Online Health Chat with Suman Jana, MD and Rosemarie Metzger, MD

January 29, 2014


Your thyroid gland plays a critical role in your overall health. The thyroid is a butterfly-shaped endocrine gland located at the base of the neck that is responsible for controlling metabolism (the energy produced and used by the body) and regulating the body’s sensitivity to hormones.

More than 20 million Americans have some type of thyroid disorder. Yet, many thyroid conditions remain undiagnosed due to rather vague symptoms and an absence of pain. Nevertheless, when thyroid conditions are ignored, they can lead to serious health conditions.

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. Diagnosis and treatment are key steps in the management of a thyroid problem, and will help in the control of related symptoms.

About the Speakers

Suman Jana, MD is an endocrinologist in Cleveland Clinic’s Department of Endocrinology, Diabetes and Metabolism. He is board certified in internal medicine for endocrinology, diabetes and metabolism, and nuclear medicine. Dr. Jana completed his endocrinology fellowship and nuclear medicine residency at St. Vincent’s Hospital, in New York. His internal medicine residency was completed at the Bronx-Lebanon Hospital Center. Dr. Jana graduated from medical school at the All India Institute of Medical Sciences, in New Delhi, India, and attended medical school at University of Calcutta, in Calcutta, India. Dr. Jana’s specialty interests include: thyroid cancer, thyroid nodules, thyroid and parathyroid disorders, Cushing’s syndrome, diabetes and pituitary disorders.

Rosemarie Metzger, MD is an endocrine surgeon in the Department of Endocrine Surgery in Cleveland Clinic’s Endocrinology & Metabolism Institute. Dr. Metzger completed her fellowship in endocrine surgery at Cleveland Clinic, and her residency in general surgery at the University of Virginia Medical Center, in Charlottesville, Va. She completed medical school at the University of Wisconsin Medical School, in Madison, Wis. 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 Ask a Thyroid Expert

Thyroid Disorder Diagnosis and Symptoms

OhioBella: What exactly is the function of the thyroid, and what are the symptoms of a thyroid that is not working?

Suman_Jana,_MD: The thyroid makes hormones that control metabolism. Metabolism is the pace at which your body processes things (i.e., how fast it burns food to make energy and heat from it). Symptoms of hypothyroidism include tiredness, unexpected weight gain, constipation, depression, dry skin, difficulty performing physical exercise, and decreased mental ability to concentrate and focus.

raymaks: Can you have a problem with your thyroid and not know it? Can a thyroid infection clear on its own? Is goiter disease is a thyroid complication? How do you keep your thyroid healthy? Can a thyroid condition be treated nutritionally? Can one get a thyroid infection by sharing a cup with an infected person or through kissing? What is the relationship between thyroid, tonsils and sinusitis? Can an infection of the thyroid lead to tonsillitis? Can the thyroid gland be removed in case of infection?

Suman_Jana,_MD: Some people experience symptoms more than others, but if you suspect that you have a problem, then let your doctor know and have your TSH level checked. A thyroid infection from a virus or inflammation can clear on its own. If the thyroid infection is symptomatic, it needs supportive care. If hypothyroidism develops, you would need thyroid medications. Thyroid infections do not occur from kissing or from sharing a cup. To keep your thyroid healthy, avoid too much iodine, kelp, soy, and goitrogens (certain thyroid-inhibiting foods, including cabbage, Brussels sprouts, pine nuts, etc.). Please note that I said too much of these, so a normal amount in daily food is OK. Except is extreme cases; there is no need to consider the thyroid for infection or inflammation. Thyroid function is not related to tonsil or sinus conditions.

Glendac: Is it possible to have normal thyroid tests and still have thyroid problems? All my tests are normal, but I have small nodules and brain fog, feel tired and sluggish, have dry skin, and cannot lose weight. Do you have any suggestions?

litvolt: I have many symptoms of hypothyroidism despite falling in the normal range of thyroid screening laboratory values. All other diagnostic tests to account for my symptoms have been negative. Do you think it would be beneficial to have a trial with a low dose of Synthroid® (levothyroxine) to see if my symptoms respond?

Suman_Jana,_MD: None of the symptoms we evaluate for thyroid are specific for thyroid. We need to exclude other causes of symptoms like anemia, vitamin deficiencies, abnormal electrolytes (including calcium, sodium, and potassium), autoimmune disease, and chronic inflammatory states, including rheumatoid arthritis, lupus, fibromyalgia, chronic fatigue syndrome, etc. If all of these conditions are excluded and TSH is 3.5 or more, then a trial of low-dose thyroid hormone under the supervision of an endocrinologist can be an option for patients who are younger than 60 years old with no history of heart disease, stroke, or osteoporosis. I have a couple of patients who have belt better after this trial of low-dose medication. Again, this should be done only under the supervision of an endocrinologist and the patient’s condition fulfills the above criteria.

kostelan: My thyroid doctor has diagnosed me with hyperthyroidism. With medication, my TSH levels and blood pressure are under control. We are keeping a watch on it every six months. However, my gastrointestinal system is out of whack. I am very irregular—sometimes good, but mostly feeling constipated. Do you feel my thyroid is doing this? Can I take a stool softener or Metamucil® (psyllium fiber) on a daily basis?

Suman_Jana,_MD: If your TSH is optimum, most likely this is not from your thyroid. You can take stool softener or Metamucil®.

LucyJ: Can your voice change with hypothyroidism?

Rosemarie_Metzger,_MD: Voice change with hypothyroidism is not typical. Voice change related to the thyroid gland can be due to a large nodule that is compressing the nerves that help move the vocal cords. Rarely, the voice can be affected if a thyroid cancer is spreading into the windpipe or the nerves to the vocal cords. More frequently, voice change is related to acid reflux, which you might not even realize you have. Especially at night, acid reflux can come to the back of your throat and irritate your vocal cords, which leads to hoarseness.

hotoldlady: With the help of my doctors, I've managed my hypothyroidism for many years. Is the onset of migraines associated with hypothyroidism?

Suman_Jana,_MD: Hypothyroidism is not a cause of migraines, but can aggravate migraine symptoms.

Low Energy

senoj: Recently I had my thyroid removed due to 4 cm growth on the left side and cancer on the right side. My doctor has placed me on 100 mg Synthroid® (levothyroxine) for six weeks and then I go for a re-evaluation. I have low energy and feel lethargic. Is this normal or should I request an increase in medication?

