Welcome to Cleveland Clinic Online Health Chat

Welcome to Cleveland Clinic Online Health Chat

Welcome to Cleveland Clinic Online Health Chat Moderator: Welcome to our thryoid webchat. Please submit your questions early. All questions will be addressed during the live chat at 12 noon ET (11 am CST)Wednesday Jan. 29th Moderator: Welcome to Cleveland Clinic's online health chat about the thyroid disease and management with endocrinologist Dr. Suman Jana and endocrine surgeon Dr. Jamie Mitchell. The chat will be live today, Wednesday, January 29th at 12 noon ET (11am Central Time.) Please submit your questions by typing in the box below and then click ‘Submit Question". Questions submitted early are in the queue and ready to roll.

Moderator: There are a number of health articles about the following conditions that may help to clarify some common questions. Please feel free to review the following prior to the chat.

Thyroid Disease http://my.clevelandclinic.org/disorders/Hyperthyroidism/hic_Thyroid_Disease .aspx Thyroid Cancer http://my.clevelandclinic.org/disorders/thyroid_cancer/hic_thyroid_cancer.a spx Hypothyroidism http://my.clevelandclinic.org/disorders/hypothyroidism/hic_hypothyroidism.a spx Hyperthyroidism http://my.clevelandclinic.org/disorders/hyperthyroidism/hic_hyperthyroidism .aspx Post Partum Thyroiditis http://my.clevelandclinic.org/disorders/postpartum-thyroiditis/hic-postpart um-thyroiditis.aspx Thyroidectomy http://my.clevelandclinic.org/services/Thyroidectomy/hic_Thyroidectomy.aspx Goiter http://my.clevelandclinic.org/disorders/Goiter/hic_Goiter.aspx Hashimoto’s Disease http://www.endocrine.niddk.nih.gov/pubs/hashimoto/hashimoto_508.pdf

Moderator: Thank you for joining today's chat. Please submit your question(s) by typing in the box below. We will begin in about 10 minutes. Moderator: Welcome to Cleveland Clinic's online health chat about thyroid disease and management with endocrinologist Dr. Suman Jana. Dr. Jamie Mitchell is unable to join us today, but all endocrine surgery related questions will be answered at a later time. These answers will also be posted to the transcript, and sent to the individual that posted. Moderator: Please submit your question(s) by typing in the box below. Dr. Jana is beginning to answer your questions, which you will see in the chat transcript.

Thanks for joining! Moderator: 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. Moderator: 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. Moderator: Good news! We have just been joined by endocrine surgeon Rosemarie Metzger. She will be available to answer your thyroid surgery related inquiries and is excited to get started! Moderator: Apologies for the delay. We are having a couple of computer issues here and physician changes. I will begin shortly

Moderator: 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 endocrinology program is ranked 2nd in the nation in U.S. News & World Report’s annual America’s Best Hospitals survey. Moderator: About the Speakers Dr. Suman Jana is an endocrinologist in the Department of Endocrinology, Diabetes and Metabolism in Cleveland Clinic’s Endocrinology & Metabolism Institute. He is board certified in internal medicine for endocrinology, diabetes and metabolism and nuclear medicine. A medical school graduate of the All India Institute of Medical Sciences, he completed his internal medicine residency at the Bronx-Lebanon Hospital Center and his nuclear medicine residency at St.

Vincent’s Hospital. He also completed his fellowship in endocrinology at St. Vincent’s Hospital in New York. Dr. Jana’s specialty interests include thyroid cancer and thyroid nodules, thyroid and parathyroid disorders, cushing’s syndrome and pituitary disorders.

litvolt: I have many symptoms of hypothyroidism despite falling in the normal range of thyroid screening labs. 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 to see if my symptoms respond? Suma_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 (calcium/sodium,/potassium), autoimmune disease and chronic inflammatory state like rheumatoid arthritis, lupus, fibromyalgia, chronic fatigue syndrome, etc.

If all 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 and no history of heart disease, stroke, or osteoporosis. I have couple of patients who did feel better after trial. Again, this can only be done only under supervision of an endocrinologist and fulfills the above conditions.

