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TREATING HYPERTHYROIDISM 12/1/2007
TREATMENT OF HYPERTHYROIDISM QUESTION-I would like to ask a question for the thryoid disease manager web site. = =0A=0AI am 58 and have Graves disease being controlled by carmbimazole 10mg= daily. I am feeling very well and able to live a full and active life. La= st test results l.4 TSH : 11 T4: 4.4 T3. I have tried coming off twice b= ut symptoms return and will continually try to reduce or come of this drug = if blood test results allow.=0A=0AIf this is not possible what are the lo= ng term consequences of staying on cambimizole compared to the multitude of= cases I have heard of and read about that have had disastrous results for = RAI treatment and the resulting hypothyroidism.=0A=0AI understand the risk = of a sore throat and the need to have a immediate test but would like to kn= ow what other risks are involved in long term use of this drug.=0A=0ADoes d= iet and stress reduction play any part if reducing symptoms?=0A=0AMany tha= nks=0A=0AJane Sinclair=0A=0A_______________________________________________= RESPONSE-It is possible to stay on Carbimazole for a long, long time. The one problem is that often you are not actually sure what your thyroid function is and if you feel unwell for another cause there is a tendency to ascribe it to the thyroid and the drugs may be increased or decreased. Therefore you still have the tendency to develop an overactivity. This is not the case if you have radioiodine although you are absolutely right that you may develop hypothyroidism, but that is easily managed by replacement thyroxine therapy. Most clinicians would recommend a specific therapy if you relapse after antithyroid drugs. It is possible that the disease may "burn out" but this is relatively unlikely. I hope these comments are of some help.Yours sincerely,PROFESSOR JH LAZARUS
POSSIBLE HASHIMOTO’S THYROIDITIS QUESTION-On September 13, 2007 I had a right thyroid lobe, partial thyroidectomy. = =20 I have been symptomatic for five years since the birth of my daughter in = May of 2002. I have been sensitive to the heat and the cold, I have = night sweats, I'm constipated, insomnia, heart palpitations, ice cold = hands and feet, dry skin, my memory and concentration is terrible, I = have vertigo and dizzy spells, my reflexes are exaggerated, my eyes get = very dry, I'm terribly moody and tense, I'm depressed, my heart races, I = have terrible headaches, I'm very tired but on edge, the muscles in my = back (mainly my shoulder blade area and now the muscles in my chest) = burn and ache, sometimes I have a low grade fever, and my face gets hot = frequently; my skin is also hot to the touch throughout my body (only to = me). Prior to the surgery, my voice was so hoarse that many people = couldn't understand me. I would get frequent sore throats and my neck = would be very tender.
I visited four Endocrinologists and each would tell me upon examination = that I definitely had thyroid disease, but when my blood work would come = back within the normal range, they would send me away. Most of the = doctors would just give me some more medicine to deal with the symptoms. = I am currently taking 800mg of Ibuprofen three times a day for the = achiness and headaches, Xanax 0.5mg four times a day for the nervousness = (which by now is not helping me because I have become immune to them), = Inderal 120mg three times a day, Topamax 25mg one time a day (somewhere = along the line a doctor put me on this for headaches but it doesn't help = but I'm still on it). And I also take Fish Oil 1000mg six times a day = for my muscle aches and the constipation. =20
By the time I visited the fourth Endo, he ran a test called a SED Rate = on me along with many thyroid labs and it came back 32. It is now up to = 54. All other labs were normal. My C-Reactive Protein was also = elevated. =20 I was so persistent that the thyroid was the cause of my problem, I had = a friend of mine (who is an ultrasound technician) scan my thyroid. She = came upon a nodule. I had an "official" scan done and then a thyroid = uptake scan (29%) and the scan showed the nodule to be cold. =20
