Online Health Chat with Dr. Christian Nasr and Dr. Joyce Shin

January 16, 2012


Cleveland_Clinic_Host: Your thyroid is a butterfly-shaped organ that weighs about an ounce and is located at the base of your neck.

This endocrine gland secretes hormones into your blood that control many important functions, including your body’s metabolism. Most people never give their thyroid a thought until something goes wrong. Yet, more than 20 million Americans have some type of thyroid disorder – whether hypothyroidism, hyperthyroidism, thyroid nodules and goiters, or thyroid cancer.

In this free online chat endocrinologist Dr. Christian Nasr and endocrine surgeon Dr. Joyce Shin will answer your questions concerning the thyroid and thyroid disease, as well as medical and surgical treatment options.

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.

Christian Nasr, MD, is co-director of the Cleveland Clinic Thyroid Center and a staff physician in the Endocrinology & Metabolism Institute. He is board certified in endocrinology, diabetes and metabolism. A graduate of the Saint Joseph University Faculty of Medicine, he completed his residency at Staten Island University Hospital and his fellowship in endocrinology at Cleveland Clinic. Dr. Nasr’s specialty interests include thyroid nodules, thyroid cancers and disorders, and flushing syndromes.

Joyce Shin, MD, is an endocrine surgeon in the Endocrinology & Metabolism Institute. A graduate of State University of New York School of Medicine, she completed her residency in general surgery at Albert Einstein College of Medicine/Montefiore Medical Center and her fellowship in endocrine surgery at Cleveland Clinic. Dr. Shin’s specialty interests include endocrine surgery (thyroid and parathyroid), advanced laparoscopic surgery, laparoscopic adrenalectomy, neuroendocrine tumors, thyroid/parathyroid ultrasound, intra-abdominal ultrasound, and laparoscopic radiofrequency thermal ablation of liver tumors.

To make an appointment with Dr. Nasr, Dr. Shin, or any of the specialists in the 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

Cleveland_Clinic_Host: Welcome to our Online Health Chat with Cleveland Clinic specialists Dr. Christian Nasr and Dr. Joyce Shin. We are thrilled to have them here today for this chat. Let’s begin with some of your questions

Thyroid Disease

Bigdon22: How do you determine if you have a thyroid problem?

Dr__Joyce_Shin: That is a BIG question! If you are talking about underactive or overactive thyroid conditions, they can be diagnosed with a simple blood test. Enlarged thyroid glands can be diagnosed on physical exam or by ultrasound. Nodules (growths within the thyroid gland) can also be diagnosed on physical exam, but better on ultrasounds.

marlalarkey: Is thyroid disease hereditary?

Dr__Joyce_Shin: Thyroid cancer is hereditary if it is part of the MEN syndrome (medullary thyroid cancer). Autoimmune diseases can be hereditary.


realeyes: What are symptoms of hyperthyroidism?

Dr__Joyce_Shin: Fatigue, heart palpitations, heat intolerance, anxiety, hand tremors, eye problems, unintentional weight loss.

marlalarkey: What are most common symptoms of an underactive thyroid?

Dr__Joyce_Shin: Fatigue, cold intolerance, thinning of the hair, brittle nails, weight gain.

More or Less

Nat22: I have been having symptoms of hypothyroidism for months now. My TSH has gone from 1.9 to 3.8 to now 5.2. My endocrinologist recommended a follow up in 6 months. I feel as though 6 months is an eternity when I feel so horrible. I have an 18-month-old and have not been able to shed the last 15 pounds no matter how hard I try. I have been on Weight Watchers® and am an avid runner (20 miles per week) plus two other gym sessions of lifting or boot camp classes. After my workouts I fall asleep! I am freezing all of the time, my skin is very dry, and I have horrible acne for the first time in my life. I am irritable and snippy! This is not me! All of my other hormone levels were normal, as well as my antibodies and free T3 and free T4. I wonder if some of us are more sensitive to hormone fluctuations than others. I wonder at what point will I be treated so I can feel normal?

