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The butterfly-shaped thyroid gland, which sits between your collarbone and the Adam’s apple, releases hormones that affect nearly every part of your body, from temperature to weight to periods and so much more. Tune in as adult endocrinologist Mary Vouyiouklis Kellis, MD, walks us through the functions of the thyroid, common disorders like Hashimoto’s thyroiditis, and how to know when something’s not right.

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The Small but Mighty Thyroid: Myths and Diagnoses with Dr. Mary Vouyiouklis Kellis

Podcast Transcript

Nada Youssef:   Hi, thank you for joining us. I'm your host, Nada Youssef. Today we'll be talking about a very important gland in our bodies that produces hormones, regulates metabolism, helps your organs work, and so much more. We're talking about this butterfly-shaped thyroid gland, located between the voice box and collarbones. Your thyroid affects almost every process in your body, and today's topic, we'll be talking about thyroid functions, dizzy symptoms, causes, treatments, and so much more, and if you have any questions for our expert today, please type them in the comment section below.

For today's discussion, we welcome our expert endocrinologist, Dr. Mary Vouyiouklis Kellis.

Dr. Mary Kellis: Thank you.

Nada Youssef:   Thank you so much for being here. If you just want to go ahead and introduce yourself.

Dr. Mary Kellis: Well thank you for having me. I'm Dr. Mary Vouyiouklis Kellis. I'm an adult endocrinologist here at the Cleveland Clinic. I've been here since 2012. I had my training in medicine and endocrinology over at NYU, in New York City.

I'm happy to be with you today. Thank you for having me.

Nada Youssef:   Thank you so much. So, let's kind of start by, what is a function of a thyroid gland, and did I point at it right? I feel like I was-

Dr. Mary Kellis: Yeah. The thyroid gland basically sits between the collarbone and the Adam's apple, here. It can affect pretty much every part of the body. It can regulate metabolism. It can regulate temperature tolerance. It can actually cause changes in periods, in mood. Basically, people can have fatigue if there's not enough thyroid hormone, or it can be revved up and have anxiety if there's too much thyroid hormone. It can also affect the heart. Weight is also a big issue. Not enough thyroid hormone can cause weight gain. Too much thyroid hormone can cause weight loss. It's very important to make sure that your thyroid function is healthy.

Nada Youssef:   It sounds like there's a huge spectrum.

Dr. Mary Kellis: Definitely, definitely.

Nada Youssef:   Absolutely, okay, so it all depends on the disorders. Let's talk a little bit about thyroid disorder.

Dr. Mary Kellis: Thyroid disorders, Hashimoto's thyroiditis is a benign autoimmune thyroid condition. It's actually the most common cause of hypothyroidism or underactive thyroid in the United States. It's very common, especially in women. Women are eight times more likely to have a thyroid condition than men, in the Hashimoto's. Typically, symptoms of Hashimoto's could be, again, everything slows down. You can have cold intolerance. You can have fatigue, weight gain, depression, decreased mood, low energy, dry skin, constipation. So those are some of the symptoms that can be associated with that.

Nada Youssef:   Now when you say hypo, there's hypo and there's hyper. What is the difference?

Dr. Mary Kellis: The difference is the amount of thyroid hormone that's around. With hypo, there's not enough thyroid hormone. As a result, all of these functions tend to be decreased. With hyper, there's way too much thyroid hormone, and as a result you have increase in temperature, so you're feeling hot and sweaty, increase in symptoms of adrenaline. You feel anxiety, insomnia, your metabolism's revved up, you're losing weight, that's all for hyperthyroidism.

Nada Youssef:   So is that like Graves' Disease? Is that similar?

Dr. Mary Kellis: Yes, Graves' Disease is definitely one of the causes of hyperthyroidism. That's an autoimmune benign condition, that basically results in antibody stimulating your thyroid gland, to make extra thyroid hormone. There are other causes of hyperthyroidism. Toxic nodular goiter is another example of that. Nodules that secrete fibroid hormone can also result in the similar symptoms of excess thyroid hormone.

Finally, thyroiditis, which is another possible cause, painful or painless is hos we describe it. One is called sub acute, where there's pain associated sometimes can result in hyperthyroidism as well, where there's release of preformed thyroid hormone as a result of inflammation. In that condition often that can resolve on its own, not requiring medication. But with Graves' Disease, we typically treat with medication or radioactive iodine or surgery. With toxic nodular goiter, the treatment is typically radioactive iodine or surgery.

Nada Youssef:   Now, when you say pain, are you actually feeling the pain on the gland itself or somewhere else in the body?