Suman_Jana,_MD: The usual starting dose of levothyroxine after complete removal of the thyroid is 1.6 mcg per kg of body weight, i.e., for a body weight of 70 kg, the dose would be 112 mcg. If your body weight is close to 70 kg or 154 lbs, 100 mcg is close—so a blood test after six weeks and adjusting the dose further is the standard. However, this dose is an average dose, so some individual may need more and others may need less. You may need more medication, and your laboratory tests in six weeks will help your doctor make that decision.

DaisyBe: I am presently taking levothyroxine 25 mcg and my TSH is 1.21. When I started taking medications about eight months ago, my TSH was 5.41 and my family doctor started me on 50 mcg. The dose was changed to 25 mcg because my TSH dropped to 0.75. I am still quite fatigued and have other symptoms, like stomach and IBS type problems. This winter, on some evenings I sit around with two pairs of socks, slippers and a heavy blanket on—and my feet and nose are still freezing. The rest of the family simply uses a blanket and they are comfortable. I keep the temperature of the house at 69 degrees in evening. I was wondering if the type of medicine could have been changed. I was told I could not change the medicine - only the dosage. I am wondering if this sounds like a thyroid issue or perhaps parathyroid problems coming back. (I had parathyroid surgery at Cleveland Clinic several years ago.)

Suman_Jana,_MD: TSH close to 1.0 is acceptable. You could have your calcium level checked, which will reflect your parathyroid status. If it is abnormal, have your parathyroid hormone (PTH) level checked. You may have vascular problem due to a rheumatological condition called Raynaud disease, which can cause decreased blood flow to the extremities.

dkmgray: I seem to require a lot of sleep—too much, according to my mother. I can sleep all day and night, getting up only to go to the bathroom, eat or drink, and to take medications. I haven't done that on multiple days though. I had my thyroid removed in 1967 at the age of 14 years old. I have had sleep studies and use a C-PAP.

My other subsequent diagnoses include type 2 diabetes, fibromyalgia, aortic stenosis, back and leg pain (treated with Conzip™ [tramadol hydrochloride]), and mild depression (treated with Effexor® [venlafaxine hydrochloride]). I have blood work done every three months, which has been OK. Would low thyroid cause me to sleep a lot, or might it not be a constellation of symptoms—any one of which may cause it?

Suman_Jana,_MD: If you are on thyroid medicine and your TSH is OK, then you do not have low thyroid function anymore. Your symptoms are probably from something else. However, your TSH should be kept close to 1.0. You may talk to your sleep doctor to make sure your C-PAP is working, make sure your type 2 diabetes is under good control (high blood sugar may make you feel fatigue and sleepy all day). Some weight loss and exercise can boost your energy level. If you didn’t have aortic stenosis, a small dose of T3 may be helpful after optimizing the above mentioned things. But, in the presence of aortic stenosis, it can be little complicated.

DW: My 19-year-old daughter takes thyroid hormone for Hashimoto disease. Her TSH is about 4.7 (borderline level). She is doing OK now except she sleeps more hours every day and gets easily tired. During her period, she is really tired. She needs 11 hours of sleep to function. Is this related to her thyroid problem? Does her need to sleep increase her thyroid hormone? Is taking thyroid hormone at bedtime OK after eating dinner at 6 p.m.? Is getting the flu shot OK for her? Is any infection will make her thyroid function decrease further? So, should she do her best to avoid the flu or another infection?

Suman_Jana,_MD: For her age the TSH should be 2.5 or less. She may feel better by increasing her thyroid medications slightly. However, she shouldn’t increase it too much, which could bring her TSH down below normal. Unless she has a contraindication for the flu vaccine as noted by her primary care physician, she can get the vaccine. However, Hashimoto disease is not a contraindication for the flu vaccine. An infection will not make her thyroid function decrease further if she is taking the proper dose of medication. Thyroid medications can be taken at bedtime provided that she doesn’t eat anything for three to four hours before taking them. Also, if she doesn’t take any other pills during that time which can interfere with thyroid medications, like iron, calcium, any metal supplement, antacids and multiple vitamins.

Hypothyroidism and Hair Loss

Cynthia: Even though I am taking Synthroid® (levothyroxine) and T3, my hair continues to thin. My scalp cycles into a period of redness and soreness to the point where it feels as if someone is pulling my hair. Steroid injections help this. I am also on bioidentical estrogen and I am on the tail end of perimenopause. I am also taking Avodart® (dutasteride) and progesterone. My scalp biopsy and all blood tests indicate no autoimmune disorder. Do you have any suggestions to reduce hair loss?

Suman_Jana,_MD: You should see a dermatologist to exclude any scalp disease. Optimize your thyroid hormone levels. Keep in mind that too little or too much both can cause hair loss). You need to check androgen levels like testosterone and DHEAS (dehydroepiandrosterone sulfated analog) level. If they are high you may get help from using androgen blocker like spironolactone or aldactone (a diuretic, or water pill, used to treat hypertension).

comptech: My hair, fingernail and toenail growth have slowed to the extent that I seldom need to trim them. Also my eyebrows are sparse and nearly invisible. Could this be a thyroid problem even though my tests come back as normal?

Suman_Jana,_MD: If TSH is between 1 and 3.0, look for other causes. In absence of thyroid hormone level abnormal, they are less likely to be from a thyroid condition.

PcTech: My hair doesn't seem to be growing, I have not had a haircut for nearly a year and what I have left is dry and breaking. Also my fingernails are the same way, seldom do they need trimmed. I also have other symptoms, cold hands, dry skin and sparse eyebrows. Could all of this be caused by my thyroid?

Suman_Jana,_MD: If your blood level of thyroid hormones is normal, you need to look for other causes. If you have untreated or undertreated hypothyroidism, these symptoms could be caused by your thyroid.

Hashimoto Disease and Hypothyroidism

Judylucy: What is the difference between Hashimoto disease and hypothyroidism? Does Synthroid® (levothyroxine) help both?

Suman_Jana,_MD: Hashimoto disease is one of the most common causes of hypothyroidism. Hypothyroidism is treated with Synthroid®. There are other causes of hypothyroidism. Therefore, not all hypothyroid is from Hashimoto disease. On the other hand, Hashimoto disease could be present but not severe enough to cause hypothyroidism. In that case you do not need Synthroid®.

mehring: I have been diagnosed as hypothyroid with Hashimoto disease, but most of my symptoms were that of hyperthyroidism? Is that common?