Mragle90: My mother-in-law has thyroid issues; however she is having some problems losing weight. Two years ago in May she had a heart attack as well. My question is 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? Suma_Jana,_MD:

Your mother-in-law needs to cut down on her sugar and carbohydrate containing drinks and foods. And also do some exercise. 1. Drink water avoid fruit juice, coke, pop etc, coffee/tea black is the best, if needed use sugar substitute and skimmed milk 2.

Avoid chewing gums of mints, if needed use sugar free products 3. Snacks: avoid cookies and candies, can use nuts/vegetables/pop corns without caramel/fruits for snacks, 4. Meals: avoid too much bread/pasta/rice/potatoes/corn, in a meals eat ¼ plate salad, ¼ cooked vegetables, ¼ protein, and last ¼ carbs. 5. Exercise 45 minutes.. per day 5 days or more per week, exercise should be cleared by cardiology due to history of heart attack. She may not be able to do 45 minutes at the beginning, so she should start 10 minutes per day at the beginning and slowly go up every couple of week by 5 extra minutes.

May need a stress test to clear that. If she develops chest pressure/pain during exercise, she should stop exercise and if the pain does not go away in 5 minutes, she should call 911. If pain goes away, then she should contact her cardiologist before doing any more exercise. Judylucy: What is the difference between Hashimoto's disease and hypothyroidism? Does Synthroid® help both?

Suma_Jana,_MD: Hashimoto’s 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’s. On the other hand Hashimoto’s disease could be present but not severe enough to cause hypothyroid, in that case doesn’t need Synthroid®. jamiehambleton: I currently take Armour Thyroid 105mg daily (within the past month bumped up from 90mg) and I have gained 5 lbs in the past month. Previous to that I was on Synthroid for a year and a half 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 chloesterol from my

thyroid and am obese also. This is becoming very concerning to me that despite exercise 5 days a week and watching what I eat I continue to gain weight at a rapid rate. You need to keep your TSH within normal range, preferably close to 1.0 No need for surgery To help your weight cut down on sugars and carbohydrate containing drinks and foods. In addition to exercise you should: Suma_Jana,_MD: You need to keep your TSH within normal range, preferably close to 1.0 No need for surgery To help your weight cut down on sugars and carbohydrate containing drinks and foods. In addition to exercise you should:  Drink water avoid fruit juice, coke, pop etc, coffee/tea black is the best, if needed use sugar substitute and skimmed milk  Avoid chewing gums of mints, if needed use sugar free one  Snacks: avoid cookies and candies, can use nuts/vegetables/pop corns without caramel/fruits for snacks,  Meals: avoid too much bread/pasta/rice/potatoes/corn, in a meals eat ¼ plate salad, ¼ cooked vegetables, ¼ protein, and last ¼ carbs.

 Exercise 45 mins per day 5 days or more per week. CynthiaHartz: Even though I am taking Synthroid and a T3 - my hair continues to thin. My scalp cycles into a period of redness and soreness (to the pt where it feels as if someone is pulling on my hair). Steroid injections help this. (although I am so keen to be using steroids regularly.) I am also on bioidentical estrogen and am on the tail end of perimenopause... Also taking Adovart and progesterone. However - scalp biopsy and all blood tests indicate no autoimmune disorder. Any suggestions to reduce hair loss?

Suma_Jana,_MD: You should to see a dermatologist to exclude any scalp disease.

Optimize your thyroid hormone levels (keep in mind too little or too much both can cause hair loss). You need to check androgen levels like testosterone and DHEAS level. If they are high you may get help from using androgen blocker like spironolactone or aldactone (one type of water pill used to treat hypertension). CUSuzi: I have Hashimoto's, hypothyroidism and many thyroid nodules. I've been on levothyroxine for about 6'years. My blood work pre-medication was coming back normal, but the medication was recommended. The nodules are now so large that they are now encircling my trachea and pushing my carotid artery, but there is no decrease in the flow or in my trachea.