Dr. Mary Kellis: For painful thyroiditis, it can be pretty extensive. We've seen patients actually go to the emergency room, the pain was so bad, but obviously every patient is different. Sometimes it's just a dull, sort of achy pain in the area of the thyroid. Sometimes you can have associated radiation to the ears. You can have ear pain or sometimes headaches, because there's pain in that area as well, there can be associated as well.

Nada Youssef:   Okay. So let's talk about iodine deficiency. Is that one of the causes?

Dr. Mary Kellis: Iodine deficiency typically can result in goiters. It's usually seen in third world countries. In the United States, actually the most common cause of hypothyroidism is Hashimoto's, because we tend to not have iodine deficiency here. Our foods are very fortified with iodine, like eggs and bread and things like that. So, having the deficiency of iodine really is not something we should be as concerned about.

Nada Youssef:   Okay, great. Now, goiter, to tell me exactly what that is.

Dr. Mary Kellis: The word goiter basically just means an enlarged thyroid gland.

Nada Youssef:   Okay. Okay. So that's when you know something could be wrong, right?

Dr. Mary Kellis: Exactly.

Nada Youssef:   You can feel it. It's swollen. Okay, great. Speaking of thyroid nodules, are they normal to have, nodules? Do you feel them?

Dr. Mary Kellis: Sometimes you actually don't feel thyroid nodules. Often you don't, actually. Usually we find them incidentally, or if you went to a doctor's office and they did a physical exam, you can feel that on exam, if they're large enough. Typically, nodules more than one centimeter are palpable. Often, if they're larger than that, sometimes a friend could pick it up, if they see you-

Nada Youssef:   Looking at it, right at it [crosstalk 00:05:54].

Dr. Mary Kellis: Yeah, you know, I looked at your thyroid, from across the room.

Usually, they're picked up incidentally. They're going for cat scans of the neck or some other imaging study, because they have neck pain. As a result, they incidentally find these nodules, but they're very common. Basically, I tell people it's usually the percent chance of you having it is with the decade of your life. If you're 50, you probably have a 50% chance of having a nodule. If you're 60, you probably have a 60% chance of having a nodule.

Nada Youssef:   Sure. Now I know you mentioned earlier, a toxic nodule? Can we talk a little bit about what it is exactly?

Dr. Mary Kellis: The word toxic is very frightening, just like the word Graves' is, but again, Graves' is just named after the guy who came up with this diagnosis, and toxic just basically means that the nodule is just secreting thyroid hormone on its own, without listening to the signals of the body. In endocrinology, we have a lot of signaling, so if something is an excess, the body shuts it off, so it's not making enough.

Well, with nodules, they don't care about what the body is telling it, they just decide to continue to secrete thyroid hormone. As a result these nodules, typically are larger, and as a result they secrete these hormones. The treatment, typically, for this is radioactive iodine, which will get rid of the overproduction of thyroid, or surgery.

Nada Youssef:   Okay, so toxic doesn't mean cancer.

Dr. Mary Kellis: Yeah. Toxic does not mean cancer.

Nada Youssef:   Now, how do you know if you have toxic? Just again with the symptoms. What kind of symptoms are we looking for?

Dr. Mary Kellis: The symptoms of hyperthyroidism, weight loss, anxiety, heat intolerance, changes in periods, hair loss, sweating, and feeling flushed hot. Then, obviously, when you have those symptoms and you go to your physician, they check your blood tests, and if the blood tests reveal hyperthyroidism and there's something felt in the neck, then we can do a thyroid ultrasound, which is a noninvasive test that looks to see exactly if there are any nodules in the neck.

Then, if that's the case, we also do what's called a thyroid uptake scan, where we take a pill that contains radioactive iodine. It's a small dose, and it takes a picture of your thyroid. If those nodules are producing thyroid hormone, you'll see them light up.

Nada Youssef:   Wow. So, what are the causes for this toxic nodule is, besides maybe iodine deficiency?

Dr. Mary Kellis: Well, it's not that. They're usually called autonomous nodule. We don't really know the true understanding, but what's happening is, there is something on a cellular level that's causing these thyroid nodules to just continue to grow. As a result they end up secreting.

Nada Youssef:   Mis-communicating.

Dr. Mary Kellis: Yeah.

Nada Youssef:   Okay, great. So what about a TSH level? You hear that a lot related to thyroid. What is that?

Dr. Mary Kellis: TSH stands for thyroid stimulating hormone, and actually that's a pituitary hormone, and it's the most sensitive marker of your thyroid. The one thing that's very important to understand is that this level, actually when it's low means that you're making too much thyroid hormone, and when it's high you're not making enough. It works opposite the thyroid.