Suman_Jana,_MD: I am not sure what age group you fall. In the elderly and in young children, there are atypical presentations. However, I suggest you try to exclude some other causes for your symptoms.

Hashimoto Disease and Peripheral Neuropathy

conteer: Do you have any patients with Hashimoto disease who are also suffering from peripheral neuropathy with upper back soreness and tightness? If so, what do you think is the cause and how do you treat it?

Suman_Jana,_MD: There are a few case reports, but there is no specific medication to treat it. The best option is to optimize your thyroid hormone levels, and then get your neuropathy treated by neurology. Multifocal motor neuropathy is a specific disorder that has shown improvement with intravenous immunoglobulin therapy. This treatment is only useful in this specific disorder and is given by a neurologist. There are some markers to diagnose this disease like antiganglioside antibodies. You should make sure that you don’t have any vitamin deficiency, like B12, which should be treated. A gluten-free diet can help if you have celiac disease.

Hypothyroidism and Acute Adrenal Insufficiency

adrenal: I have both hypothyroidism and acute adrenal insufficiency—although I do not have Addison disease. (Last January, prior to the beginning of treatment with steroids, my cortisol level at 8:00 was 1.) I have not been able to locate a doctor who has experience handling both of these conditions simultaneously, or even any experience handling adrenal insufficiency that does not involve Addison disease. How should the treatment of these two conditions be coordinated? Could you also tell me who—if anyone—has an expertise in this area?

Finally, the effects of long-term steroid use are extremely risky for me. Even before these problems, I had high cholesterol and high blood pressure. My father died of cardiac arrest at the age of 45 years old. Given the considerable increase in risk associated with steroids, I would like to work with a doctor who is willing to supervise and is knowledgeable about a means of using supplements or other medications to reduce the dependence on steroids.

Suman_Jana,_MD: Addison disease is also called primary adrenal insufficiency and associated with deficiency of both cortisol and aldosterone. On the other hand, secondary adrenal insufficiency is associated with only cortisol deficiency. This is usually associated with prior high-dose steroid use. However, treatment consists of a low-dose, short-acting steroid like Cortef® (hydrocortisone). The usual dose is 10 to 15 mg in the morning, 5 mg at noon and 5 mg around 3 to 4 p.m. It is very important to take this medicine everyday and increase the dose during stress and sickness. Thyroid hormone replacement can potentially unmask the adrenal insufficiency. Cortisol should be always replaced before thyroid hormone. The thyroid hormone dose can change after adequate replacement of cortisol. You need an endocrinologist to take care of your current condition. Adrenal insufficiency needs to be confirmed first by doing an adrenocorticotropic (ACTH) stimulation test.

Grave Disease

Lowry: What other methods of disabling the thyroid exist—other than removal or radioactive iodine? Two of my friends have just gone through these procedures for Grave disease. Afterward they were told by other doctors that neither choice is better and radioactive iodine should be avoided. What is your opinion?

Suman_Jana,_MD: Thyroid-blocking medicines, like Tapazole® (methimazole) and PTU (propylthiouracil), can be used to treat Grave disease. Iodine I-131 (radioactive iodine) is a very effective permanent treatment to kill the thyroid for Grave disease and is most commonly used in the United States. This treatment is not used in children or pregnant woman. Surgical removal of the thyroid is another way to treat Grave disease in appropriate patients. This method is also very effective. Commonly, after surgery and I-131 treatment, patients develop hypothyroidism and require thyroid replacement therapy with Synthroid® (levothyroxine).

Causes of Thyroid Disorders

OhioBella: I have been told that Ohio has many cases of thyroid problems. Is this true, and why would this be so?

Suman_Jana,_MD: Thyroid problems are very common in Ohio. There are a number of environmental exposures or triggers that can contribute to autoimmune thyroid disease. These include infections, life stress, iodine intake, smoking, medications (such as amiodarone and interferon), radiation and environmental toxins. Environmental exposures may be subtle and occur over a long period of time. Thus, it makes it difficult to determine in a patient and to link a specific exposure to thyroid autoimmune disease.

marthalm: How can I get more information about what causes hypothyroidism? I have taken Synthroid® (levothyroxine) for over five years in increasing amounts and I really don't see any improvement. I am still losing hair, still am overweight, tired most of the time, dry skin and I don't sleep well. This is the only health condition I have with the exception of high cholesterol.

Suman_Jana,_MD: The most common cause of low thyroid function is Hashimoto thyroiditis. If your thyroid hormone levels are optimum and you still have these symptoms, you need to look for other causes, e.g. sleep apnea. If your TSH is fluctuating, then you need to optimize your levothyroxine treatment. It is most likely that your thyroid hormones are not stable, and you need to see an endocrinologist. You may need to make sure that you are taking the medicine properly, i.e. on an empty stomach first thing in the morning only with water, not taking other medicines with it, not drinking coffee or tea with it, waiting for 45 to 60 minutes before eating any food or drinks like coffee or tea, and waiting for four hours before taking supplements with iron, calcium, metals, antacids, etc.

TSH, T3, T4 and More: Diagnostic Tests and Laboratory Values

Cynthia: I have heard that TSH levels closer to one to twp are more desirable. Therefore, this warrants low-dose thyroid hormone when symptoms exist. What are your thoughts?

Suman_Jana,_MD: None of the symptoms we evaluate for thyroid is specific for thyroid. We need to exclude other causes of symptoms like anemia, vitamin deficiencies, low electrolytes (including calcium, sodium, and potassium), autoimmune disease and chronic inflammatory state (like rheumatoid arthritis, lupus, fibromyalgia and chronic fatigue syndrome). If all of these are excluded and TSH is 3.5 or more, then a trial of low-dose thyroid hormone under the supervision of an endocrinologist can be an option for patients younger than 60 years old with no history of heart disease, stroke or osteoporosis. Again, this should only be done only under supervision of an endocrinologist and in a patient who fulfills the above conditions.

patrice43015: What are the best tests for a patient with Hashimoto disease? My previous TSH was 19. My family doctor does not want to do any additional tests other than TSH. I feel horrible all of the time.