Dr__Christian_Nasr: According to your TSH level, you are at the upper limit of normal, most likely. I don't have the ranges to support this, but the usual upper limit of normal for a TSH level is around 5. IF you have symptoms of hypothyroidism, which you do, you should be on thyroid hormone medication now. You should be started on a low dose and your TSH should be rechecked in 2 months. Your symptoms are typical for hypothyroidism, and with your high-normal TSH level, starting on medication now is a good choice.

ellisd4: Is there any type of surgery for hypothyroid or just medication? What if you were to get it removed, would that help?

Dr__Joyce_Shin: Surgery is not recommended for hypothyroidism unless you have nodules in your thyroid gland. If you do have nodules that are greater than 1 cm, then you should have a biopsy. Only if the biopsy shows cancer, then should you have surgery.

WN: I have a thyroid question for the chat. What would cause someone to suddenly become hyperthyroid after being stable on the same dose of levothyroxine for 10 years? No change in other health issues leading up to this. No change in brand of medication. With this sudden change from euthyroid to hyperthyroid, atrial fibrillation started. Now that the thyroid is back to normal on a different dose of levothyroxine, the atrial fib has been stable. Thanks.

Dr__Christian_Nasr: Thank you. Any change in your overall health might affect your thyroid level when you depend on the thyroid medication: new medication added, weight gain, weight loss, different batches of levothyroxine, etc. Frequent monitoring is needed.

Thyroid Cancer

vespark: How fast can a tall cell variant of thyroid cancer grow (papillary)? And does RAI treatment work successfully with this type of cancer?

Dr__Joyce_Shin: Tall cell is a variant of papillary thyroid cancer. No one knows for sure how fast these cancers grow, but tall cell features are associated with a slightly worse prognosis. The good news is that RAI (radioactive iodine) can be used for all types of papillary thyroid cancer.

vespark: Dr. Shin, RE: "slightly worse prognosis" for tall cell papillary cancer -- Does that mean it can spread to other areas of the body quicker?

Dr__Joyce_Shin: Papillary thyroid cancer usually spreads to the lymph nodes in the neck (central and/or lateral neck compartments). To answer your question, if you have tall cell features, it has been associated with a higher chance of recurrence in the neck lymph nodes.

vrichards: I had 1/2 my thyroid out. After sending to pathologist, they found a minuscule spot of cancer. What are the chances of the other 1/2 they left in being cancerous, and should I get it out?

Dr__Joyce_Shin: Microscopic cancer (less than 1cm) is commonly found now. If the microscopic cancer does not show any extrathyroidal extension, and if the other side does not have any nodules, then you don't necessarily need the other side out. However, I would have someone follow the side that is not out with serial neck ultrasounds.

realeyes: I am having a biopsy on the 27th of the month because of a slightly enlarged thyroid. What is the chance it may be cancer? What is the treatment for cancer if it is?

Dr__Joyce_Shin: Most thyroid nodules greater than 1 cm should be biopsied (unless they are simple cysts). The chance of a nodule being cancer is around 3 percent to 5 percent, 5 percent associated with hypothyroidism. The treatment for cancer is thyroidectomy. There are other possible biopsy results that your doctor should discuss with you.

KareninBluffton: What role do dental X-rays play in causing thyroid cancer? How many are too many?

Dr__Christian_Nasr: Good question. People started speculating on this issue because of the increase in the incidence of papillary thyroid cancer. I am not sure I have the answer to how many are too many. I would discuss or argue with the dentist about why they are getting frequent dental X-rays.


marlalarkey: My TSH level is 5.5. What do you consider the normal range for a 51-year-old female?

Dr__Joyce_Shin: That depends on the range from the laboratory, but 5.5 (at any age) is high (hypothyroidism), which means that you may benefit from thyroid hormone medication.

marlalarkey: The range from the laboratory is: 0.400 - 5.500. Would this be considered high?

Dr__Joyce_Shin: If your TSH is 5.5, then yes, it is high and you should start on medication.

sheken: I'm scheduled for thyroidectomy in 2 weeks. Wondering your opinion on HRT with T3 AND T4 versus just T4? Thanks.