So, free T4 and free T3 are actual thyroid hormones. T3 is the active form of thyroid. When those levels are up, that means you have a lot of thyroid hormone onboard.

Nada Youssef:   Okay, great. Now, if any of our audience or viewers would like to do this at home and check for their thyroid, is this something we can do at home?

Dr. Mary Kellis: Yes.

Nada Youssef:   Maybe we can walk through it, because we also have listeners and not viewers, so we'll do both. We have a glass of water here. Tell me what to do.

Dr. Mary Kellis: You basically take the glass of water.

Nada Youssef:   Okay.

Dr. Mary Kellis: And you lift your head up and you take a sip. Hold it in your mouth, and then you look in the mirror and swallow. 

Nada Youssef:   You're checking, just as you swallow.

Dr. Mary Kellis: You check from your collar bone up here, and when you swallow you're checking and looking for any lumps or bumps in this, from here down. Okay?

Nada Youssef:   Okay.

Dr. Mary Kellis: So, if you swallow and you feel like you see something there, then obviously it's very important to see your doctor to have that checked out.

Nada Youssef:   Okay. So it's nothing that you feel for. You have to look in the mirror, to see when you take a gulp of water, if there's any bumps. It's not just like [inaudible 00:09:57].

Dr. Mary Kellis: You could just feel for it, but sometimes it's easier if you drink the water, because you can see the nodule going up and down, if it's a large one. Sometimes though, you don't see any nodules and you still have them, but those typically are small and under a centimeter and those usually are not concerning.

Nada Youssef:   Okay, great. So, if I'm having any of these symptoms in this huge, vast spectrum that we just talked about, from hypo to hyper, how do I know when to see a doctor? It just sounds like there's so many symptoms that could almost sound like something else.

Dr. Mary Kellis: Well, I always tell people, if you're just not feeling yourself, then you need to see a doctor. You tell them your symptoms and they will run some labs. It's not always a thyroid issue that can cause these things, because again, these are such general symptoms, but it's always important to let them know.

If you have a family history of thyroid, you're a much higher risk of having a thyroid condition. That's really important to know as well. If you're experiencing any of these symptoms, it's important to see your doctor, to have that further evaluated.

Nada Youssef:   Great, and then when is surgery needed, then?

Dr. Mary Kellis: Surgery is usually needed in situations where your gland is so large that it's causing issues swallowing or breathing. That would be one indication. Obviously, if there's thyroid cancer ,when you get a biopsy of a nodule that is found, and again, in certain situations like for example, toxic nodular goiter or Graves' Disease, it can also be used for those conditions, as well.

Nada Youssef:   Sure. And I know, so thyroid really affects your hormones, right?

Dr. Mary Kellis: Yes.

Nada Youssef:   If your hormones are out of whack, how do I know if it's, what if it's the age of menopause? How can you tell the difference?

Dr. Mary Kellis: That's very important, because thyroid can be diagnosed at any age, but often we see people, ages 40 to 60, women who are getting diagnosed with thyroid conditions, and sometimes a lot of these symptoms can be menopause symptoms. It can be sort of poo pooed that, "Hey, you know, whatever, you're going through menopause, leave me alone." But that's actually not the case, because sometimes while it is menopause, you can also have a thyroid condition that needs to be evaluated. So, if you're going through the change and you're having irregular periods, it is important to have your thyroid evaluated, just in case that that could be the cause that your periods are irregular. Maybe your body's not ready for menopause, but you're having these irregular periods, because there's thyroid dysfunction.

Nada Youssef:   Sure, sure. Okay. And then let's talk a little bit about diets or supplements. What should we eat? What should we not eat? What do you have for us?

Dr. Mary Kellis: Okay, this is very controversial. There's a lot of stuff online about this. So, once your youth thyroid, or if you have normal thyroid, you don't have to avoid things. You read about cruciferous vegetables, which are broccoli and cauliflower. You read about kale and all these things that can have potential to affect your thyroid, but you don't necessarily have to avoid these things, especially if you're on thyroid hormone supplementation and if your thyroid function is normal.

Similarly with soy, there's a lot about soy and how it affects the thyroid. I would say that if you're taking a lot of soy around the time of when you take the medication, perhaps there can be issues with absorption, but in terms of the way you take that medication, we do have some guidelines of waiting, taking with a glass of water, waiting before eating or drinking anything. Keeping vitamins and iron tablets three to four hours after taking those pills.

Nada Youssef:   Oh, good information. Thank you. Okay, so I have some thyroid myths. I want you to debunk them for me, and then tell me why. Tell me the correct answer.

Dr. Mary Kellis: Okay.

Nada Youssef:   So, number one. Obvious symptoms. It's obvious if you have thyroid.