Suman_Jana,_MD: A TSH level of 19 is abnormal by any laboratory standard and needs treatment. I am assuming that you meant 1.9. The TPO antibody is a test for Hashimoto disease that is commonly used. However, if your thyroid hormones are normal even though you have TPO antibodies, you will not require treatment. In our institute as a first-time test, we always use TSH and Free T4 (one of the thyroid hormones). We test both because TSH comes from the pituitary gland. If for some reason the pituitary is not normal, we can miss the diagnosis. However, pituitary abnormality is not very common, so for all practical reasons TSH testing is reasonable. Commonly, TSH reflects the thyroid status more accurately than T4 alone.

nezimm: Is it normal for TSH numbers within a two-month period to vary dramatically? My TSH results have been 1.19, then 3.13, and finally 0.728. Do TSH numbers vary throughout the day (like blood pressure), or should changes come about more slowly? Two different doctors have answered this differently. Also, should low total T3 be treated? If so, what treatment would be expected? Could treating symptoms of hypothyroid (even though testing results are normal) decrease goiter size?

Suman_Jana,_MD: Thyroiditis can cause such a variation, as well as if you are taking any thyroid medicine. For instance, if you take T3, it can influence your TSH level faster than T4. If your TSH was varying so much, you should get tested for TPO antibody (marker of Hashimoto thyroiditis). If you have positive TPO, you should be followed with TSH at least once a year or anytime you have severe symptoms of hypothyroidism. When you develop hypothyroidism, you need treatment.

If your TSH is normal, there is no need to treat low T3. In this case, low T3 could be from so many other reasons and not related to your thyroid problem. One example is, if you have any other sickness, it will cause some low T3.

Treatment with thyroid hormone is not recommended routinely if TSH is normal (less than 3.0). Goiter could be from thyroid nodule, in that case you need a thyroid ultrasound, and if you have a nodule more than 1 cm, you need a biopsy.

BettyP: I was taking 50 mcg Synthroid® (levothyroxine) and 17.5 mcg. My free T3 and Free T4 are at the lower end of the range. My free T4 was 0.7 (0.7-1.8) and free T3 was 2.7 (1.8-4.6). My TSH was 0.117 (0.4-5.5). My doctor was concerned with the TSH and did not seem to care that my Frees were low. I had no hyperthyroid symptoms and no heart palpitations. The doctor left my Synthroid® dose alone and lowered my Cytomel® (liothyronine sodium) dose to 10 mcg. The doctor told me if I didn't like this dose that he would recommend another doctor. This did not make sense since my free T4 was almost below the range. This was six weeks ago and I am now having hypothyroid symptoms. Why are so many doctors hung up on TSH levels? I know Cytomel® suppresses TSH, and therefore it is not a reliable test when taking a T3 medication.

Suman_Jana,_MD: You are partly right that T3 suppresses TSH. Once your T3 is lowered, your TSH will go up—instead of going up on T3, go up on your T4 to keep your TSH close to 1.0. We depend on TSH because “your brain knows best.” TSH comes from an endocrine gland in your brain called the pituitary. Low TSH has been shown to cause osteoporosis (you don’t feel it) and irregular heartbeats called atrial fibrillation (that may occur suddenly). Overall, humans need less T3 than animals. Ideally, humans need 10 percent T3 and 90 percent T4. We can convert T4 to T3 easily. So, even if we want to give T3, ideally 10 percent should be OK. But, T3 kind of gives a kick and high energy level so people get used to that and then when brought it down they feel like they have “crashed” (which is a similar effect to what happens a few hours after consuming an energy drink).

tabialex: I am an Asian female who is 71 years old. At the age of 14 years old, thyroid enlargement was noticed. I had a subtotal thyroidectomy in 1979, with goiter on both sides and positive antibodies. My current test results are TSH-1.71, T3 Free -3.2, T4 and Free -1.2. I do not take thyroid supplements. If I were to have a total thyroidectomy, would I no longer have the antithyroid antibodies? Recently, my primary care physician ordered an ANA test which came back “positive, pattern 1-speckled, titer 1-1:320.” Could this be related to autoimmune thyroid disease? I will be evaluated further, but I would like to know from a thyroid specialist whether there is a connection between this test and autoimmune thyroid disease?

Suman_Jana,_MD: Both are autoimmune diseases and they can co-exist. Anyone who has one form of autoimmune disease is more prone to get another form of autoimmune disease. If you undergo a total thyroidectomy, your thyroid antibodies will go down. However, your antibodies so far have not done any damage, so why will you taking such a drastic step? I would not suggest that you undergo a thyroidectomy for just antibodies. Your thyroid is working fine based on your laboratory results, but once you take it out you would have to take thyroid medicine. If you are ANA positive, you should consult a rheumatologist.

nance: Why do laboratory reference ranges and normal ranges differ from laboratory to laboratory? This seems irresponsible and does not offer a true diagnosis of either hypothyroid or hyperthyroid status of a patient.

Suman_Jana,_MD: Laboratory reference values vary due to the type of assay performed in that particular laboratory and also how advanced the assay is. (An assay is a determination of the amount of a particular constituent of a mixture, or of the potency of a drug.) Still in any laboratory, if your TSH is between 1 and 2.5 you are in very good shape.

janet e.: My acupuncturist says the swelling in my left ankle seems jellylike rather than watery and suggests I have my thyroid checked. What do you think?

Suman_Jana,_MD: You can request your doctor to check TSH and free T4. If they are normal, it is unlikely caused by your thyroid. You would then need to look for other causes.

Genetics and Thyroid Disorders

OhioBella: Are thyroid problems genetic and run in the family? My cousin has had thyroid problems. Now I have a thyroid problem and I am having a biopsy soon.

Suman_Jana,_MD: Yes, thyroid disorders run in families and are more common in women than in men. According to the American Thyroid Association, women are five to eight times more likely than men to have thyroid problems. It is also noted that one in eight women will develop a thyroid disease during her lifetime.

Thyroid Medications

vhouseholder: I have hypothyroidism, and take 88 mcg of Synthroid® (levothyroxine) per day. Generally, how is the dosage of medication determined?