Dr__Christian_Nasr: Most patients will do just fine on T4 alone, and that is what I recommend. If you experience symptoms on T4 alone (tiredness, sleepiness) then you could try adding T3.

Tumbleweed: Thyroid lab results, on the therapeutic range, where should the level be between 1 and 100?

Dr__Joyce_Shin: That would depend on what thyroid function test you are talking about. The most common thyroid function test is TSH, and the ranges differ, depending on the laboratory. But the usual ranges go from 0.5 to 5.5.

Tumbleweed: My question is about the therapeutic range. From what I have been reading on the Internet, there are new thoughts on what the normal range should be. I have hypo, on medication for 6 years, but still have symptoms: cold, moods, weight gain, and dry skin. My doctor likes my range to be at the low end of the scale. He says 25 percent. I am a small person and he usually gives me the lowest amount of a script because he knows I only need a small dose of any medication. I think I am on the lowest dose now levothyroxine 0.05 mg tab. I would like to take half. Is there any info I can take to my doctor to discuss the option of taking less? I have talked to him about it before, but he says I am at the range I should be at. He did explain to me taking less medication is more in helping with thyroid.

Dr__Christian_Nasr: Thank you for the question. Normal range is for normal patients.

The range is the same for patients with thyroid disease. Some patients will feel better when the TSH is in the lower end of normal. 25 mcg is the lowest dose. Be careful with lower doses because you might feel worse.

dragonfly: I recently read an article that the "normal range" for TSH and other thyroid tests is much wider, causing those who may fall into the range to still feel very uncomfortable with symptoms. Do you have recommendations of a tighter range, which would help in evaluating medication levels?

Dr__Christian_Nasr: The "normal range" is considered 0.4 to 2.5. The range of normal for the general population is 0.4 to 5. We know that some patients in the 2.5 to 5 part of the range might be considered hypothyroid, but that does not cause any problems. Sometimes patients will have very mild symptoms in that range, but treatment will not make a difference, except maybe in a minority of individuals.

vespark: Is it typical or expected to see TSH tests go up and down or down and then up after thyroidectomy even while on same dose of levothyroxine?

Dr__Joyce_Shin: Your TSH levels should only fluctuate slightly if you are on the same dosage of levothyroxine.


leeanne: How soon can the TSH level be checked after a change in Synthroid® (levothyroxine) dosage?

Dr__Joyce_Shin: Six to 8 weeks afterward.

vespark: Is a TSH test after thyroidectomy helpful in reading recurrent "cancer" or just a sign of a functioning pituitary? What about thyroglobulin tests after?

Dr__Joyce_Shin: If you have cancer, your TSH should be suppressed (very low). If it is not suppressed enough, the dosage of your thyroid hormone medication should be increased. The marker for recurrence is the thyroglobulin level (Tg). Tg should be undetectable if your thyroid is completely out and if there is no recurrence in the thyroid bed or in the lymph nodes.

myrichmail: If you have a complete thyroid removal due to papillary thyroid cancer, is it normal practice to have a thyroglobulin test after the procedure?

Dr__Joyce_Shin: Yes, the thyroglobulin level is the most important test to check after a thyroidectomy. If you do not have any thyroid cells left in your body, your thyroglobulin level should be undetectable. This is the test we used to detect recurrence.

myrichmail: After thyroid removal for papillary thyroid cancer, how often is a thyroglobulin test given?

Dr__Joyce_Shin: We check Tg levels every 6 months for the first 2 years after the thyroid comes out. Then it should be checked yearly. But these are just guidelines. It can be checked more often or less often, depending on individual cases.

myrichmail: Does a person still have to stop taking Synthroid® before a thyroglobulin test?

Dr__Christian_Nasr: I assume you meant Thyrogen test. If that was the case then the answer is no. Your doctor might ask you to hold one or two doses of levothyroxine.