Dr. Mary Kellis: It's definitely not obvious. So, like we've talked before, a lot of this can be vague because there's so many different things that you can have. And sometimes people have weight gain, but you know, they're feeling heat intolerance. So how do you tease that out? One symptom could be hyper and one symptom could be hypo. That's why it's important, if you aren't feeling right, just have it looked at.

Nada Youssef:   Even if it feels like menopause.

Dr. Mary Kellis: Exactly.

Nada Youssef:   Okay, because that was my second one. So I'll scratch that one. How about thyroid disease makes your eyeballs bulge. Because I have bulging eyeballs.

Dr. Mary Kellis: Okay, the eyeballs thing is, the eyeballs bulge is a rare situation of Grave's. Eye disease is typically, usually seen with Grave's, which is the benign autoimmune condition, and it can sometimes be seen in smokers more, so if you're a smoker with Grave's disease I would urge you regardless to quit smoking. But for people who have Grave's eye disease, it's a treatable condition. Sometimes we give supplements if it's a mild condition. We can give selenium. If it's severe, we give steroids, and obviously ophthalmology helps along, and sometimes if things aren't as good, we might have to do surgery.

Nada Youssef:   Okay. All right. And then we talk a little bit about thyroid nodules does not mean you have cancer.

Dr. Mary Kellis: Yeah, so the nodules 90% of the time are benign.

Nada Youssef:   Okay, great. And then iodine supplements are needed if you have thyroid disease?

Dr. Mary Kellis: So, no. No. Absolutely not. I mean, if you want to take a multivitamin, that contains iodine in it, that's fine, but you don't need to take extra. And the problem is, sometimes taking extra can be an issue, because it can throw you into hypo or even hyper, in certain situations.

Nada Youssef:   Right. We're getting a lot of questions. Can I ask you one more thing before I go to the live? Now, if I see a nodule, if I do this drink of water like we talked about, and I see a little nodule, a little bump, is it something to be concerned about right away, or is it something I can just do at home to regulate what I have before going to a doctor.

Dr. Mary Kellis: If you see a bump, you should probably see a doctor.

Nada Youssef:   Okay. Great.

Dr. Mary Kellis: And I would say seeing an endocrinologist would be a good start because they can sometimes do the ultrasound in the office, or send you for an ultrasound and then decide if it's something that needs further evaluation. Sometimes you'll need a biopsy which is a little needle that they put into the nodule to take cells and see and make sure that they're healthy.

Nada Youssef:   Okay. Great. Excellent. So let's get some of these questions. I have Marilyn, "When I first started taking the medication, I felt better, now I just feel as bad as I did before I started taking it. I don't go to see my thyroid doctor til August, but I told her the last time, which was two months ago that I wasn't feeling any better, and she did not increase my thyroid meds. Why would that be, and what can I do?"

Dr. Mary Kellis: Okay, thanks for your question, Marilyn. So, I'm not sure what your labs show. The range for the thyroid is very wide. It really depends on the lab. TSH is about .4 to 4.5 in certain labs. It's a very wide range. So personally, as an endocrinologist, if someone's not feeling right, and they're in a place where I could potentially increase their dose a little bit, but keep them in a safe healthy range, I could do that, and I usually do. But if you’re in a very healthy range and you're still not feeling right, well, then, maybe it's not your thyroid.

So these are other things that I like to tell people, when you have Hashimoto's, which is an autoimmune condition, you can have other autoimmune issues. You can have B12 deficiency, which is pernicious anemia, that can cause fatigue. You can have Celiac, which is a gluten intolerance, that can cause fatigue. You can have adrenal insufficiency, which is low cortisol. It's rare, but that can cause fatigue. You can have diabetes, Type 1. Which is autoimmune. So there are a lot of other things that can cause fatigue. And by the way, sleep apnea, which is very undiagnosed, can also cause fatigue.so if fatigue is the issue, we need to look into what's causing that. We need to review diet, we need to rule out other things.

Nada Youssef:   Okay. Great. Thank you. And I have Kathy. "Can an enlarged goiter right itself after menopause?"

Dr. Mary Kellis: So, enlarged goiter is just basically an enlarged thyroid gland, and going through menopause doesn't necessarily change the anatomy of the gland. So you'll probably still have enlargement of the gland. Sometimes thyroid levels can change, because of the estrogen going do with menopause, but it doesn't really affect the anatomy of the gland much.

Nada Youssef:   And Bethann, "My medicine was increased on June 1 to 75 milligrams, of is it armor thyroid?"

Dr. Mary Kellis: Yes.

