid hormone production, and then develop hypothyroidism or vice versa. This may be due to the effects on the thyroid by thyroid antibodies.

Yes, it is likely that the atrial fibrillation may be precipitated by the hyperthyroidism. This certainly can be a side effect of untreated hyperthyroidism.

 

Symptoms of Hyperthyroidism

thumper26: I am a 66- year-old male being treated for hyperthyroidism for approximately three years due to low TSH. I have hyperthyroid symptoms which have continued to get worse. This includes extreme fatigue, shakiness, occasional insomnia, heat intolerance, occasional atrial fibrillation and irritability. Is it possible to be hyperthyroid and also have normal values of TSH, free T4 and T3 uptake? I’m on methimazole (Tapazole®) 5 mg. When I try to wean off, I feel much worse. My doctors are stumped.
Dr_ Vouyiouklis:  Is your T3 also normal?  If you have been treated with methimazole for three years and your thyroid levels are not improving when you are tapered off medication, you likely need another form of treatment for your Grave’s disease (either radioactive iodine [RAI] or surgery) especially since you have significant symptoms from the hyperthyroidism (atrial fibrillation). Do you have a large thyroid gland? Sometimes patients with larger thyroid glands do not respond as well to medical treatment of Grave’s disease. Given the length of your treatment without significant improvement, you should probably consider alternative treatment.

GritGirl: My laboratory tests all show my levels for Grave's disease are normal after 1.5 years on medication.  I still have tremors. My doctor has suggested I may need to consider radioactive iodine therapy or see a neurologist about these tremors.  To complicate the condition I also am post-menopausal at 46 years old. It has been very complicated treating both medical issues going on at the same time. What are your thoughts on treating the tremors?
Dr_ Vouyiouklis:  If you are tapered off the medication and your thyroid hormone levels end up remaining in the normal range, it may be that the tremors are not related to your hyperthyroidism. It also depends on what kind of tremor it is. Is it both hands? Are there any other neurologic issues? I would agree with an evaluation by a neurologist if the tremors do not subside despite 1.5 years of improvement in thyroid function. There may be different medications that may help your tremors, but we first must identify the cause.

 

Treatment for Hyperthyroidism

greyhoundlady5: I have a TSH of 0.01. My free T3 and free T4 are borderline high normal and low elevation. My other thyroid levels are normal. I am told that it's not all about the numbers, but I am not being treated. I exhibit about 85 percent of the symptoms of Grave’s disease, but no one will listen to me. I have an immediate family history of thyroid issues, rheumatoid arthritis and lupus erythematosus. I'm feeling just miserable and I need some help! What can I do?
Dr_ Vouyiouklis: Your TSH is certainly low. Given your symptoms, treatment is likely warranted. To determine the cause of hyperthyroidism, a thyroid uptake scan is typically recommended with a neck sonogram as well if you have any notable thyroid nodules on examination. Based on the diagnosis, different treatment options will be considered. If the diagnosis is Graves’ disease, there are three options for treatment: anti-thyroid hormone medication, radioactive iodine (RAI) or surgery. If you have thyroid nodules producing excess thyroid hormone though, treatment is either RAI or surgery. There is another possibility with hyperthyroidism, called thyroiditis, which may resolve on its own. This condition likely will not warrant treatment. This is why the nuclear uptake thyroid scan is important as it can help to differentiate between these possibilities.

sugarcookie: I am a 61-year-old female who has recently been diagnosed with Grave’s disease.  I also had a hyperparathyroidectomy 12 years ago.  I had normal free T4, a normal free T3 and a high TSH receptor antibody.  My only symptoms are a mild tremor and palpitations caused by atrial bigeminy. I've chosen not to start a beta blocker for that condition, since it's not too troublesome.  I began taking methimazole one week ago. Would you have started me on treatment or assumed a "watch-and-wait" course?
Dr_ Vouyiouklis: What was your TSH level? If your TSH level was below normal and you had symptoms of hyperthyroidism (the tremor and palpitations that you described), then treatment would be indicated.