Radiation Therapy

vespark: Is an MRI body scan the same thing as RAI scan? Will the RAI ONLY detect thyroid cancer or other? Would a body MRI or a head and neck MRI be an option to see about cancer that has spread? Or if it (thyroid cancer) spreads to other areas, is it still in the form of "thyroid cancer" in the body? Thank you.

Dr__Joyce_Shin: No, they are two separate imaging tests. The RAI scan is most commonly used to detect spread of thyroid cancer. The iodine used for the imaging study is only taken up by thyroid cells, so it can image even metastatic or distant disease.

myrichmail: If you have the thyroid removed for papillary thyroid cancer is RAI given?

Dr__Joyce_Shin: Not always. It depends on the type of cancer, if there is extrathyroidal extension, the size of the cancer, if there are positive lymph nodes, etc.

sly12: I recently completed RAI therapy and have lost sensation in my mouth. Can you tell me how long this will last?

Dr__Christian_Nasr: That is common. It is reversible. I have seen it last up to 1 year but it will come back.

leeanne: If you had radiation therapy once and it didn't work, should you try it again or opt for surgery?

Dr__Christian_Nasr: It depends how long ago you had it and whether the dose was sufficient. If it was done recently, then give it some time (6 to 12 months). You might need some treatment to control the thyroid levels in the meantime. A re-treatment with radioactive iodine might be needed. I would reserve surgery for patients who do not want to hear about radioactive iodine treatment.

leeanne: I had radiation therapy 7/11 for hyperthyroidism, TSH .008. By late Aug. TSH was 6 and I went on 50 mcg of Synthroid®. Oct. TSH went to 39 and I took 100mcg. It suddenly swung the other way and TSH was .5 and I cut to 75 mcg. 12/11 TSH was .06 and I was cut to 50 mcg. I am still experiencing hypo symptoms but the doctor doesn't want to retest for 6 weeks. Can I have an accurate test sooner and cut back more, and did the radiation not work, and what can I do about it. I just feel somewhat hyper and feel an extra heartbeat sometimes. Most of my life I had been hypothyroid, and I've been told my antibody number is extremely high.

Dr__Christian_Nasr: Thank you for the question. Obviously the treatment worked because you became hypothyroid. Sometimes, a few cells might recover from the radiation treatment and start making thyroid hormone again. Those will eventually die. It does not look like you will need another radioactive iodine treatment. I am in favor of more frequent testing if you are having symptoms.

leeanne: I had radiation therapy in July 2011 and am back on Synthroid®, but my TSH keeps going down and we reduce dose but it keeps happening. At what point do you say the radiation didn't work and do something else? What else can be done? I have very high antibody levels also.

Dr__Christian_Nasr: Thank you for the question. I assume you got treated for Graves’ disease.

I think the radioactive iodine worked. Your dose of levothyroxine will need to be reduced. We usually wait 6 to 12 months before discussing another radioactive iodine treatment. Close monitoring is needed.

DRJ110145: If you have had radioactive iodine treatment for hyperactive thyroid, will that rule out any concern for thyroid cancer?

Dr__Joyce_Shin: If you do not have any nodules in your thyroid gland, then you should not be at risk for cancer. However, if you did have nodules and were not worked-up, then you should do so.

tmocherman: I am considering radioactive iodine as the treatment option. How long, and to what extent will I return to "normal," for want of a better word?

Dr__Christian_Nasr: Thank you. I am assuming you have hyperthyroidism for which you have been offered radioactive iodine. It depends when it was diagnosed and if other things have been tried. Surgery to remove the thyroid is an option, but again it depends on the cause of the hyperthyroidism. You have to know that you will become hypothyroid permanently, so there is no return to normal without needing lifelong thyroid medication.


sdolgae: Ultrasound 2/11/09 showed thyromegaly – mild, generalized, consistent with a goiter. I have been on 25 mcg of Synthroid® since that time. My OB/GYN, who found the thyromegaly, says it was gone in 2010. All blood work comes back WNL on 25 mcg of Synthroid®. With the goiter allegedly gone, do I need to continue on the Synthroid®? Is this something I will take for the rest of my life? Thank you. Susan #18550474

Dr__Joyce_Shin: Sometimes, your thyroid gland is enlarged at the initial state of hypothyroidism. Over time, the thyroid gland shrinks in size. You should continue to have your thyroid function tests checked yearly to make sure that your dosage of thyroid hormone medication is appropriate. As your thyroid gland shrinks in size and no longer functions, you may need to increase your dosage. Twenty-five mcg is a small dosage for an adult, so it means that your thyroid is still functioning to a point. Just because you no longer have a goiter, it doesn't mean that your thyroid gland is functioning well.