Nada Youssef:   Because I had symptoms of hypothyroid and my latest blood work shows my TSH at .92 and my T3 at 4.2. Hormonal levels are normal, however my hair continues to fall out in handfuls and without even touching it. How long should I expect this to last? Is there anything I should be doing? Could my medicine be too high now, causing my hair to fall out, as all my other symptoms have subsided."

Dr. Mary Kellis: So, hair loss is a big issue. I don't know, how old is Bethann? Do we see how old she is?

Nada Youssef:   Nope.

Dr. Mary Kellis: So any changes in thyroid function could potentially cause hair loss, and sometimes it could be prolonged and it could be three months later, even when the levels are normal that you can start seeing improvement in the hair issue. But sometimes it's not just the thyroid that can be affecting the hair loss, it can be other things, so looking to make sure there's no iron deficiency would be one other thing to consider. And sometimes if you're in menopause, in low estrogen state, that hair follicle starts to thin, so things start to appear, like you have thinning or thin hair, and that could also be a reason.

Nada Youssef:   Okay, and speaking of thin hair, Kathy wants to know is hair loss or shedding a symptom of thyroid disease?

Dr. Mary Kellis: Yeah, it definitely can be. A lot of people with thyroid dysfunction can lose hair, and typically it can be reversible. When you're losing hair, kind of falling out, there's also another condition called alopecia areata, it's an autoimmune condition, which actually can result in hair loss. Usually it's round spots of hair loss. So definitely there is actually connection between thyroid and hair loss.

Nada Youssef:   All right. And Mary Jane, "Why do my thyroid tests always come back okay, but I have almost every symptom of thyroid?" That always my issue, I'm like, it just sounds like I have every symptom.

Dr. Mary Kellis: Well, see that's the thing. It's very hard to tease out because it's such a general, there's so many symptoms that can be associated with thyroid, because thyroid affects everything. So the most important thing is, if you're keeping the levels within a healthy normal range. So, yeah you could have a TSH that's considered normal, but it's really not normal. And in that situation we could increase the dose to see if you feel better. But if we do increase the dose and you're not feeling better, then definitely it be multifactorial. There could be other things causing this to happen. So we'd have to tease out little by little, dietary, you know refined sugar, processed foods can make you feel fatigued. They can create a lot of symptoms that could be comparable to thinking it's a thyroid issue. Fatigue definitely is a pretty non specific issue. So we would have to look into other causes.

Nada Youssef:   If I want to check my TSH levels, do I just go to, can I go to my primary doctor? If I don't have any issues but I would like to check on my thyroid, because it seems like it controls a lot, and hormones are a big thing. So I could just go to my primary care physician, just ask them for these levels to be checked?

Dr. Mary Kellis: Yes. So we, primary care physicians check thyroid levels all the time. So you can just tel them, they usually start with a screening test, which is TSH. Other tests we check are free T4 and free T3, and people who are hyperthyroid, and then thyroid antibodies are clues to autoimmune thyroid conditions. So thyroid peroxidase antibody, thyroglobulin antibody, and in the case of hyperthyroidism, TSH receptor antibody and thyroid stimulating immunoglobulin.

Nada Youssef:   Great. Awesome. Okay let's go to Celia. "My sister does not take her medication all the time, and lately she's been having suicidal thoughts and depression."

Dr. Mary Kellis: Oh no.

Nada Youssef:   Is this from lack of thyroid medication?

Dr. Mary Kellis: So, thyroid medication can, absence of, when you're hypothyroid can certainly affect your mood and cause a decreased mood, and thank you for that question. I hope your sister can get help. And very important for you to get her to a medical facility to have that checked out. If she's not on medication, she needs to be on it, but also for the suicidal thoughts that she's having, definitely needs to have her evaluated right away.

Nada Youssef:   Sure. Sure thing. And then Linda. "Should one positive test of thyroids that's over the normal level mean you need Synthroid?" What is Synthroid?

Dr. Mary Kellis: Synthroid is brand levothyroxine.

Nada Youssef:   Okay, okay, so it's a brand medication.

Dr. Mary Kellis: Her question is?

Nada Youssef:   If you got one positive test of thyroid that's over the normal level, does it mean you need that medication?

Dr. Mary Kellis: So that's a complicated question, because I don't know what the TSH is. A onetime level, I'd probably would repeat it, because sometimes there is fluctuation in thyroid levels. If I would repeat it with a thyroid antibodies, and if you're having any symptoms, then I would consider putting you on medication.

Nada Youssef:   Okay. And Mary. "Is extreme fatigue common with a treated thyroid?"