MOX878:  What is the recommended treatment for Grave's disease?  I have been on methimazole since October 2011. I have teetered back-and-forth between hypothyroidism and hyperthyroidism, with my worst case of hypothyroidism this past August with a TSH of 141! I have been debating with taking the RAI test (131l uptake test) and surgery.  Can a patient stay on methimazole for long periods of time? I have had regular blood work. The latest test showed I was within normal range, and my liver function was normal, etc.
Dr_ Vouyiouklis: Is your thyroid very enlarged? The size of your thyroid gland is also important in determining the best treatment approach. Methimazole is a good treatment option for Grave’s disease, but sometimes patients with Grave’s disease who have large glands may not respond as well with medication alone. The goal is that methimazole could be used for about one year then tapered off while maintaining a euthyroid state (normal thyroid function). If this cannot be achieved, then other treatments should be considered, such as radioactive iodine (RAI) or surgery. Again, if your gland is big and/or if there is any concern with breathing or swallowing issues due to the size of your thyroid, then surgery may be the better option. Surgery will require permanent thyroid hormone replacement, but it will make these wide fluctuations that you have been experiencing less likely.

JFKAcres: Our 27- year-old daughter was diagnosed with Grave’s disease two years ago and is currently taking methimazole. She has recently done extensive, additional research and wonders if diet could be considered an alternative to thyroid removal or radioactive iodine treatment, if it becomes necessary? She is very leery of such invasive treatments, and is willing to undergo extensive diet modifications if it could possibly work for her. She has a small goiter, but no bulging eyes. What is Cleveland Clinic's stand on diet as a treatment to curb Graves' disease symptoms?
Dr_ Vouyiouklis: What are her thyroid function levels? It is quite unlikely that diet alone will normalize thyroid function. She is 27 years old, and of child-bearing age. I am not sure what pregnancy plans she has or will have, but these are important questions to consider. If she would like to get pregnant in the near future, it is best that she is euthyroid (normal thyroid function) prior to this and during pregnancy—as untreated hyperthyroidism may have adverse effects on the fetus. Also note—methimazole should not be used in the first trimester of pregnancy, so barrier protection or birth control is recommended if she is sexually active. With a small thyroid gland, she may respond very well with a course of methimazole. She has been on methimazole for two years? If her thyroid levels have been normal on methimazole, she should be slowly weaned off by her endocrinologist. She should then be re-assessed to see if her thyroid function is normal off of medication.

 

Nutrition and Hyperthyroidism

clam4: I have hyperthyroidism. Are there any foods that would help keep this under control? I have gained more than 20 pounds. What can I do to lose this weight? Are there any diets or programs I can follow?
Dr_ Vouyiouklis:  There are several different causes of hyperthyroidism. Your treatment options will differ depending on the reason for your condition. Also, depending on how hyperthyroid you are, you may not need medical treatment right away. For example, if you have subclinical hyperthyroidism where you do not exhibit any symptoms of hyperthyroidism, you can be watched closely. We do not typically recommend any particular foods to keep it under control.
You have gained 20 pounds in what period of time? If this weight gain has been within a short period of time, you will likely need further evaluation with blood and or urine testing. Have your eating patterns changed? Do you exercise regularly? If nothing has changed and you have put on this weight, I recommend following up with your doctor or endocrinologist. You doctor will review your diet, do a full evaluation and possibly order lab testing. Hyperthyroidism typically causes weight loss, not gain.

 

Thyroid Nodules

thetop2: I have a calcified nodule on my thyroid gland that was found by an ultrasound. I found a Mayo Clinic study that says out of 374 patients who were having their thyroid removed, 29 had calcified nodules. Out of that group, 75.5 percent of the nodules were found to be cancerous. This is even after biopsies had come back fine. I have several health conditions, and my thyroid seems to be causing a lot of the new health symptoms. These include extreme exhaustion, atrial fibrillation, tachycardia, high blood pressure, muscle fatigue, joint pain, altered mental awareness, etc. Is it better to have the thyroid removed or do we, the patients, have to endure more severe health symptoms before it's a good idea to be removed?
Dr_Nasr: I am not sure the thyroid is causing the symptoms that you are experiencing because you have not mentioned anything about the thyroid function. Typically, thyroid function is independent of thyroid anatomy. So, having a nodule in general does not affect the function except when it is an overactive nodule. If the calcifications are suspicious on ultrasound, then a biopsy should be performed (also depending on the size). If cancer or a suspicion of cancer is found on biopsy, then surgery would be indicated.