They 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's disease, a total thyroidectomy would be recommended. There is not 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 on the order of 1-3 %. There are six endocrine surgeons here at the Cleveland Clinic, of which I am one. We all have advanced fellowship training in endocrine surgery and our surgical practices include large volumes of thyroid and parathyroid surgery.

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 ?

Suma_Jana,_MD: If TSH is between 1 and 3.0, look fior other causes. In absence of thyroid hormone level abnormal, they are less likely from thyroid. 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. Also have other symptoms, cold hands, dry skin and sparse eyebrows. Could all this be caused by my thyroid? Suma_Jana,_MD: If your blood level of thyroid hormones are normal, you need to look for other causes. If you have untreated or under treated hypothyroidism, these symptoms could be caused by your thyroid.

nezimm: Is it normal for TSH numbers (with in a two month) period vary dramatically? Ie., 1st reading 1.19, 2nd reading 3.13, Third reading 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. 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? Suma_Jana,_MD: Thyroiditis can cause such a variation, as well as if you are taking any thyroid medicine, like if you take T3 that can influence your TSH level fasted than T4.

If your TSH was varying so much, you should get tested for TPO antibody (marker of Hashimoto’s thyroiditis), if positive

you should be followed with TSH at least once a year or any time you have sever symptoms of hypothyroid, and when you develop hypothyroid you need treatment. If your TSH is normal, 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, (I will not go into detail). Treatment with thyroid hormone is not recommended routinely if TSH is normal (less than 3.0) to just goiter. Goiter could be from thyroid nodule, in that case you need a thyroid ultra sound, and if you have a nodule more than 1 cm, you need biopsy.

tabialex: I am female, age 71 of Asian descent, thyroid enlargement noticed at age 14, subtotal thyroidectomy in 1979, goiter on both sides and positive antibodies. My current test results are TSH-1.71, T3 FREE-3.2, T4 FREE-1.2 and I am on no 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. Is this in any way related to autoimmune thyroid disease? I will be evaluated further but would like to know from a thyroid specialist if there is a connection between the this test an autoimmune thyroid disease?

Thank you for your help. Suma_Jana,_MD: Both are autoimmune disease and they can co-exist. Anyone who has one form of autoimmune disease are more prone to get another form of autoimmune disease. If you under go total thyroidectomy, yes, your thyroid antibodies will go down, but your antibodies so far is not doing any damage, so why will you taking such drastic step? I will not suggest you to undergo thyroidectomy for just antibodies. Now your thyroid is working fine based on you lab results, but once you take it out you have to take medicine for thyroid. For ANA positive, talk to a Rheumatologist.

catg64: I have thyroid nodules which I had biopsied and were benign. Is there anything to shrink the nodules short of a surgery? My TSH was .603 Suma_Jana,_MD: no medicines to shrink the nodule, in 1990s, T4 and or T3 was used to shrink the size, but 99% people got side effect from those and only 1% had shrinkage, therefore, not recommened by ATA (American Thyroid Association.) senojmd: Recently I had my thyroid removed due to 4 cm growth on left side and cancer on right side. Dr has me currently on 100mg levothyroxine for 6 weeks then I go for a re-

evaluation.

I am low on energy and feel lethargic. Is this normal or should I request a increase in med? Suma_Jana,_MD: Usually a starting dose of levothyroxine (Synthroid®) after complete removal of thyroid is 1.6 mcg/Kg body weight, i.e., for a 70Kg body weight dose will be 112mcg. If your body weight is close to 70Kg or 154 lbs, 100 mcg is close, so blood test after 6 weeks and adjusting the dose further is the standard. However, this dose is average dose, so some individual may need more, and others may need less. You may need more, and lab tests in 6 weeks will help to make that decision.

DaisyBe: I am presently taking levothyroxine 25 mcg and my TSH is 1.21. When starting meds (about 8 mos ago) through family doc it was 5.41 and doc started me on 50 mcg. Changed it to 25 mcg because TSH was then 0.75. I am still quite fatigued and having other symptoms like stomach and IBS type problems. With it being winter, some nights I can sit and watch TV in the evening with 2 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. House temp is 69 in evening when watching TV.