Suman_Jana,_MD: The dose is based on your TSH level and also the cause of your hypothyroidism. If you have total thyroidectomy (removal of your thyroid), the average dose is 1.6 mcg per kg of body weight, but again the dose for you is dictated by TSH, unless you have a pituitary problem, in that case we keep free T4 in the mid- to high-normal range. Otherwise, TSH should be kept between 1 and 2, if possible.

FLOR1: Six months ago, my thyroid medication level was lowered from 100 mcg to 88 mcg based on TSH results. I am 76 years old and have been taking thyroid medication since I was ten years old. With the lower dose I seem to have all the symptoms of bring hypothyroid, including a lack of energy, nails and hair problems, very slight depression, etc., but I am in otherwise good health. My doctor feels that the higher dose is bad for my heart (my HDL is 80) and I think that I know my body, but what is your thought?

Suman_Jana,_MD: Thyroid hormones affect the heart rhythm and oxygen consumption. So, even if you have very good HDL (which will protect you from heart attack), it cannot protect you from irregular heartbeats we call atrial fibrillation (A-fib). Low TSH can cause osteoporosis. So, I will not suggest keeping your TSH below the lower limit of normal. I would also suggest that you consult your physician to make sure that you don’t have any other cause of your symptoms that can be masked by high-dose thyroid medications. These conditions include anemia, vitamin deficiency, electrolyte problem, subclinical depression, rheumatoid arthritis, fibromyalgia, etc. After that, to improve your symptoms, you may talk your doctor about setting your dose between 88 mcg and 100 mcg. To keep your TSH level within the normal range, you can take one and a half pills on Sunday and one 88 mcg pill all the other days to see how your TSH responds.

nance: Please explain what is meant by the half-life of Synthroid® (levothyroxine).

Rosemarie_Metzger,_MD: The half life refers to the time it takes for the body to metabolize half of the amount of the drug. The half life of T4, which is the hormone in Synthroid®, is approximately seven days. So, if you took a dose of Synthroid® on Thursday and took no more thyroid medication following that, you would still have circulating T4 in your system. One week later though your level of circulating T4 would be decreased by approximately half. The half life is a function of both the drug and the way the body breaks it down (metabolizes it). Some drugs and hormones are rapidly metabolized in the matter of hours and others take much longer.

Armour® Thyroid

alice: Please discuss the differences in Armour® Thyroid and levothyroxine effectiveness. It seems that Armour® Thyroid is not readily available currently and must be compounded. Is this correct? My thyroid gland was irradiated in 1981 and I have felt much better on the Armour® Thyroid, but lately I have had to take the levothyroxine. I have my T3, T4 and TSH checked regularly by my primary care physician.

Suman_Jana,_MD: Armour® Thyroid was out of supply in the recent past but now it is available. There are other preparations like Armour® Thyroid, i.e. made from the extract of an animal thyroid gland—mainly pig and cow. One of them is Nature-Throid®. It has both T4 and T3. On the other hand levothyroxine has only T4. If you respond well to T3, you can go back and try one of the other products or try a small dose of T3 with levothyroxine. Your TSH should be kept within normal range, unless you have a history of thyroid cancer.

jamieh: Is there a difference between generic vs. brand name Armour® Thyroid?

Suman_Jana,_MD: There is a very small difference. With the generic preparation, you may get the thyroid medicine from a different manufacturer, leading to slightly different level of thyroid hormone in the blood. So, taking generic medicine can make your blood level of thyroid hormones vary from time to time. Generally, 95 percent of patients can adjust to that on their own and do not need anything. However, five percent may need a brand-name medication. Also you can request your pharmacist to give you same brand all of the time with each refill for 90 days.

Rose5: I was diagnosed with Hashimoto thyroiditis by an endocrine physician. I am on Armour® Thyroid 90 mg by a wellness doctor. The endocrine physician who diagnosed me felt I should not be on any medication, but was OK with low-dose Armour® Thyroid 30! Now he is worried about atrial fibrillation. My blood work has been monitored. Does Armour® Thyroid cause atrial fibrillation over the long term? What other recommendations do you have for this diagnosis?

Suman_Jana,_MD: Atrial fibrillation is from too much thyroid hormone (T4 and T3) leading to low TSH. So, if your TSH is not low, the risk of atrial fibrillation is not high. Compared to T4, T3 has a high potency to suppress TSH. In Armour® Thyroid, there is a relatively higher percentage of T3 than we really need. Armour® Thyroid is made from thyroid gland extract from pig and cow. Now, animals need more T3 than humans. T3 helps them with more thermogenesis (body heat production). Since animals don’t wear clothes, they need to preserve body heat by generating more heat production.

Jack_in_Florida: Does overcompensating on thyroid medication contribute to potential atrial fibrillation episodes? Can you comment also on target levels for T3 uptake, T3, free T3, TSH, T4 and free T4 for those on thyroid replacement therapy? (I have no thyroid gland.)

Suman_Jana,_MD: Atrial fibrillation is from too much of thyroid hormone (T4 and T3) leading to low TSH. So, if your TSH is not low, the risk of atrial fibrillation is not high. Compared to T4, T3 has a high potency to suppress TSH. TSH levels should be above the lower limit of normal.


HASHIMOTO: Do corticosteroids normally have an effect on a goiter's size? As a treatment for shingles, my corticosteroid dosage was 10 mg for 10 days and tapered by the tenth day. I read something about Hashimoto encephalopathy and steroid responsive treatment. Although this medication use was not related to thyroid disease, my response to this steroid treatment was amazing. The size of my goiter was noticeably reduced for about a month, but has since gone back to the size it was. I felt remarkably clear-headed and like a different person after that treatment. (I was not rheumatoid arthritis [AR] positive upon recent blood work.) Is there an effect of the steroids on my goiter? Is there a test for Hashimoto encephalopathy or a treatment for the thyroid goiter that would involve steroids?

Suman_Jana,_MD: Hashimoto encephalopathy is a diagnosis of exclusion when a patient has encephalopathy and thyroiditis. Spinal fluid TPO-antibody is a marker when all other causes have been excluded. We don't use steroids for goiter unless someone has a very severe thyroiditis (usually subacute) that is causing severe pain, high body temperature, and other symptoms of severe hyperthyroidism. Please keep in mind that in the short term steroids may make you feel better, but long-term high dosages of steroids can lead to osteoporosis, glaucoma, diabetes, hypertension and weight gain.