IrishGram: I am 64 years old and have undergone follow up for several years for thyroid nodules, which have always been biopsied as benign. Because these nodules have worrisome characteristics, I seem to be at high risk for developing cancer. Is there a point in time where I can relax about these follow ups and not need to keep under surveillance, or would this be unwise to do so? I love my doctor and trust her judgment.  The nodules have grown over time (4 cm is the largest), but they are not causing structural problems.  
Dr_Metzger: Typical risk factors for developing thyroid cancer include previous history of head or neck irradiation (this does not include just routine x-rays for the dentist) and a family history of thyroid cancers. Worrisome characteristics on ultrasound can indicate that the nodule has cancer within it, but do not change your risk of developing cancer.  One of the reasons we continue to follow nodules is to assess for growth, which can signify to us that there might be a cancer growing within. It is reassuring to hear that your repeated biopsies have all been benign, and I would hope that your most recent biopsy was following the growth of your nodule. Even with a benign biopsy, we always say there is an up to a five-percent chance of there being a cancer contained within the nodule. That is one of the reasons we continue to monitor these nodules. I would continue to see your physician for yearly ultrasound examinations of your thyroid as well as repeat biopsy should there be any significant change in size or other feature.

chihuahua3mama: I had a cancer biopsy done because an ultrasound showed an enlarged thyroid. Three nodules inside my thyroid were causing it to be enlarged, but the biopsy came back negative for cancer. It's still enlarged like it was one and one half years ago. Do I need to have it checked for cancer periodically? 
Dr_Metzger: You should have your thyroid rechecked every year with an ultrasound to make sure the nodules have not changed in size or appearance. There is no good blood test to show whether you have thyroid cancer, so it is important to have the ultrasound performed. A significant increase in nodule size can indicate a cancer within, and this should trigger a re-biopsy. I do not know if all of your nodules were biopsied, but it is standard for any nodule greater than 1 cm to be biopsied. There is always a small risk that even a benign biopsy missed an underlying cancer (about three to five percent of the cases), which is why follow up is important.

BTroyer:  Can thyroid nodules affect vocal quality and, if so, should they be removed?
Dr_Metzger: Thyroid nodules can occasionally affect vocal quality depending on their size and location. Nodules that are big enough to cause voice changes often cause other compressive symptoms in the neck, including difficulty swallowing or feeling like your air is getting cut off. It is very reasonable to be evaluated by a thyroid surgeon if you are having these types of symptoms from a thyroid nodule. Most often, the pressure of the nodule on other structures in the neck causes these symptoms. Rarely, the nodule might be growing into important structures in the neck that help control your voice. Many times, however, people experience voice changes for other reasons that are entirely unrelated to the thyroid nodule. Gastric reflux, for example, can affect voice quality.  These things can be easily sorted out by a thyroid surgeon, and it might be worthwhile for you to be seen and evaluated.

klileigh: I have a goiter and nodules on my thyroid.  I have had tests that all come back negative. However, a lot of the symptoms described here in this web chat I have, such as weight gain, diabetes and no energy. I watch my diet and work out four times per week, yet I can't seem to lose weight. Is it possible that I have metabolism problems that the regular tests are not showing?
Dr_Nasr: You probably have a slow metabolism, which cannot be measured through blood work. A rough estimate of your metabolism rate is through your average calorie consumption over a week. From that your energy requirement could be estimated and would reflect your ‘metabolism’. If all of your blood work tests came back negative, then you do not have a significant abnormality of your thyroid. Therefore, focusing on the thyroid will not help. You should watch your diet more and continue to work out. You should be able to lose weight by following the basic rules of diet and exercise which affect metabolism.