I was wondering if the type of medicine could have been changed but was told I could not change the medicine - only the amount (dosage.) I am wondering if this sounds like a thyroid issue or perhaps parathyroid problems coming back - - I had parathyroid surgery there at Cleveland Clinic several years ago.

Wondered if you had any thoughts. Thank You! Suma_Jana,_MD: TSH close to 1.0 is acceptable. If you can have your calcium level checked which will reflect your parathyroid status. If abnormal check PTH level. you may have vascular problem, rhematological called Raynouds which can cause decraesed blood flow to extermities.

mehring: I have been diagnosed as Hypo ( hashimotos) but most of my symptoms were that of hyper? Is that common? Suma_Jana,_MD: I am not sure what age group you fall, in elderly (and young children), there are atypical presentations. However, I will still suggest you to exclude some other causes for your symptoms.

OhioBella: I am wondering what exactly the function of the thyroid is and what are the symptoms of a thyroid that is not working? Suma_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:  Tiredness  Unexpected weight gain  Constipation  Depression  Dry skin  Difficulty performing physical exercise  Decreased mental ability to concentrate and focus OhioBella: I am 67 yrs old and scheduled for an ultra sound guided biopsy of the right thyroid. I had an ultra sound done in July and again in January 2014 and there are 3 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 negative?

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 to be biopsied. 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 do the biopsy is that they are also the one providing your comprehensive care and are the one to follow up on the biopsy results.

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, it 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 change in size - unless the nodule is big enough to cause symptoms - in which case surgery may be recommended to help alleviate the symptoms (compressive symptoms).

raymaks: Is there any possibility of one having a problem with the thyroid and is not aware in such a way that the condition can go unnoticed? Can thyroid infection clear on its own? Is goiter disease is a thyroid complication? How can one ensure that they keep their thyroid healthy? Can thyroid condition be treated nutritionally? Can one get thyroid infections by sharing a cup with an infected person or through kissing? What is the relationship between thyroid, tonsils and sinusitis? Can infection of thyroid lead to tonsillitis? Can thyroid glands be removed in case of infection?

Suma_Jana,_MD: some people feels symptoms more than others, but if you have suspicion let you doctor know and they can check your TSH level.

Thyroid infection by virus or inflammation from antibodies can clear on its own, if symtomatic needs supportive care, if develops hypothyroid needs thyroid meds.Thyroid infection doesn't happern from kissing or other things you mentioned above.To keep thyroid healthy avoid to much of iodine, kelp, soy, and goitrogens. Please note that I told too much, so normal amount in daily food is OK.Except is extreme cases, there is no need to revome thyroid for infection or inflammation.Thyroid in not related to tonsil, or sinus.

OhioBella: Are thyroid problems genetic through the family? My cousin has had thyroid problems and being watched and now I have a thyroid problem and I am having a biopsy soon. Suma_Jana,_MD: Yes, thyroid disorders run in families and are more common in women than in men. According to the American Thyroid Association (ATA), 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. patrice43015: What are the best tests for a Hashimoto's patient? My previous TSH was 19. My family doctor does not want to do any additional tests other than the TSH.

I feel horrible all of the time. Thank you.

A TSH level of 19 is abnormal by any lab standards and needs treatment. I am assuming that

you meant 1.9. The TPO antibody is a test for Hashimoto’s disease commonly used. However, if your thyroid hormones are normal even though you have TPO antibodies you will not require treatment. In our institute for first time test we always use TSH and Free T4. T4 is one of the thyroid hormones. We do so because TSH comes from Pituitary gland, if for some reason 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. “Our brain (pituitary) knows best”. Suma_Jana,_MD: A TSH level of 19 is abnormal by any lab standards and needs treatment. I am assuming that you meant 1.9. The TPO antibody is a test for Hashimoto’s disease commonly used. However, if your thyroid hormones are normal even though you have TPO antibodies you will not require treatment. In our institute for first time test we always use TSH and Free T4. T4 is one of the thyroid hormones. We do so because TSH comes from Pituitary gland, if for some reason 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. “Our brain (pituitary) knows best”. conteer: Do you have any patients with hashimotos that are also suffering from peripheral neuropathy and upper back soreness/tightness? If so what do you think is the cause and how do you treat it? Thank you.