Thyroid Nodule Biopsy and Treatment

HASHIMOTO: Do thyroid nodules have any purpose? If they are benign does that mean they are part of the thyroid and act to produce thyroid hormones?

Rosemarie_Metzger,_MD: Thyroid nodules have no specific purpose—and there are many types of thyroid nodules. Millions of people have nodules and most don't even know it. With rare exception, most nodules are inside the thyroid gland and do not stick out of it. Most nodules do not affect thyroid function at all. Occasionally, a thyroid nodule will produce thyroid hormone and will contribute to hyperthyroidism.

Gregmoney7: I have had two ultrasounds on my thyroid in 2012 and 2013. The interpretation is as follows, “Right thyroid lobe measures 4.7 x 1.6 x 1.4 cm. There is an inferior isoechoic nodule which measures 0.5 x 0.3 x 0.3 cm. Again, this is difficult to tell if it is exophytic from the gland or just adjacent to the gland. This appears similar to the prior study. The left thyroid lobe measures 4.7 x 1.5 x 1.4 cm. The left thyroid lesion is seen. Thyroid isthmus measures 5 mm and shows no focal abnormality. Impression: 5 mm solid right-sided nodule is similar in appearance to the 12/11/2012 ultrasound. Again, it is difficult to tell if this is exophytic from the thyroid gland or just adjacent to the gland.” Would you recommend further testing, considering I still have symptoms (especially brain fog) even though my TSH stays between 1.0 and 3.0?

Rosemarie_Metzger,_MD: The right-sided thyroid nodule does not meet our standard criteria for biopsy (which is a nodule measuring 1 cm or greater). If you have specific risk factors for thyroid cancer, i.e. history of head and neck irradiation, family history of thyroid cancer, or an inherited syndrome that is associated with thyroid cancer (such as familial adenomatous polyposis [FAP]), then you will want to follow this more closely. A biopsy might be recommended even if it is smaller than 1 cm. Otherwise, given that the nodule is stable, you can increase the interval of your thyroid ultrasounds. I doubt that your brain fog is related to your thyroid nodule.

jrcarr: I have Hashimoto thyroid disease that was diagnosed in 1998. My nodules are growing very fast with multiple nodules now appearing. I am scheduled for frequent biopsies of the nodules. The biopsies are frequent and recurring. Do I have any other options?

Suman_Jana,_MD: An ultrasound of the thyroid is the usual yearly follow up once fine-needle aspiration cytology is benign. Sometime nodules that appear with Hashimoto’s thyroiditis may not be real nodules. These are areas of inflammation that may appear nodule-like.

catg64: I have thyroid nodules that have been biopsied and were benign. Is there anything I can do to shrink the nodules short of a surgery? My TSH was .603.

Suman_Jana,_MD: There are no medicines that shrink thyroid nodules. In the 1990s, T4 and T3 were used to shrink nodule size, but 99 percent of people had side effects from treatment and only one percent experienced shrinkage. Therefore, T4 and T3 are not recommended by the American Thyroid Association.

catg64: My TSH was .603. Is that in normal range? Do nodules that have grown ever stop growing or shrink?

Rosemarie_Metzger,_MD: A TSH of .603 is on the low side of normal—so, yes, it is still in the 'normal range'. Some nodules will always continue to grow, and others stay the same. Rarely will they shrink. Using thyroid hormone to try to 'shrink' nodules is an 'historical' practice and has largely fallen out of favor. Continued growth should be followed with a biopsy. All nodules greater than 1 cm are typically biopsied. Nodules that grow by 20 percent or more in two or more dimensions on follow-up imaging should be re-biopsied as well. It is important to remember that there are almost always small differences in size on follow-up thyroid ultrasounds because a different person conducting the examination. These small differences are typically of no consequence.

catg64: I have two benign nodules that were biopsied. They increased in size from one ultrasound to the next. Is there anything besides surgery that will stop growth or decrease nodules?

Rosemarie_Metzger,_MD: No, not really. Historically, some people were started on thyroid hormone to try to 'shrink' nodules, but this practice has largely fallen out of favor. If the nodules are not otherwise bothering you, then monitoring for growth is the usual practice of following benign thyroid nodules. Significant growth, i.e. greater than 20 percent in two or more dimensions warrants repeat biopsy. It is important to remember that nodules can be slightly different sizes from one ultrasound to another just based on who is doing the ultrasound. These slight differences in measurement are typically not concerning.

OhioBella: I am 67 years old and scheduled for an ultrasound-guided biopsy of my right thyroid. I had an ultrasound in July and again in January 2014. There are three new nodules! How do they biopsy a thyroid or nodule? How worried should I be? What should I ask the doctor doing the biopsy? What should one do if the biopsy of a thyroid comes back inconclusive, cancer, or benign?

Rosemarie_Metzger,_MD: Most biopsies are done these days with the guidance of an ultrasound. The ultrasound probe is placed above the nodule and the needle is viewed passing into the nodule. Thyroid biopsies are very routine. Typically, any nodule greater than 1 cm is recommended for biopsy. There are several different types of doctors who do thyroid biopsies—endocrinologists, endocrine surgeons, and radiologists. The advantage of having an endocrinologist or endocrine surgeon perform your biopsy is that he or she is the person who will follow up on the biopsy results and provide your comprehensive care. We do these biopsies right in the office. There is nothing specific, per se, to ask the physician prior to biopsy. Biopsy results can be variable. First, the pathologists need to see enough cells to make a diagnosis—if not, the biopsy will be “non-diagnostic.” If there are enough cells to make a diagnosis, then the results can range from “benign” to “malignant.” There are several “intermediate” or “inconclusive” diagnoses in between benign and malignant that may require either another biopsy or surgery for a diagnosis. A diagnosis of cancer by biopsy almost always leads to a recommendation of thyroid surgery. Benign biopsy results mean that the nodule can be “followed” with follow-up ultrasounds to evaluate for a change in size—unless the nodule is big enough to cause symptoms—in which case surgery may be recommended to help alleviate the compressive symptoms.

OhioBella: If I have a thyroid that isn't working or has a bad biopsy, then should I be put on supplements or medication? What if I have to have surgery, then what medication would be prescribed?