I visited one surgeon who would not do the surgery because I was = possible "hyperthyroid". My TSH was always normal but always ran = between 0.6-0.8. He explained that removing part of my thyroid would = just intensify the symptoms. =20
The next surgeon I visited agreed to take it out. I wanted it out = because of the possibility of cancer. My Aunt died of thyroid cancer. = My mom also is hypothyroid and my paternal grandmother is hyperthyroid = (but nobody would listen to the family history either). Anyway, I had = the surgery and the pathology report came back noncancerous Follicular = Adenoma and the surrounding thyroid gland demonstrated chronic = lymphocytic thyroiditis. =20 My labs before the surgery were: TSH 0.98 (0.46 - 4.68) = T3 Uptake 27.20 % (23.50 - 40.5) 08/29/07 T4 11.2 = (5.53 - 11.0) FTI 3.04 (1.65 - 3.89)
My labs after the surgery were: TSH 1.91 (0.46 - 4.68) = T4 9.1 (5.53 - 11.0) 09/27/07 SED Rate 54 = Thyroid Peroxidase < 10 (0-34) ANA = Negative Antithyroglobulin Ab < 20 (0-40)
Okay, so after this long story, here is my question. I'm going to see = an Endo in Columbus Ohio at the Ohio State University. Her name is Dr. = Elizabeth Diakoff. I'm confused as to how I can have Hashimoto's = Disease with no antibodies present in my body? Also, my primary care = doctor has not started me on any thyroid medication because he said my = thyroid is working just fine and he is not going to give me anything = until it isn't. The surgeon explained that I needed to be on thyroid = medicine so that the left side of my thyroid did not work too hard and = become enlarged. I'm confused as to why this was not started as soon as = I was out of surgery.
I am not feeling better at all. My neck is still swelling and I am = still getting the tender throat and the sore throat, so I know the = thyroiditis is still there. Plus the SED Rate being elevated tells me = that as well. I still feel exactly the same as I did before the = surgery. Actually, I didn't expect to feel any different. But to know = that I'm not nuts and to actually have a "diagnosis" is very comforting. = It was just a shame that it took cutting open my throat to get that = diagnosis. I wish more doctors would "listen" to how we feel and not go = by the numbers.
I'm not real familiar with this disease. My Primary Care Doctor is = treating it like it is Viral Thyroiditis because of no antibodies in my = blood. But I've read that you can still have Hashimoto's with no = antibodies. I'm just going by what the pathology report said. And when = I research lymphocytic thyroiditis, it takes me to Hashimoto's. My = tonsils are very large and trap a bit of bacteria. I do get sore = throats frequently. My dr. believes that I am getting Strep which is = traveling down to my thyroid which is causing the thyroiditis. He put = me on a month supply of antibiotic, but this has not helped.
Any suggestions? What should I ask when I go to my appointment? Should = I demand to be put on some medicine even though my labs are normal? = What will be my options? Should I just have the other side removed?? =20 I'm so tired of feeling sick. It's been five very long years. Thank you so so much for taking the time. Sincerely,Dani
RESPONSE-Although you have a family history of thyroid disease your
antibodies as you say are negative. However patients with Hashimoto's
disease have been described with negative circulating thyroid antibodies.
Although you had a follicular adenoma the surrounding thyroid gland did
demonstrate chronic lymphocytic thyroiditis, i.e. Hashimoto's disease and I
think it is safe to say that you have that condition. I would agree that if
your thyroid is OK (and your TSH and T4 are normal), then you do not
necessarily need thyroxine at this point.