Suma_Jana,_MD: There are few case reports. But there is no specific Rx. Still best option is to optimize your thyroid hormone levels, and get your neuropathy treated by neurology. Multifocal motor neuropathy is a specific disorder which has shown improvement with intravenous immunoglobulin therapy. This treatment is only useful in this specific disorder and given by neurologist. There are some markers to diagnose this disease like antiganglioside antibodies. Make sure that you don’t have any Vit deficiency, like B12, if recent needs to be treated. A gluten free diet can help if you have celiac disease.

BettyPietro: I was taking 50 mcg Synthroid & 17.5 mcg. My Free T3 and Free T4 is at the lower end of the range. Free T4 was 0.7 (0.7-1.8) & 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 hyper symptoms and no heart palpitations. The doctor left my Synthroid alone and lowered my Cytomel to 10 mcg. The doctor told me if I didn't like this dose that he/she would recommend another doctor. This did not make sense since my Free T4 was almost below the range. This was 6 weeks ago and I am now having hypo symptoms.

Why are so many doctors hung up on TSH levels? I know Cytomel suppresses the TSH, and therefore it is not a reliable test when taking a T3 medication. Suma_Jana,_MD: You are partly right that T3 suppresses the TSH. Once your T3 is lowered your TSH will go up then 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 the best”. TSH comes from an endocrine gland in your

brain called Pituitary. Low TSH has been shown to cause osteoporosis (you don’t feel it) and irregular heart beats called Atrial fibrillation (may come suddenly). Overall humans need less T3 than animals. Ideally, humans need 10% T3 and 90% T4. We can convert T4 to T3 easily. So, even if we want to give T3, ideally 10% 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 crashed (kind of similar effect happens few hours after energy drink).

OhioBella: I have been told that Ohio has many cases of thyroid problems.....is this true and why would this be so? Suma_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 making it difficult to determine in a patient and link a specific exposure to thyroid autoimmune disease.

Glendac: Is it possible to have normal thyroid tests and still have thyroid problems? All tests are normal but I have small nodules, feel tired, sluggish, dry skin, can't lose weight, brain fog. All the symptoms! Any suggestions? Suma_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, abnormal electrolytes (calcium/sodium,/potassium), autoimmune disease and chronic inflammatory state like rheumatoid arthritis, lupus, fibromyalgia, chronic fatigue syndrome, etc. If all are excluded and TSH is 3.5 or more, then trail of low dose thyroid hormone under the supervision of an endocrinologist can be an option for patients younger than 60 and no history of heart disease, stroke, or osteoporosis.

I have couple of patients who did feel better after trial. Again, can be done only under supervision of an endocrinologist and fulfills the above conditions.

aryanee89: I just want to know if there are any other medications of levothyroxine that can corresponds to on how control the weight changes? I've been taking authyrox 100mcg for almost 3 months and I can see that I gain so much weight even though I tried doing exercises and food diets. Suma_Jana,_MD: need to keep your TSH close to 1.0. need to take thyroid meds in empty stomach with water only. foods, coffee, and medications can interfere with your thyroid med absorption. there are other factors which contributes to weight, make sure they are exclude.

OhioBella: Should a person be on vitamins, supplements or iodized salt for helping the thyroid? Suma_Jana,_MD: There is no need for vitamins or supplements, rather avoid too much iodine like Kelp and avoid too much soy products.

Just use normal amount of iodized salt and soy, not too much. If you are deficient in any vitamin, you should take that. Supplements like selenium, zinc, glutathione, Vit D etc. can potentially help theoretically, but there is no research study to support that. Excess amount of these substances can potentially cause harm. So, none of these are routinely recommended. Three-four Brazil nuts per day can provide selenium and could be OK to take.

jrcarr: I have Hashimoto Thyroid Disease and was diagnosed in 1998. My nodules are growing very fast with multiple nodules now appearing. I am being scheduled for frequent biopsies of the nodules. The biopsies are frequent and recurring. Do I have any other options? Suma_Jana,_MD: Usually follow up US thyroid is yearly once FNA is benign. Sometime nodules in the Hashimoto’s thyroiditis may not be a real nodule. There are areas of inflammation that may appear like nodule. adrenal: I have both hypothyroidism and acute adrenal insufficiency--although I do not have Addison's. (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's.