Dr. Mary Kellis: Yeah, so with a treated thyroid, extreme should hopefully be improved with being on thyroid hormone. That's why do urge people to have further evaluation of fatigue once things start getting within that healthy normal range. And I say healthy, because you know, sometimes people are petering out at that upper end of normal, TSH range, where there is room for increase in the dose, so once we get you to that mid normal range, if you're still having fatigue, you need to look elsewhere to make sure there's nothing else going on.

Nada Youssef:   Speaking of TSH, Leslie wants to know if TSH blood test with normal range, does that mean that thyroid is healthy?

Dr. Mary Kellis: So that means thyroid function is healthy, but that does not necessarily mean that the thyroid is healthy. So you can still have an enlarged thyroid, you can still have thyroid nodules. Even with a normal TSH.

Nada Youssef:   Okay. And then Renee, "I have hypothyroidism, and my doctor prescribed me 100 milligram of Synthroid, but I have seen no effect. Is there something better on the market or anything in home remedies?"

Dr. Mary Kellis: So, effect, I'm not sure in regards to what particular symptoms, but other just to sort of generally talk about other things that can be used. So, Synthroid is the brand, there are other brands, Levoxyl, for example, there's also the generic levothyroxine. Synthroid is T4, some people need the addition of T3 which is active thyroid hormone. And that can be given either with liothyronine, which is Cytomel, a T3 supplementation, or the pill can be switched over to Armor, or Naturethroid, which is currently not on the market. But those are natural desiccated thyroid products that contain both T4 and T3.

Nada Youssef:   Okay. Awesome, great. And then I have Allison. "I have hypothyroidism and feel terrible most of the time. My doctor has me on Armor Thyroid, but it tends to make my main number run two points over or under. I feel the best when this happens. Is this bad for me? Or should she keep changing it? I feel like she should leave it alone. My body feels better, and I may be just a little off from the manmade chart. Thanks."

Dr. Mary Kellis: So, I'm assuming that feeling better is when you're mildly hyper, so when the dose is more than you need. I don't encourage, or allow patients to be in that abnormal range because it can be associated with other things, like irregular, rapid heart rate, atrial fibrillation, which would require anticoagulation or blood thinners. It can worsen your bone health. Cause rapid heart rate. There are a lot of risks that can occur with prolonged over treatment of thyroid. So I don't recommend being over treated. So I hope that answers her question.

Nada Youssef:   Sure thing. And then Mona, "If my TSH is five over 140 can it cause heart palpitations?" Does that sound right?

Dr. Mary Kellis: Five over 140? No. Maybe 5.14. Maybe that's what she meant. TSH of five should not cause heart palpitations.

Nada Youssef:   Okay. And then Sue. "My daughter has thyroid problems and is on medication but she still is gaining weight. Her tests just came back okay. So what is the next step for her?"

Dr. Mary Kellis: Weight gain is very complicated. So thyroid is definitely something that we think about when that comes back normal, there are other proteins and other hormones that play into weight. And a lot of stuff that we actually cannot test for. Other things that we could potentially test for, if the weight is significant and there's no causes.

Excess cortisol production or Cushing's syndrome, that would be one thing to consider, but also working with a nutritionist to review the diet and see how many calories her daughter is taking in and what kind of exercise. The choice of exercise is also important, so high intensity interval training can be very effective in boosting metabolism, so that's sometimes better than just doing a slow moderate job on a treadmill for an hour. You can do a shorter amount of time in high intensity interval training, which can spurt or boost your metabolism.

Nada Youssef:   I see. That's very interesting to know. Then I have Janice. "How often should I have my thyroid be checked? I have Hashimoto's. Is the TSH adequate?"

Dr. Mary Kellis: In some people the TSH is adequate. People who feel well, you don't necessarily have to do the whole gamut of testing, but sometimes if you're not feeling well, it could be helpful to look at the other stuff as well. The frequency of testing really depends. I have my patients who are very well controlled and their doses don't change. I have them come back every year. There are some people who like to come every six months just because they want to make sure their levels are stable.

Nada Youssef:   Okay. Great. And then Sandy. My 67-year-old husband has three tiny bilateral mildly complex thyroid nodules. Doctor said they will recheck in one year. About five years ago, though, he had one cyst-like nodule, diagnosed with ultrasound, that they were just going to watch. In your opinion, is continuing to watch it standard treatment at this point? All lab work with his checkup including PTH and calcium was within normal limits. History of osteopenia, multiple kidney stones. Thank you.

Dr. Mary Kellis: Just to clarify for others out there who want to know, parathyroid glands are not part of the thyroid, they just sit next to, so the word para means next to. And the parathyroid actually affects calcium metabolism, so I'm not sure if these cysts are in the thyroid is what she's saying, which I think they are, small bilateral tiny, tiny cysts we don't really worry about much. So just following with ultrasound is definitely appropriate.