 

Treatment for Thyroid Nodules

JaneyL: I have had small thyroid nodules on both lobes for eight years. These have increased in number on periodic ultrasounds, and all measured under one centimeter until May 2012. In December 2010, my blood work showed an autoimmune attack on the thyroid, but my repeat blood work has not indicated this. In May, my ultrasound showed dominant nodules—one on each lobe—each measuring 2 cm. Follow-up fine-needle aspiration biopsy showed follicular neoplasm on the left lobe. My thyroid blood work was within normal range, and I feel fine. As of October, there have been no changes in the size of the dominant nodules on ultrasound. Due to the follicular neoplasm and dominant 2 cm size, a total thyroidectomy is being recommended by my endocrinologist and ENT surgeon. Do you concur with this thyroidectomy recommendation? Is there any possibility that eating many vegetables, walnuts and soy, as part of a plant-based diet, for the past two years could have caused increased the in size of multinodular goiter, and creating the dominant nodules?  With a follicular neoplasm , are there any alternatives to total thyroid removal surgery? Does postponing surgery increase the chances of these dominant nodules being cancerous?
Dr_Metzger: I completely agree with the recommendation for a total thyroidectomy.  The diagnosis follicular neoplasm carries with it a 20 to 30 percent chance of there being a cancer inside of the nodule. This is not the chance of developing a cancer in the future, but that there currently is cancer in the nodule. Pathologists cannot make this determination from a needle biopsy, which is why we recommend proceeding with surgical removal. When pathologists can examine the whole specimen, they can figure out whether or not there is a cancer within. Because of your bilateral nodules, it is appropriate to proceed with a total thyroidectomy. If only the left side was removed and the pathologists said it was cancerous, you would need a second operation to remove the other side. Even if you removed the left side and it wasn’t cancer, the right side would have to be monitored because it has a nodule. You would still likely need biopsies of that nodule in the future and serial ultrasound evaluation. If the other nodule became suspicious at all, you would need a second surgery. Second surgeries are always slightly more risky that initial surgeries due to the scarring that happens after the first surgery.

There is really no other alternative. You could have the nodule re-biopsied and some of the cells sent to a company to look at the genetic profile of the cells. This can help determine whether the nodule is benign or suspicious. However, this only really helpful if the result is benign. If the result is suspicious, you are back in the same spot as previously and still need surgery. 

Delaying surgery does not increase the chance of it being cancerous. Remember, what follicular neoplasm means is that the pathologists cannot tell from just looking at the biopsy cells whether or not it is cancer. Seventy to eighty percent of the time it is not cancer, but 20 to 30 percent of the time it is cancer. This means that the cancer cells are already there in the nodule right now. Regarding your other question, no, your diet did not cause these nodules.
finnishgirl: Can a patient remain on medications (i.e. Tapazole®) for hyperthyroidism due to a nodule rather than going the route of radiation or surgery? Can a patient take this drug for a long period of time?  Can the dose be lowered (i.e. taking it  every other day) or does that have side effects?  Does this drug cause weight gain?
When a patient is hyperthyroid will the troubling symptoms of sensitivity to temperatures and some hair loss resolve with the medication?
Dr_ Vouyiouklis:  Tapazole® is only a temporary solution for people who are hyperthyroid due to a thyroid nodule. This is because the nodule is ‘autonomous’ and it is not ‘checked’ by the rest of the body. So, after you stop the medication, the nodule will begin secreting excess thyroid hormone again. This is why radioactive iodine (RAI) or surgery is the preferred treatment for a nodule. In addition, if you are of child-bearing age, you should not get pregnant while on Tapazole®, since there may be risks to the fetus in the first trimester.

Yes, the dose of Tapazole® can be lowered. Tapazole® should not cause weight gain unless you become hypothyroid due to too much medication.

Yes, symptoms of hyperthyroidism improve with treatment. Please note that sometimes there may be a delayed response, but symptoms do typically improve.

 

Medications Following Thyroidectomy

Blpayton: Since my thyroidectomy in 2009 I have experienced hair loss, and I do not have the energy that I once did before my thyroid cancer. I am taking .150 mg of Synthroid® and .10 mg of Cytomel®. Is there anything else that you can recommend to help lessen these conditions?
Dr_Nasr: You should make sure your TSH level is not too wild— although TSH would be difficult to interpret when you are on this combination of medications. Measuring T4 and T3 would not help in this case. Also, your doctor should look for other causes of low energy and hair loss, such as vitamin or mineral deficiencies. 

 

Appointment Locations

jhansen:Do you make appointments at the Willoughby Hills location?
Dr_ Vouyiouklis: Yes, there are two endocrinologists at Cleveland Clinic Willoughby Hills Family Health Center: Dr. Mary Vouyiouklis and Dr. Leila Khan.


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