Could you please explain to me how the treatment of these two conditions should 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 age 45. Given the considerable increase in risk associated with steroids, I would like to work with a doctor who is willing to supervise/is knowledgeable about a means of using supplements or other medications to reduce the dependence on steroids. Suma_Jana,_MD: Addison’s 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 high dose of steroid used in the past. However, treatment is low dose of short acting steroid like hydrocortisone or cortef usual dose is 10-15 mg in the morning, 5 mg at noon and 5mg around 3-4 PM. 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. Thyroid hormone dose can change after adequate replacement of cortisol. You need an endocrinologist to take of your current condition. Adrenal insufficiency needs to be confirmed first by doing ACTH stimulation test. Lowry: What other methods of disabling the thyroid are there other than removal or radioactive iodine? Two friends have just gone through these procedures for Graves Disease and afterward were told by other doctors that neither is great and radioactive iodine should be avoided. What is your opinion?

Suma_Jana,_MD: Thyroid blocking medicines like methimazole and PTU can be used to treat Grave’s disease.

Iodine I-131 (radio active iodine) is a very effective permanent treatment to kill thyroid for Grave’s disease and most commonly used in USA. This Rx is not used in children and pregnant woman. Removal of thyroid by surgery is another way to treat Grave’s 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 levothyroxine or Synthroid®.

CynthiaHartz: I have heard that TSH levels closer to 1-2 are more desirable and therefore warrant thyroid hormone low dosage when symptoms exist. What are your thoughts? Suma_Jana,_MD: Please refer to an earlier response to litvolt at the beginning of the chat. marthalm: How can I get more information about what causes low thyroid, causes and what all can be caused by it? I have taken Levothyroxine for over 5 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.

Suma_Jana,_MD: The most common cause of low thyroid is Hashimoto’s 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 TSH is fluctuating then need to optimize you levothyroxine treatment, most likely your thyroid hormones are not stable, need to see an endocrinologist. You may need to make sure that you are taking the medicine properly, i.e., empty stomach first thing in the morning only with water, not taking other medicines with it, not drinking coffee/tea with it, waiting for 45 –60 mins before eating any food or drinks like coffee/tea, and waiting for 4 hrs before taking iron/calcium/metals/antacid etc.

kostelan: My thyroid doctor has diagnosed me with hyperthyroid. With medication, she has my TSH levels and blood pressure under control. We are keeping a watch on it every 6 months.I was just in to see her and failed to ask a question. My gastro intestinal system is out of wack. I am very irregular...sometimes good and most times feel constipated. Do you feel my thyroid is doing this? Can I take a stool softener or Metamucil on a daily basis? Suma_Jana,_MD: If your TSH is optimum, most likely, this is not from your thyroid. You can take stool softener or Metamucil.

HASHIMOTO: Wondering if corticosteroids would normally have an effect on a goiter's size? Dosage for shingles was 10 mg.

for 10 days, taken with pills dwindling to the 10th day. Read something about hashimoto's encephalopathy and steroid responsive treatment. Although not related to thyroid disease, my response to this steroid treatment was amazing, and the size of my goiter was noticeably reduced for about a month, and has since gone back to where it was . I felt remarkably clear headed and like a different person after that treatment. (Not RA positive in recent blood work) Is there a correlation that the steroids would have had on my goiter, and is there a test for the Hashimoto's encephalophy, or a treatment for the thyroid goiter that would involve steroids? Thank you for this opportunity.