Gatorfrog5: I am hypothyroid and I currently take Armour® Thyroid 30 mg, 1x a day. I have not really seen any improvements in my symptoms, but my lab work always comes back within the range my doctor thinks is OK. Should I do anything different? Would this be the correct medicine and dosage for me? I also have chronic fatigue syndrome and fibromyalgia, and I know that the thyroid is indicated in these conditions. Thank you for any help!

Dr__Christian_Nasr: Thank you for the question. Testing the TSH while on Armour® Thyroid is a bit tricky. I usually ask my patients to have the TSH done before they take the Armour® in the morning. It could be right for you. Chronic fatigue shares some of the symptoms of hypothyroidism and it might be difficult to differentiate the two.

mj75982: Do you prescribe Armour® Thyroid medication?

Dr__Joyce_Shin: Yes, we all can.

pogano4: I have had hypothyroid for over 20 years and have been on Synthroid®. This past year I have had some health issues, lightheadedness, etc. Over the past year, my thyroid cannot get regulated. I go from hypo to hyper then back to hypo. I am currently treated by a Cleveland Clinic endocrinologist.

Dr__Christian_Nasr: Thank you for the question. The levothyroxine dose usually stays stable, but when the patient goes through a change in health with weight changes, new medications, etc., the dose might need to be adjusted based on more frequent TSH checks.

rxpast10: Quick review. On presentation, 8-11-11 T4= 6.99 TSH < .01 thyroperoxidase ABs >900. Diagnosis Graves’. Began methimazole 10 mg 2-TID (60mg) Month later 9-12-11 T4 = 3.37 T3= 13.5 Continue 60mg methimazole daily. Month later 10-14-11 develop rash. T4= <0.4 T3=2.33 TSH= <0.1 Discontinued methimazole but symptoms returned 10 days later. I re-started methimazole myself but at 10mg BID. Month later at checkup 11-11-11 T4= 1.21 T3= 3.99 TSH still <0.1 but no rash return. MD increased methimazole to 10mg TID, wait 90 days and test again. I have been on 30 mg daily for 60 days no problems so far. He recommends surgery or radioactive to kill gland and finalize hyper. I contend I am still doing well on maintenance dose with no further complications, which he says are inevitable. Should I continue trying to control with medication or do you advise surgery also?

Dr__Christian_Nasr: Thank you. If you were on 5 mg of methimazole a day, I would not worry about staying on that for 2 years or more. However, we all get nervous with higher doses of methimazole given long term.

LorettaJohnson1: Is there any disease that affects the thyroid and joints and sockets in the body? I have a 22-year-old that has experienced psychosis. Her thyroid readings went up to 35.5. She is on 240mg. of Armour® Thyroid now. Her levels are normal. She is now experiencing joint and socket pain. Her psychosis seems to be returning also on a smaller scale.

Dr__Christian_Nasr: That is a big dose of Armour®. I wonder if she is taking it correctly or she might be overweight. If her dose was appropriate then she should suffer from pains or aches but when hypothyroid. That could explain some of the symptoms. Not to mention that mental problems could be exacerbated with fluctuation in the levels.

jodilynne89: Why do I still feel symptomatic even if I am taking Synthroid®? Are there any certain vitamins or supplements your recommend taking for hypothyroidism?