THYROID ANTIBODIES AND THE RISK OF
MISCARRIAGE 2 Apr 2007
PREGNANCY AFTER RAI TREATMENT 24 MARCH 2007 TESTS
DURING PREGNANCY
14.02.07 RESPONSE-Some obstetric services only do a booking scan at 12 weeks. Others do a 12 and 20 week scan. I am afraid I do not know any evidence as to which strategy is more effective. If your daughter is on thyroxine, and has increase the dose when she become pregnant, and is being monitored from the thyroid point of view, it is probably not necessary to do a 20 week scan. However, if there is any doubt about the progression of the pregnancy then such a scan should be done. As far as I am aware a 20 week scan is not specifically indicated in this situation. PROFESSOR JH LAZARUS
TREATMENT OF SUB-CLINICAL HYPOTHYROIDISM 08.02.07 QUESTION-I am a 25 yr old Dentist,a case of Sub clinical Hypothyoidism.In Dec 2006 during treatment for a chronic cough my physician advised me to get a routine Thyroid function test done.(I have a family history of Hypothyroidism,both maternal and paternal).T3,T4 were normal,TSH 6.9.I was then referred to an Endocrinologist who got my weight checked.I had gained 7 kgs in the past months from 50 to 57.Anti-TPO was negative.The Doctor started me on 100 mcg of Thyroxine sodium on 29 dec 2006.Following medications,i experienced palpitations,breathlessness,severe irritability and joint pains that persisted for the next 1 week.After 1 month, i had gained another 3 kgs and now weighed 60kgs inspite of cautious dieting and regular exercises.The dose was raised to 150 mcg.My medico friend who knew my medical status discussed it with his Endocrinology professor who felt the dose was too high for my case.He advised to completely stop the medications immediately and start afresh in April with fresh tests.IAM CONFUSED NOW!!! The following are the doubts in my mind which i would be grateful if u can clarify 1.Should i stop the medications immediately ? 2.Are my symptoms due to overtreatment? 3. Why am i continuing to gain weight inspite of treatment? 4.Is subclinical Hypothyroidism mandatory to be treated? 5.Is this condition likely to cause any future problems,as in conception and delivery? 6.Is Hypothroidism related to Lichen planus?(I have lichen planus of the skin) Dr. Nair RESPONSE-In answer to your questions relating to your question of subclinical hypothyroidism: 1. Yes I would stop the medications immediately and re-test everything in six weeks time. The guidelines state that subclinical hypothyroidism should not be treated until the TSH rises above 10. However it is reasonable to individualise in some cases. 2. It is difficult to be categoric as to whether your symptoms are due to over-treatment, but certainly some of them sound like this. 3. This is difficult to answer. Although the weight increase is a worry, I would rather look at the thyroid function tests in the future and if you do need treatment then the weight will be easier to lose if you are on adequate thyroxine replacement therapy. 4. I have already answered this in my response to question 1. You say the anti-TPO antibodies are negative but you have a positive family history. If they continue to be negative I would check the antithyroglobulin antibody levels (these are not normally done in the laboratory, but can be done if specially requested). It may be worthwhile having an ultrasound of your thyroid as well to see whether there is any evidence of autoimmune thyroiditis. 5. I presume from your question that you are a female. If there is mild hypothyroidism then fertility may be impaired and the risk of miscarriage is increased. If you did become pregnant, then thyroxine treatment would be indicated if your TSH level is high, and it would certainly be worth screening in early pregnancy. If you are already on thyroxine and become pregnant, there is a requirement for an increased dose during pregnancy and this should be implemented as soon as possible. 6. There are one or two isolated case reports of patients with different forms of lichen planus who have got thyroid disease, but there is really no evidence that the two are connected. Yours sincerely, PROFESSOR JH LAZARUS