Suma_Jana,_MD: Hashimoto's encephalopathy is a diagnosis of exclusion when a patient has encephalopathy and Thyroditis, spinal fliud TPO- antibody is one of marker, when all other acuses has been excluded. we don't use steroid for goiter, unless some one has a very sever thyroidditis (usually subacute) causing sever pain, high body temp, and other sympotoms of sever hyprthyrodism. Please keep in mind in shortterm, steroid may make you feel better, but high dose for long time can lead to osteoporosis, glaucoma, Diabetes, HTN, weight gain, etc Suma_Jana,_MD: To help your weight cut down on sugars and carbohydrate containing drinks and foods.

In addition to exercise, you should:  Drink water avoid fruit juice, coke, pop etc, coffee/tea black is the best, if needed use sugar substitute and skimmed milk  avoid chewing gums of mints, if needed use sugar free one  Snacks: avoid cookies and candies, can use nuts/vegetables/pop corns without caramel/fruits for snacks,  Meals: avoid too much bread/pasta/rice/potatoes/corn, in a meals eat ¼ plate salad, ¼ cooked vegetables, ¼ protein, and last ¼ carbs.

 Exercise 45 mins per day 5 days or more per week You need to check TSH and make sure not higher than 3.0. If >3.0 needs further evaluation. There are approved weight loss meds like Belviq and qsymia, as well as gastric bypass surgery can help to lose weight. staciers99: I have been told that I have a an enlarged goiter, a cyst, and mass but the blood function test results came back fine. I have had many doctors in the last 3 years including an

infectious disease doctor from Cleveland Clinic tell me that they would not be surprised if my thyroid was the issue.

My question is: I have been trying to lose weight for the last 6 weeks by eating fruits and vegetables, lean meat (mainly poultry), and limited carbohydrates with no sweet drinks. I have lost 1 pound! Only 1 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? Any help would be greatly appreciated.

To help your weight cut down on sugars and carbohydrate containing drinks and foods. In addition to exercise, you should: dkmgray: Can you recommend an expert in treating thyroid disease anywhere from Williamsburg to Va. Beach, VA? Suma_Jana,_MD: I can’t tell off hand but I can send a message to our staff member if any one has any specific recommendation. You can also do a goggle search and look at their experience and affiliation, any one affiliated to a university hosp should be good. It doesn’t mean that others are not good. My thinking logic is if any one involves in teaching medical students/residents/fellows they will be up to date with current recommendation.

The American Thyroid Association (ATA) has a list of thyroid specialists that may be searched by location. You are welcome to visit http://www.thyroid.org/patient-thyroid-information/endocrinology-thyroid-do ctor/ for further informtion.

Suma_Jana,_MD: 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:  Drink water avoid fruit juice, coke, pop etc, coffee/tea black is the best, if needed use sugar substitute and skimmed milk  Avoid chewing gums of mints, if needed use sugar free one  Snacks: avoid cookies and candies, can use nuts/vegetables/pop corns without caramel/fruits for snacks,  Meals: avoid too much bread/pasta/rice/potatoes/corn, in a meals eat ¼ plate salad, ¼ cooked vegetables, ¼ protein, and last ¼ carbs.

 Exercise 45 mins per day 5 days or more per week Panda: I have hypothyroidism and I am on Synthroid, 88 mcg. 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 5 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 5'5 and 172 pounds which makes me overweight and I am very concerned. What are your recommendations? 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: eatveggies: Hello, I'm a 68 yr female, had a left hemithyroidectomy in June 2013 at Johns Hopkins for a suspicious thyroid nodule (benign). Presurgery US report: 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 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 midpole, likely corresponding to previously biopsied nodule. There is increased vascularity within this nodule. Now on Synthroid 25 mg daily. Will have follow-up labs to monitor dosage. I still have hypothyroid symptoms - fatigue, weight gain, dry skin, cold intolerance.

Do goitrogens and soy from a vegetarian diet interfere w/synthroid absorption? Might iodine/zinc supplements help? When & how best to monitor nodules in right lobe?

Suma_Jana,_MD: To monitor thyroid nodules you should get ultrasound thyroid once a year, if any new suspicious signs like increased vascular, calcification, irregular border, or significant increase in size, needs biopsy. Goitrogens can potentially interfere: but you can still eat then normally don’t do too much. Iodine will not help rather make more hypothyroid, Zinc can help theoretically but no data to support that, as this is a metal too much can potentially harm you, so we don’t regularly prescribe them, as you are already on synthroid, I don’t see any need to take Zinc. However, you need to keep your TSH around 1.0.