Dr__Christian_Nasr: I hope you had the correct diagnosis of hypothyroidism in the beginning. If it was truly hypothyroidism, then symptoms should improve after normalization of the levels. If, however, your level is still abnormal, you need to have the dose adjusted. If the dose is already appropriate and you are continuing to have symptoms, then you should consider other possible diagnoses.


vespark: After thyroidectomy, is a bump persisting under the incision scar (1 month) typical, or should any topical ointment be applied to aid healing?

Dr__Joyce_Shin: A bump after a month is not unusual. No ointment will decrease it. You can massage it, but the body will heal itself.

myrichmail: How long after the thyroid has been removed will the tiredness start to subside?

Dr__Joyce_Shin: You should have plenty of thyroid hormone left in your body, even after the thyroid has been removed, up to 2 to 3 weeks. So I am not sure why you are fatigued. Patients are often tired after undergoing surgery for various reasons. You should have been on medication shortly after surgery.

suzyq: Can thyroid and parathyroid surgery be done together, and what are the choices?

Dr__Joyce_Shin: Yes, thyroid and parathyroid surgeries SHOULD be performed together to avoid a re-operative neck surgery (more risks to the nerve to your voice box). Here at the Clinic, if we see a patient for hyperparathyroidism, we always do a neck ultrasound to look for thyroid nodules. This way, if we see a thyroid problem, we can address it at the same time. If you have both problems, your thyroid and parathyroid glands should be removed during the same surgery.

suzyq: Can the thyroid be removed with minimally invasive surgery along with the parathyroid?

Dr__Joyce_Shin: The surgeons here at the Clinic remove thyroid glands through a very small incision (typically an inch and a half) if you have a normal size thyroid gland. The other option is to have it removed through an axillary incision (under the armpit) so that you won't have a scar in your neck. There are benefits and risks to the latter choice.


vespark: Is there an alternative diet to adopt so as not to "feed" a thyroid cancer if cells remain in the body?

Dr__Joyce_Shin: Unfortunately, I am not aware of any alternative diets for thyroid cancer.

vespark: RE: the low iodine diet restrictions before a RAI scan -- Certain fruits and vegetables that are high in iodine are not specifically "banned," so I am concerned about eating incorrectly, i.e., strawberries, spinach, banana. Most ThyCa references say fruit is OK, yet these are noted as containing iodine. Any advice?

Dr__Christian_Nasr: I agree with ThyCa references. Those fruits have negligible amounts of iodine. You should be OK. Good luck on your test.

Puggle: I have Hashimoto's, hypothyroidism with poor control on Synthroid®. Are there foods I can eat or foods I should avoid that might help?

Dr__Christian_Nasr: Thank you for the question. You should be able to control the thyroid level with the right dose of levothyroxine. The only foods that can affect the level are soy products, if consumed in large amounts and on a frequent basis.

dragonfly: Is there any harm, or does it even work, in trying certain foods or frequency in eating to speed up metabolism since hypothyroidism slows down your metabolism? Or is the attempt in controlling metabolism by food/exercise futile since medication is the only thing you can take?

Dr__Christian_Nasr: I am in favor of trying everything in addition to taking the correct dose of medication. You know that you cannot change your metabolism but you can work around it by either increasing the expenditure or reducing intake.

pogano4: What daily amount of vitamin D is appropriate to assist proper thyroid function?

Dr__Christian_Nasr: There is no fixed dose that fits all. If your vitamin D level was normal, then there would be no role in recommending more than just what you are getting in your diet. Vitamin D deficiency might have a role in autoimmune diseases, including thyroid diseases; however, it is not known whether correcting the deficiency would do anything to the course of the thyroid disease.

Graves’ Disease

bmartin90: I have Graves’ disease and am taking total replacement for my T3 and T4. Have there been any studies that show how menopause symptoms can be lessened for someone who has little or no natural thyroid production? Will any off-the-counter products that lessen menopause symptoms help me at all?