THIRTEEN YEAR OLD WITH THYROID NODULES AND LOW TSH 07.02.07 QUESTION-I have a 13 year old daughter who displayed a large lump on her neck after Thanksgiving. An ultrasound showed at least 7 nodules on both sides of her thyroid. The largest one (3cm), we believe resulted from the cyst bleeding into itself. We have completed three blood panels to confirm a suppressed TSH. A biopsy on 3 nodules was done: two were benign, but 1 (the largest) was "inclusive but could not rule out a low grade tumor". The first pediatric endocrinologist and the surgeon recommended removing the entire thyroid. We felt this was too drastic for an "inclusive biopsy." My thyroid doctor met with the pathologist and said the samples were too poor to send out for a second opinion. In addition, as a result of that meeting, the pathologist revised his original report to read epithelial cells, instead of "neoplasia". With surgery looming over our heads, we wanted more proof that Surgery was the only option. Last week my daughter had a radioactive scan (no uptake was done). The large nodule was "HOT." Our understanding of this meant that the risk of cancer was greatly reduced. The NEW pediatric endocrinologist still recommends surgery due to her suppressed TSH, claiming that eventually she will become hyperthyroid, and risk bone loss. He also mentioned that she would probably not need medication. Thyroid issues run in our family. When my mother was approaching 50, she had multiple nodules and had 1/2 her thyroid removed. When I was 38, I also had multiple nodules and had 1/2 my thyroid removed. I am currently taking levoxyl. At the advise of two doctors, we are having my 11 year old daughter checked with an ultrasound, as she has an enlarged thyroid. With this information, would you also recommend surgery, or would you recommend another course of treatment? Do you have any resources I could contact, or research regarding suppressed TSH, or prognosis without surgery, in teens? My husband does not believe surgery is necessary and wants to take a wait and see approach. I am afraid this is only postponing the inevitable, risking bone loss during critical growing years. Thank you for your opinion. A concerned mother. Dear Mrs Fisher, RESPONSE-I understand your concern for your daughter who has been found to have multiple nodules in association with a positive family history. Although the nodules are "hot" on scan this does not entirely exclude a cancer. In my opinion thyroxine treatment is unlikely to succeed in reducing the size of all these nodules significantly. There is no other recognised tablet treatment for these nodules, therefore I would suggest that surgery is entirely appropriate. It is a safe operation and it means that there can be a complete examination of the tissue that is removed to reassure you that there almost certainly is no cancer present. If your daughter has to take thyroxine substitution therapy after surgery, this is not a major problem.Yours sincerely, PROFESSOR JH LAZARUS
MILDLY ELEVATED TSH 07.02.07 QUESTION-I hope you can answer a question for me. I have an 11 yr old son who is overweight yet very active in 3-4 sports. His dr. ran a bunch of blood work on a fast to check for diabetes which he doesn't have however, I have been concerned with an underactive thyriod for a while since he has put on weight. He is 5'2" tall and weighs 145lbs. He plays soccer, basketball and baseball (year round). He has started other sports as well. He gets a lot of exercise but is always tired and gets winded easily. His TSH is 4.4 which tells me his thyroid might be slightly underactive. Do you have any other ideas or suggestions. He does also have beta-Thalassemia minor (trait) which might add to him being tired. Thanks. Sue Creighton RESPONSE-Your son's TSH is certainly in the high normal range and I would suggest a repeat of this and a check on his thyroid antibodies (particularly thyroid peroxidase or TPO antibody). If this is positive and his TSH is still in this range I think a trial of thyroxine would be indicated. I think his beta-thalassemia minor trait would only affect him if he was anaemic. PROFESSOR JH LAZARUS
TREATMENT OF HYPOTHYROIDISM- 29.01.07 QUESTION-I'm 25 years old female, and in May 2003 I have been diagnosed with Hashimoto's after having a severe clinical depression and a suicide trial. My doctor started me on Synthroid at a dose of 50mcg. In the past 3 years it put on 200mcg of Synthroid daily with 10mcg of T3( a combination preparation of T4 and T3 ) and I am on an appropriate dose of thyroid based on the blood tests. I asked him about this combination, and he said that in my case it was perfect by the tests, and I'm better now. But I'm worried about the consequences that all this medical treatment will bring me 'cause I'm only 25, and I'm taking it for the rest of my life. What will happened ? What about Vitiligo, Rheumatoid Arthritis, Addison's Disease and Diabetese ? Please help me if at all possible. Jenniffer Mary RESPONSE-The normal treatment for Hashimoto's thyroiditis is thyroxine. There is no evidence that adding T3 provides any significant benefit. However if you are on it and your levels of T3 are normal this is satisfactory. There is no significant long term effect of thyroid hormone if the levels are checked routinely, and maintained in the normal or near normal range. This is because you are merely taking replacement therapy which is what you would have if you didn't have thyroid disease. The other conditions you mention are certainly associated with Hashimoto's thyroiditis and if you become ill at all your doctor should know that you have Hashimoto's so that appropriate tests for these other conditions may be instituted if necessary. PROFESSOR JH LAZARUS TREATMENT OF HYPOTHYROIDISM QUESTION-My elder sister aged 42 yrs old had gone for her blood test and following was the result thyrotropin sensitive TSH >100.00 HI 0. 