Nada Youssef:   Then Maggie, I have a nodule on my thyroid, had a biopsy on the lump, it was all okay, but I still have that lump. ENT, ear, nose, throat doctor, told me they do not remove that as long as it's not cancer. Is this okay?

Dr. Mary Kellis: If the nodule came back benign, then you don't have to remove it. Indications for surgery at that point would be if you're having trouble swallowing, foods, liquids, and if you're having breathing issues. So for those reasons I definitely would recommend surgical evaluation.

Nada Youssef:   So someone like Maggie, she would get it checked like every few months then, just to make sure.

Dr. Mary Kellis: Well for the nodule, if the biopsy was normal, one-year follow up is probably fine.

Nada Youssef:   And then Janice. My thyroid was large enough to show up on a mammogram and has displaced my trachea, but not noticeable on the outside. My ultrasound shows it has a very large nodule. How often should I have that done?

Dr. Mary Kellis: So again, lab function can be different from actually the anatomy of the gland, so you might have normal thyroid, but you have a huge gland that's pressing on your airway, moving it to one side or another. If you're having issues with breathing, that's definitely an indication for surgery. I usually tell people who are young and healthy without issues, if you are having an issue like this, take care of it now that you're young and you have no complications and anesthesia risk would be much lower than when you're older and all of a sudden this becomes a problem.

Nada Youssef:   Heather. Have you ever heard your nodule being calcified? If so, is this a good thing and not concerning anymore?

Dr. Mary Kellis: Calcified nodules sometimes we can see a really long history of thyroid nodules. You can sometimes see calcification, but the calcifications that we are concerned about are called micro-calcifications. These are really small calcium deposits we could sometimes see within the thyroid nodules, which can be suspicious for thyroid cancer. Those are usually the micro-calcifications, so that not actual ... entire nodule being calcified.

Nada Youssef:   Heather, if you have had a biopsy on a nodule, how often do you have another biopsy done, and at what point do you stop having biopsies?

Dr. Mary Kellis: If it's benign the first time, then we do a repeat ultrasound, and if the ultrasound stays fine, then we just continue to monitor with ultrasounds. We wouldn't rebiopsy unless we see that there's significant growth or if there's abnormalities on the ultrasound.

Nada Youssef:   I have hypo-enlarged nodule and several small nodules, but all blood work always comes back within normal range. All symptoms of thyroid issues, just turned 40, have been dealing with this since I was 25 and still have never been put on any medication. At what point do you do something about it?

Dr. Mary Kellis: That's the thing. You can have a huge thyroid and not have any thyroid dysfunction. It depends again where that TSH is, so if the levels are in the healthy range, I wouldn't necessarily start any medication, but she does have multiple nodules that need to be followed with ultrasound.

Nada Youssef:   If surgery is needed, so this is something that an endocrinologist would refer to? So who would you would see first?

Dr. Mary Kellis: We typically refer to endocrine surgery or ears, nose, and throat, the doctors who typically do, and general surgery also does it, but those are the doctors that typically do our thyroid surgeries.

Nada Youssef:   Let's see. Sharon. Is there truly a difference between synthetic thyroid hormone and animal-based thyroid hormone, when it's used to treat hypothyroidism?

Dr. Mary Kellis: There is a difference in the fact that synthetic is T4, the levothyroxine synthetic, and then the animal thyroid has the T4 and T3. There's also synthetic T3, liothyronine. Everybody is different. There are plenty of people on the T4 that feel perfectly fine, and then there's some people who don't, so that's why it's important to have a good doctor/patient relationship that you trust, because they know you, and if you're not where you need to be, you have that conversation, and they can consider putting you on something different if it's just not working for you.

Nada Youssef:   Alice. Do you prescribe Armour or Synthroid for most of your lower thyroid patients?

Dr. Mary Kellis: I have people on everything. Synthroid, levothyroxine, Levoxyl, Armour, Nature-Throid, combinations of levo and liothyronine. Everybody's different and I treat every individual the way ... we have the conversation, and again, the guidelines tell us to use the levothyroxine, but in the real world, not everyone does well on that. There's a small percentage of people that don't convert T4 to T3, and in that group of people, adding T3 is helpful. Another population of people where it's helpful is people with mood disorders, so depression, adding T3 sometimes can be helpful in that group of people, because it makes them feel overall well. 

Nada Youssef:   Everybody needs their own customized treatments.

Dr. Mary Kellis: Yes.

Nada Youssef:   And now Mary. Could you explain hypoparathyroidism?