Dr__Christian_Nasr: There is no direct relationship between thyroid replacement and menopausal symptoms. Starting estrogen replacement might increase the requirement for thyroid medication. Changing the doses of thyroid hormones will not change the menopausal symptoms.

rjcnortheast: I have been diagnosed with Graves’ disease. My symptom was my heart, spastic beating and angina, some night sweats -- but I only realized that afterwards – some eye irritation -- but that dissipated after beginning drugs. I am now on 30 mgs of methimazole. What are my treatment options?

Dr__Joyce_Shin: Radioactive iodine treatment and surgery are the other two options for Graves’ disease. If you have nodules in your thyroid gland (get an ultrasound), then I would highly recommend surgery over RAI. If you have a large thyroid gland or have associated eye symptoms, then I would also recommend surgery.

rjcnortheast: When first diagnosed with Graves’ disease, I noticed itchiness in my eyes. Since starting methimazole, the itching has notably decreased. Was that coincidental or was there a causal relationship between the medication and the decreased symptom?

Dr__Joyce_Shin: Graves’ disease and eye problems can be related. Graves’ disease can cause your eyes to "pop" out and cause dryness, which can explain the itchiness.

rjcnortheast: If my initial symptom with Graves’ was an itchiness of the eyes, is that it? Or is it still possible that I will exhibit more extreme ocular symptoms?

Dr__Christian_Nasr: Graves’ eye disease could present with inflammation, double vision, bulging, or all the above. Progression is usually over several months. If the only symptom was itching and that was not progressing, then hopefully you would not develop any more problems.

rxpast10: I've been diagnosed with Graves’ disease for which your surgery is not recommended. How do you differentiate and verify Graves’ from other forms of hyperthyroidism?

Dr__Joyce_Shin: Graves’ disease can be diagnosed by a lab value (TSH receptor antibody) and/or by a nuclear scan.

Associated Disorders

clara: My parathyroid is 79.3 and my calcium is 9.4. The calcium was higher on another test last year. My concern is I have osteoporosis. I also read that thyroid hormone is important for normal cardiovascular function. I have had open heart surgery and now six stents.

Dr__Joyce_Shin: I am assuming that your parathyroid hormone level (PTH) is 79.3. Depending on the range used at your laboratory, this is slightly elevated. But because your calcium level is normal, I am not convinced you have hyperparathyroidism. There are other reasons why your PTH level may be increased, the most common being vitamin D deficiency. You should have your vitamin D levels checked and see if that is the cause. To answer your second question, hyperthyroidism and hyperPARAthyroidism are both associated with osteoporosis. Both the thyroid and parathyroid glands are important for cardiovascular function.

nutzy: What is now the treatment for thyrotoxicosis Only propylthiouracil or mercaptizol? What is new in the surgical treatment?

Dr__Joyce_Shin: The usual medication for thyrotoxicosis is methimazole or tapazole. PTU is not as commonly used due to side effects. Depending on the cause of thyrotoxicosis, surgery is a treatment option, but it can also be treated with medication and/or radioactive iodine treatment. For instance, if you have a multinodular goiter and hyperthyroidism, I would recommend surgery. If you have Graves’ disease with associated eye symptoms, I would also recommend surgery.

billandcheryld: Hello, I have been diagnosed with autoimmune thyroiditis since August 2010. Despite an increase in Synthroid®, I continue to experience fatigue and weakness. I poop out like clockwork at around 3:00 each day and have severe foot camps each night. Is there anything I can do to manage these symptoms? Will my body continue to attack my thyroid? Will I have to continually go to the doctor to adjust my medications through this process?

Dr__Joyce_Shin: The autoimmune process can last for decades, so if you have been diagnosed with thyroiditis, you should have your thyroid function tests checked yearly. The usual dosage of the medication is 1.6 x Kg (weight), so if you are on less than that, that means that your thyroid gland is still working to a point.

Puggle: Do vitamin D deficiency and anemia always go hand in hand with Hashimoto's/hypothyroidism?

Dr__Joyce_Shin: Vitamin D deficiency can worsen autoimmune disease, but this has never been proven.

sd1moore95: Can a thyroid that was said to be 'disintegrating' for the last 3 years after nodules that came and went suddenly begin to work again? My doctor has decreased my medication and I feel worse with all the symptoms when first diagnosed in 2000. Can the TSH level be sensitive to that extent?