35--- 5.00 MIU/L FREE THYROXINE (FREE T4) 4 LO (9- 23)PMOL/L FREE T4is reflexively added when TSH> 10.0 MIU/L The doctor has adviced my sister to take the following medicine and asked to get a scan done next Week.ELTROXIN 0.05MG.LEVOTHYROXINE 0.05MG 1 tablet each for this week and 2 tablets for the next week after which another bood test is required! After going through the reports can u suggest your opinion about this case and I would also like to know that if she will have to undergo a surgery or can this be cured with medicines? Thanking you in advance and waiting for ur response so that all the doubts are cleared out soon! An Anxious sister , Jessica, RESPONSE-Your sister clearly has gross and significant hypothyroidism (under activity). If she is otherwise fit, I would suggest she needs to take to start off 0.1 mgs of thyroxine (I don't think she needs one tablet of each sort, the one brand is satisfactory). One needs about four to six weeks to equilibrate the dose so I wouldn't get a blood test two weeks after starting, I would get it one month to six weeks after starting and be prepared to increase it after that. It can take many months for her to feel well again. PROFESSOR JH LAZARUS ____________________________________________________________________
TREATMENT OF A CYSTIC NODULE 21.01.07 QUESTION-Firstly, I must state that I am not a medical professional. I have just found your website and would like to congratulate you and your team for doing such a brilliant job in giving your time to helping others! I hope you realise that your few words of advice means the world to all those people. God bless you.
Secondly,
may I join in the queue and ask for your professional advice, please? I
have recently been found to have a large, well defined benign thyroid cystic
nodule, measuring 3cm in the lower half of the right hemi-thyroid (biopsy
done). Two further small nodules of 6mm and 10mm are found in the lower
half of the left hemi-thyroid during the scan. There is no cervical
lymphadenopathy seen. My blood test result reads: Thyroid Peroxidase Abs
3.8 u/ml and Anti-thyroglobulin 25.7 u/ml. (I do not understand much about
these technical terms. Are they related to T3 / T4 ?) Other biochemistry
results appear normal. My questions are: (1) Is it true that I cannot opt to have the cyst drained? Would draining the liquid out through needle aspiration help, if not completely but partially reduced the size (I understood from the radiologist that 50% of my cyst appeared to be 'liquid'!)? Are there any risks in this procedure? (2) What are the chances of the cysts growing bigger? (3) Do statistics show a high risk of these cysts turning cancerous over time?
(4) Do you
reckon there is any need for me to go on medication? (I honestly hope not,
as I already feel like a 'walking chemist' taking medicine for angina!) Best regards, Swan RESPONSE-You have a cyst in the right lower half of your thyroid and two small nodules in the left thyroid. Your thyroid antibodies are negative. They relate to the chance of getting autoimmune thyroid disease and so this is not a problem with you. They are not related to T3 or T4. If your other biochemistry results are normal, then you have a normal thyroid status.In answer to your question: (1) Yes you can indeed have the cyst drained by a relatively simple procedure of fine needle aspiration. It doesn't always work, but can reduce the size. There are no significant risks in this procedure. (2) The cyst could grow bigger, sometimes there can be a bleed into the cyst which could cause pain and increase the size. On other occasions it can just grow. (3) The statistics do not show a higher risk of these cysts turning cancerous. A recognised procedure is to try and drain it and if it occurs more than once, then operation should be considered. (4) I do not think there is any need for you to go on medication. Actually the book Thyroid Manager is not in book form it is only available on the web at WWW.thyroidmanager.org. Yours sincerely,,PROFESSOR JH LAZARUS