Suman_Jana,_MD: A thyroid nodule and thyroid function are two different issues. Commonly, nodules are inactive. Rarely, they can make excess hormone leading to hyperthyroidism. This condition requires thyroid-blocking medicine or radioactive iodine to kill the nodule or surgery to remove the nodule. However, for the majority, nodules are inactive and the rest of the thyroid gland is good enough to maintain normal thyroid function. So, there is no need for any medication. I am not sure what you mean by a “bad biopsy.” Biopsy itself doesn’t cause destruction of the gland, so thyroid supplement is not needed after biopsy. However, if surgery with a complete or partial thyroid removal is needed, you will require a thyroid medication (commonly used levothyroxine or Synthroid®).

eatveggies: I am a 68-year female who has had a left hemithyroidectomy in June 2013 at Johns Hopkins for a suspicious thyroid nodule that proved benign on biopsy. The ultrasound before surgery reported “right thyroid lobe measures 4.4 x 1.1 x 1.7 cm. Small complex nodule in mid- to lower pole measuring 5 x 2 x 5 mm with solid and cystic component. No detectable flow within this nodule. Solid hypoechoic nodule in the right pelvis measuring 8 x 4 x 8 mm with no detectable flow. Left thyroid lobe measures 4.9 x 1.6 x 1.9 cm. Heterogeneous solid nodule with hypoechoic rim measuring 2.4 x 1.5 x 1.7 cm in the mid pole, likely corresponding to previously biopsied nodule. There is increased vascularity within this nodule.” I am now taking Synthroid® (levothyroxine) 25 mg daily, and will have follow-up laboratory tests to monitor dosage. I still have symptoms of hypothyroidism, including fatigue, weight gain, dry skin and intolerance to colder temperatures. Do goitrogens (certain thyroid-inhibiting foods, including cabbage, Brussels sprouts, pine nuts, etc.). and soy from a vegetarian diet interfere with Synthroid® absorption? Might iodine/zinc supplements help? What is the best way to monitor nodules in the right lobe?

Suman_Jana,_MD: To monitor your thyroid nodules, you should get an ultrasound of your thyroid once per year. If any new suspicious signs appear, like increased vascularity, calcification, irregular border, or significant increase in size, your thyroid modules need biopsy. Goitrogens (thyroid-inhibiting foods) can potentially interfere, but you can still eat foods containing them normally—just don’t eat too much of them. Iodine will not help—and will rather make you more hypothyroid. Theoretically, zinc can help, but there is no data to support that. Since this is a metal, too much zinc can potentially harm you. We do not regularly prescribe zinc. As you are already on Synthroid®, I don’t see any need to take zinc. However, you do need to keep your TSH around 1.0. During the first year after diagnosis, the rate of hypothyroidism is high, so you should get your TSH checked every three to four months and adjust the dose as needed. After the first year, you can get it checked once every six to 12 months.

Thyroid Surgery

CUSuzi: I have Hashimoto hypothyroidism and many thyroid nodules. I have been taking Synthroid® (levothyroxine) for about six years. My blood work pre-medication was normal, but the medication was recommended. The nodules are now so large that they are now encircling my trachea and pushing on my carotid artery, but there is no decrease in the flow or in my trachea. The nodules are also beginning to go down to my sternum. I'm told I need surgery to remove the thyroid. Is there anything that can be done non-surgically? I am worried about damage to the laryngeal nerves. If surgery is recommended, is a general surgeon who specializes in thyroid surgery good? Or do I need otolaryngology?

Rosemarie_Metzger,_MD: From your history, it does seem that you likely need thyroid surgery. In your case, with multiple thyroid nodules and Hashimoto disease a total thyroidectomy would be recommended. There isn’t any non-surgical option in this setting. Total thyroidectomy is a common surgery and in the hands of an experienced endocrine surgeon, the risk to the recurrent laryngeal nerves is about one to three percent. There are six endocrine surgeons here at Cleveland Clinic—including myself. We all have advanced fellowship training in endocrine surgery. Our surgical practices include large volumes of thyroid and parathyroid surgery.

Food Choice and Hashimoto Thyroiditis

nmezic: I have Hashimoto thyroiditis. I am wondering what I can do to put the autoimmune component into remission and, thus, save my thyroid.

Suman_Jana,_MD: If you want to do something, avoid too much iodine, soy products and goitrogens (thyroid-inhibiting foods.) You can take the normal amount of these supplements and foods, but avoid consuming too much because they can make you hypothyroid a little earlier. However, you need to monitor your TSH regularly at least once per year and make sure you get treated when your TSH is high, i.e. causing hypothyroidism.

chrish: If you do not test positive for celiac disease, can eliminating gluten still reduce thyroid antibody levels?

Suman_Jana,_MD: Eliminating gluten can help theoretically, but I can't assure you that it will reduce thyroid antibody levels. Levels may go down spontaneously, and they can fluctuate with time—it is your immune system doing this. So, by keeping your thyroid hormone level monitored and taking medication as needed, there should be no need to worry that much about antibodies. They are not as harmful as lupus or other autoimmune diseases.

Thyroid Disorders and Weight Control

Mrag: My mother-in-law has thyroid issues, and is having some problems losing weight. In May 2012 she also had a heart attack. How can she take off some of her weight the healthy way without any medications because it's hard to find any that she can combine with her medications?

Suman_Jana,_MD: Your mother-in-law needs to cut down on sugars and carbohydrate-containing drinks and foods. She should also exercise.

She should adhere to the following:

  • Drink water and avoid fruit juice, soda or carbonated drinks, etc. Black coffee or tea is the best. If needed, she should use sugar substitute and skimmed milk.
  • Avoid chewing gums or mints, but if needed, use sugar-free products.
  • Avoid cookies and candies, but she can eat nuts, vegetables, and popcorn without caramel for snacks. She should limit fruit as well.
  • Avoid too much bread, pasta, rice, potatoes and corn in a meal. She should eat one quarter plate salad, one quarter plate cooked vegetables, one quarter plate protein, and one quarter plate carbohydrates.
  • Exercise 45 minutes per day five days or more per week. Her exercise should be cleared by her cardiologist due to her history of heart attack. She may not be able to do 45 minutes right away, so she needs to start ten minutes per day at the beginning and slowly go up every couple of week by five minutes. She may need a stress test to clear that exercise regimen. If she develops chest pressure or pain during exercise, she should stop exercising. If the pain does go away within five minutes she should call 911 emergency. If goes away, then she should contact her cardiologist before doing any more exercise.

jamie: I currently take Armour® Thyroid 105 mg daily. Within the past month, the dose was bumped up from 90 mg. I have gained five lbs. in the past month. Previously, I took Synthroid® (levothyroxine) for one and a half years and gained 20 lbs. Is this normal for a thyroid condition? Is there anything else that can be done? Is surgery necessary? I have high cholesterol from my thyroid and I am also obese. This is becoming very concerning to me despite exercising five days a week and watching what I eat. I continue to gain weight at a rapid rate.