Dr__Christian_Nasr: I assume you were told you had Hashimoto's disease with the thyroid being chronically inflamed and gradually failing. Patients can recover from that, but the condition might eventually lead to permanent hypothyroidism. TSH is the most sensitive and reliable test to be followed, and in your case I recommend following that every 3 months until stable.

Not Your Thyroid

brotjes: I have hypothyroidism and I am also perimenopausal. I gain weight at the drop of a hat. (I gained 2 pounds after the MS bicycle ride last year - 150 miles in two days.) To lose weight is an almost impossible task. I don't think my thyroid is under control, yet my doctors are not listening to me. How do we know if my weight problem is because of my thyroid? If it is under control, then shouldn't I be able to lose weight? How do we know that these are the only two issues I have? What about my adrenal glands, etc.? What kind of doctor should I be seeing? I need help getting all of this under control and, frankly, so far I am not getting that help from the Cleveland Clinic. Thanks.

Dr__Christian_Nasr: Thank you for the question. If your levels were truly normal, then the thyroid could not be blamed for the inability to lose weight. Cushing syndrome (too much adrenal cortisol) could cause abnormal weight gain and that can be looked at if you have a specific type of weight gain.

Elizabeth: I am post-menopausal by many years now, and use progesterone cream nightly. My body's thermostat is way off. I can be extremely hot in parts of my body while being extremely cold in other parts. I lost about 40 percent of my hair. I have huge symptoms of vasodilation and constriction, to the point of pain sometimes, with vasodilation of hands, feet, and head. TSH, T3 and T4, and antibodies are negative with tests. Are these thyroid symptoms? What should I do next? Elizabeth

Dr__Christian_Nasr: Thank you. It is easier to tell when you have had TSH, T4 and T3 but you are right, those symptoms do suggest the possibility of thyroid disease. However, that has been ruled out with the tests. Your symptoms are more suggestive, however, of menopausal symptoms and you should consider a treatment for that.

mj75982: My TSH is 1.88, free T3 2.8 "normal" range, but have all classic low thyroid symptoms. I too have many of those symptoms plus my hair texture has changed to steel wool, dry snake skin, loss of outer eyebrows, poor night vision, high cholesterol, my TSH is 1.88 and free T3 is 2.8, what doctor tells me I'm in normal range. What should I do? Would you recommend USP progesterone cream and nutritional supplements to help raise free T3 to optimal 3.4-4.2 range?

Dr__Christian_Nasr: Thank you for the question. You seem euthyroid. I agree with your doctor that you do not have hypothyroidism. Your symptoms are not unique to hypothyroidism and you should look for other things. I cannot recommend progesterone cream and that does not raise the T3 and actually that should not be a target for any intervention.

General Questions

vespark: Are there any new treatments on the horizon to ablate papillary thyroid cells, other than surgery or RAI? Is there anything that would be considered aggressive to keep ahead of the long wait?

Dr__Christian_Nasr: Unfortunately, this ancient management continues to work in most patients. You probably forgot that the most important treatment while you are waiting is taking suppressive dose of levothyroxine.

Tumbleweed: Can thyroid issues cause seizures?

Dr__Christian_Nasr: No. Patients who have undiagnosed or untreated severe hypothyroidism could develop low serum sodium, and that could lead to seizures.

mj75982: Will raising free T-3 numbers to optimal range reduce my high cholesterol levels?

Dr__Christian_Nasr: In the absence of hypothyroidism, doing anything with T3 or T4 will not help the cholesterol numbers.


Cleveland_Clinic_Host: I'm sorry to say that our time with Christian Nasr, MD, and Joyce Shin, MD, is now over. Thank you again Drs. Nasr and Shin for taking the time to answer our questions today about thyroid disease.

Dr__Christian_Nasr: Thank you for all of your questions.

Dr__Joyce_Shin: It was a pleasure chatting with you all. Great questions!

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This chat occurred on 1.16.2012

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