For first year hypothyroid rate is high with time so you should get your TSH check every 3-4 months and adjust the dose as needed. After 1st year you can get it checked once in a 6-12 months. catg64: I have two nodules which when biopsied turned out to be benign. They had increased in size fom one u/s to the other. Is there anything beside 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 way of following benign thyroid nodules. Significant growth, i.e. greater than 20% in 2 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.

Gregmoney7: I have had 2 ultrasounds on my thyroid since 2012 -2013. The interpretation is as follows:[The 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 (brain fog especially) even though my TSH stays between 1.0 - 3.0?

Rosemarie_Metzger,_MD: The right sided thyroid nodule does not meet our standard criteria for biopsy (which is 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 FAP, then you will want to follow this more closely and 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.

Rose5: Hi I was diagnosed with Hashimoto by an endocrine physician. I am on Armour 90 mg by wellness MD and the endocrine physician who diagnosed me felt I should not be on any med but was ok with low dose of Armour 30! He was worried about atrial fib if I was started on this med now! My blood work has been monitored! Does Armour cause atrial fib long run? What other recommendations do you have for this diagnosis? Suma_Jana,_MD: Atrial Fib is from too much of thyroid hormone (T4, T3) leading to low TSH. So if your TSH is not low risk of Atrial fib is not high. Compared to T4, T3 has a high potency to suppress TSH.

In armour thyroid there is 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 thermo genesis (body heat production), because they don’t put on any cloths, they need to preserve body heat by more heat production.

FLOR1: My thyroid was lowered to 88mcg 6 months ago from 100. I was told this was based on TSH results. I am 76 years old and have been taking thyroid since I was 10. With the lower dose I seem to have all the symptoms of bring hypothyroid including lack of energy, nails and hair problems,

very slight depression, etc. but otherwise in 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? Suma_Jana,_MD: Thyroid hormone effect on heart is on the rhythm and oxygen consumption.

So, even if you have very good HDL (which will protect you from heart attack), but cannot protect you from irregular heartbeats we call Atrial fibrillation (A Fib). As well as low TSH can cause osteoporosis. So, I will not suggest keeping your TSH below the lower limit of normal. I will also suggest you to make sure that you don’t have any other cause of your symptoms which is masked by high dose of thyroid meds, like anemia, vitamin deficiency, electrolyte problem, sub clinical depression, rheumatoid arthritis, fibromyalgia, etc.

After that, to improve you symptoms you may talk your doctor to a dose between 100 and 88, and still keep your TSH within normal range. I.e., you can take 1.5 pills on Sunday and 1 pill of 88 all other day and see how your TSH responds. jamiehambleton: is there a difference in generic vs. brand name armour thyroid? Suma_Jana,_MD: very small difference, in generic you may get thyroid medicine from different maufacturer, leading to slightly differnet level of thyroid hormone in the blood. so taking generic medicine can make your blood level of thyroid hormones vary from time to time. 95% of the pts can adjust to that on their own and do not need anything.

5% may need brand name. also you can request your pharmacisit to give you same manufcaturer all the time, and each time refill for 90 days, dkmgray: I seem to require a lot of sleep--too much, according to my mom. I can sleep all day and night, getting up to go to the bathroom and eat or drink to take meds. Haven't done it multiple days, though. Thyroid removed in 1967 at age 14. I have had sleep studies done and use a CPAP.

Other subsequent diagnoses: diabetes type 2, fibromyalgia, aortic stenosis, back & leg pain for which I take Conzip; mild depression for which I take one Effexor. I have blood work done every 3 mos, which is okay. 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? Just curious if you have a suggestion or opinion? Not sure where to turn for help. Suma_Jana,_MD: If you are on thyroid medicine and your TSH is OK, then you are not low thyroid any more, and probably your symptoms are 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 DM-2 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

You can also read