Dr. Mary Kellis: Hypoparathyroidism again, is not a thyroid conditions. It's related to the parathyroid, so I don't know if you guys can see this little guy here, he's a thyroid, he's this guy. Parathyroids are little glands that sit behind the thyroid. Sometimes they're in other weird locations, behind the esophagus or even in the chest, but for the most part, they sit behind the thyroid and they regulate calcium metabolism, so high parathyroid hormone basically can be from various things. So if you have a high calcium, it could be that one of those parathyroid glands are running amok. It could be two, it could be three, it could be four, but usually it's one. If the calcium is normal but the parathyroid level's high, it could be from other conditions like a malabsorption or a vitamin D deficiency.

Nada Youssef:   Now these kind of things on the thyroid, are you saying they're behind the thyroid?

Dr. Mary Kellis: Yeah, they're usually ... sometimes they're in the thyroid. You can't see them, you can't feel them. They're usually very, very small and even ultrasound typically doesn't show them. Every once in a while we can see them on ultrasound, but they're tiny.

Nada Youssef:   Oh wow. So is there a pill that would help with that?

Dr. Mary Kellis: It's a different type of nuclear test, so if we do have suspicion that there's a high calcium level and a high parathyroid hormone, there's a parathyroid nuclear scan that could sometimes localize the abnormality. You're smart.

Nada Youssef:   Thank you. And then Shari wants to know what is subclinical hyperthyroid.

Dr. Mary Kellis: Subclinical just means that usually when the TSH is low, but your free T4, free T3 levels are normal, and/or you're not having symptoms of hyperthyroidism.

Nada Youssef:   Leslie. An ultrasound accidentally found a thyroid nodule which was later deemed to be predominant, 1.6 centimeters. When should I be concerned? Should I just keep watching for any further growth?

Dr. Mary Kellis: If the thyroid ... it depends on what that nodule looks like. If it's solid, it probably needs to be biopsied, just to make sure that there are enough healthy cells.

Nada Youssef:   Kelsey. Do you recommend treating subclinical hypothyroidism? I have high TSH levels and positive for TPO antibodies but no obvious symptoms. And then I'll have you talk about what is TPO.

Dr. Mary Kellis: TPO is thyroid peroxidase antibody. It's one of the antibodies for Hashimoto's. Again, subclinical hypothyroidism, very dependent on the person and the patient. I have patients who do not want to start any medication. I had an 80-year-old women the other day who I've been following for five years, and she just refuses to take medication. She feels perfectly well, and her TSH is seven, which is in that subclinical range. She feels great, so we're not going to treat her. We're following her, she doesn't feel well, we'll put her on medication. But there are some people who are subclinical, who are gaining weight, who have fatigue, who do need to be treated. So if you're one of those people, then definitely follow up with your endocrinologist or primary care doctor.

Nada Youssef:   Holly. Why is it so hard for a regular person to but their doctor to order a complete thyroid panel including parathyroid tests?

Dr. Mary Kellis: The parathyroid hormone we don't typically check unless the calcium level's elevated. So again, different from thyroid. For thyroid, usually ... there are a lot of primary care doctors I work with here who actually do run the gamut of testing. You can just ask them nicely if you have a good relationship with them. TSH, free T4 is usually where we start and if you have a family history, you could ask them to check the TPO antibody or a thyroglobulin antibody. We don't typically do more further testing until there's abnormalities, but that's where we would go.

Nada Youssef:   And Pamela. Is it true that we have to avoid broccoli, kale, soy, peach, et cetera, for that who have thyroid?

Dr. Mary Kellis: As we said, earlier in the program, I don't think you should take those away, because those are healthy things for your diet. And if you have normal thyroid function, it should not be of concern that you take that in. Obviously, if you're eating kale breakfast, lunch, and dinner, in massive amounts, then you might be a little concerned, but who does that?

Nada Youssef:   I'll give you one more question and then we'll go. I have Darlene, do you usually stay on medication for life?

Dr. Mary Kellis: Most people do if they're put on a replacement dose, then they typically are on it for life, but the pill is very small, and very easy to swallow, so it's not as much an issue.

Nada Youssef:   Great. Well, that's all the time that we have for today. Is there anything else that you want to talk about that we haven't touched on?

Dr. Mary Kellis: I think we've covered most of it.

Nada Youssef:   We did.

Dr. Mary Kellis: Thank you everybody. Thank you so much for having me. Thank you.

Nada Youssef:   Certainly. For more information for Cleveland Clinic endocrine services, please visit clevelandclinic.org/endocrinology. And for more health tips and information, please follow us on Facebook, Twitter, Instagram and Snapchat. Thank you, we'll see you again next time.

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