Suman_Jana,_MD: You need to keep your TSH within a normal range, preferably close to 1.0. There is no need for surgery. Please see my previous response.

cricket03: I had heart failure in November 2012 and there were several problems that I had neglected. I had also passed a mass when I was in intensive care. By April 2013 I felt like someone was choking me all the time and was diagnosed with hypothyroidism. I had gone from 160 lbs to 190 lbs, and was retaining so much water. I have now been on Synthroid® (levothyroxine) for eight months, I am eating healthy and I have not lost any weight. What can I do to change this? I am active and I have started taking vitamins, I don't know how else to change this.

Suman_Jana,_MD: TSH should be kept close to 1.0 and not equal to or greater than 2.5. Talk to your cardiologist about water retention and exercise. Additionally, please see my previous response.

Panda: I have hypothyroidism and I am on 88 mcg Synthroid® (levothyroxine). I used to be on 112 mcg and my weight was in the normal range. Now that my dosage is lower, I have gained 40 pounds over five years. My TSH numbers were in the negative range and that is why the dosage was gradually reduced. Now the TSH is normal, but my weight isn't. I am five foot five inches tall and 172 pounds, which makes me overweight. What are your recommendations?

Suman_Jana,_MD: Your TSH should be kept close to 1.0 and not >2.5. To help your weight cut down on sugars and carbohydrate containing drinks and foods. In addition to exercise, you should follow the advice in my previous response.

staciers9: I have been told that I have an enlarged goiter, a cyst and a mass, but the blood function test results came back fine. I have had many doctors in the last three years, including an infectious disease doctor from Cleveland Clinic, tell me that they would not be surprised if my thyroid was the issue. I have been trying to lose weight for the last six weeks by eating fruits and vegetables, lean meat (mainly poultry), and limited carbohydrates with no sweet drinks. I have only lost one pound! I was told that this too could be tied to my thyroid. How do I know what to do to aid me with this? Is there a test I should have done?

Suman_Jana,_MD: You need to check TSH and make sure not higher than 3.0. If it is greater than 3.0, it needs further evaluation. There are approved weight-loss medications, like Belviq® (lorcaserin hydrochloride) and Qsymia® (phentermine and topiramate extended-release), as well as gastric bypass surgery that can help you lose weight. Please see my previous response on diet and exercise.

aryanee89: Are there any other medications other than levothyroxine that better respond to my attempt to control weight changes? I've been taking Euthyrox (levothyroxine) 100 mcg for almost three months. I have gained so much weight even though I tried exercising and dieting.

Suman_Jana,_MD: You need to keep your TSH close to 1.0. Thyroid medications should be taken on an empty stomach with water only. Foods, coffee and medications can interfere with your thyroid medication absorption. There are other factors which may contribute to weight gain and should be excluded.

Vitamin and Supplement Use

OhioBella: Should a person be on vitamins, supplements or iodized salt to help the thyroid?

Suman_Jana,_MD: There is no need for vitamins or supplements. However, it is important to avoid too much iodine, like in kelp, and to avoid too many soy products. Just use a normal amount of iodized salt and soy, but not too much. If it is determined you are deficient in any vitamin, you should take that vitamin. Supplements like selenium, zinc, glutathione and vitamin D can potentially help, but there is no research study to support this. Excess amounts of these substances can potentially cause harm. Therefore, none of these are routinely recommended. Three-four Brazil nuts per day can provide selenium and could be OK to take.

laura628: I take a variety of daily vitamins and supplements. Can any over-the-counter vitamins or supplements interfere with Synthroid® (levothyroxine)? I have Hashimoto hypothyroidism.

Rosemarie_Metzger,_MD: Yes, many supplements can interfere with the absorption of Synthroid® . Calcium, iron and multivitamins are especially problematic and should be taken several hours (ideally four or more) after taking levothyroxine. Black coffee is also known to affect the absorption of levothyroxine. The best way to take it is on an empty stomach—and to wait for one hour before having anything to eat or drink. You should wait four hours to take multivitamins, calcium and iron.

Finding a Specialist

dkmgray: Can you recommend an expert in treating thyroid disease in the area of Williamsburg to Virginia Beach, Va?

Suman_Jana,_MD: I do not know of anyone firsthand, but I can send a message to our staff member to see if anyone has any specific recommendation. You can also do a Google search and look at a physician’s experience and affiliation. A thyroid doctor who is affiliated with a university hospital likely would be a good choice. A physician who is involved in teaching medical students, residents and fellows will be up-to-date with current recommendations. The American Thyroid Association (ATA) has a list of thyroid specialists that may be searched by location. For more information please visit


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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.

Cleveland Clinic’s Thyroid Center has nationally and internationally recognized expertise in thyroid ultrasound, novel diagnostic markers and genetic evaluations of thyroid cancer patients. It is one of only a few centers nationwide to provide radiofrequency ablation of liver metastases from thyroid cancer and have robotic surgery expertise.

Our high-volume center is the home of the largest thyroid cancer surgical program in Ohio and the five surrounding states, performing more than 500 endocrine surgical procedures every year―many of which are complex and reoperative surgeries.

The center is structured for collaboration among experts from a variety of Cleveland Clinic specialties, including endocrinologists, endocrine surgeons, pathologists, radiologists, genomic medicine experts and oncologists from Taussig Cancer Institute, as well as the physicians and surgeons from other Cleveland Clinic Institutes, when needed.

The Endocrinology & Metabolism Institute at Cleveland Clinic includes the departments of endocrine surgery; endocrinology, diabetes and metabolism along with the thyroid center, diabetes center, and endocrine calcium clinic. We treat various disease and conditions of the endocrine system, including diabetes (types 1 and 2), obesity, hyper- and hypothyroidism, Cushing disease, and Addison disease among other illnesses.

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

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Reviewed: 02/14