TREATMENT OF HYPOTHYROIDISM QUESTION -I am a 50 year young women with thyroid disease. I have had under active thyroid for 20+ years. My problem is they cannot get it regulated. My TSH numbers are between 31 and go as high as 101. The only thing they do is up me medicine change the brand and so on and so on. Mean while I feel awful and have severe heart palpitations. Where and what should I do next?Thanks,Ann in Delaware RESPONSE-Certainly your TSH should not be as high as this if you are on thyroxine replacement therapy. I suggest you should have an independent heart check and possibly also take beta blockers to counteract the palpitations. Your thyroxine dose should be such that the TSH is around 1 or 2. PROFESSOR JH LAZARUS
ALCOHOL USE WHILE ON THYROXINE 17.01.07 QUESTION -My daughter Jody age 30 underwent removal of her thyroid due to cancer two years ago. We have noticed she has an intolerance to drinking alcohol drinks. By removing the thyroid - does this change her metabolism rate? Thank You. Joyce Caywood RESPONSE-When the thyroid is removed the metabolism would slow down significantly unless the patient was taking replacement levothyroxine therapy. Assuming that she does take thryoxine therapy her metabolism would not be slowed. It is true that in a hypothyroid (under active) state, the metabolism of alcohol can be altered. PROFESSOR JH LAZARUS
MANAGEMENT OF HASHIMOTO’S THYROIDITIS QUESTION- I need some advice. I am a 45 year old female, normal weight and was recently diagnosed with Hashimoto's thyroiditis--the labs I remember are TSH 2.17 and thyroid antibodies 481. I also have vitiligo. I saw an internist/dermatologist who diagnosed the thyroiditis. He started me on synthroid 0.05mg two months ago and have not had repeat levels done yet. I have no hypothyroid symptoms. My GP sent me for an US last week and the results are: rt lobe measures 4.5 x 2.0 .1.4cm in sagittal AP and transverse diameters respectively. A focal area of calcification measuring approx 6m in diameter in the lower midpole of the right lobe. The isthmus is 2mm in thickness. The left lobe measures 4.8 x 1.l x 2.9 cm. In the upper pole, there is an 8 mm focal soft tissue nodule. Both lobes demonstrate increased vascularity in keeping with the patient's history of Hashimoto's. On the right side of the neck there is a normal appearing 2.3 x .4 x 1.1 cm lymph node. Impression: Coarse area of calcification in the lower midpole of the right lobe. This is likely benign in nature. The 8 mm hypoechoic nodule in the left lobe likely represents a thyroid adenoma. This could be followed up with a repeat study in three to six months to ensure stability. QUESTIONS: Should I be followed by an endo? Should I be worried about the nodule/calification? Is the follow-up US in 3 mos a reasonable approach? Susan Jacks RESPONSE-You have Hashimoto's but normal thyroid function, and there is currently no specific reason why you need to take thyroxine. The ultrasound appearances are consistent with Hashimoto's disease. I think you should be followed by an endocrinologist and I agree that three months is a reasonable time for you to be seen. At that time a blood test should be taken to see whether your thyroid function is stable. Palpation of the neck should occur, and if there is considered to be any enlargement of the nodule then this should be subjected to fine needle biopsy. Yours sincerely, Professor JH Lazarus TREATMENT OF THYROID NODULES- 04/01/2007 I have thyroid solid nodules (upper, lower, right & left lobes). I sweat, have heart palps, always depressed, fatigue and dizzy and tired. I went to the doc had biop was B. Also stated hot. Doc put me on synthyroid 150 mcg that cuased me to have severe palps to the point I was jerking and affected my breathing. I though I was going to die. Stop med went to doc he wanted to do surg. I left never went back. I’m 25, and want your advice. I went to my Ob which did order lab and the test are always normal and not overactive like it showed at first. I have a knot that sticks out on the lower right side that really bothers me. If you have any opinion at all please get back. Tiffany Lee RESPONSE-Sometimes these nodules may cause a condition known as subclinical hyperthyroidism, which may make you develop palpitations. Thyroxine therapy is unlikey to be effective in this situation. However, you say your tests are always entirely normal and not suggestive of overactivity. If the nodules are bothering you then surgery is definitely an option. If you develop an overactivity, radioiodine treatment is also a reasonable option. PROFESSOR JH LAZARUS
>>> "Barbara Link" <1952bandb@cox.net> 03/01/2007 03:40 >>> I have Hashimoto Thyroiditis and have not been able to conceive a child, I currently take Synthroid, however what else if any can I take that will help me to conceive.Thank you.onya Rodgers Dear Ms Rodgers,If you are on an adequate dose of Synthroid this is all that you can do to ensure fertility as far as the thyroid is concerned. If you do become pregnant you should increase the dose of Synthroid immediately by about 50 mcgs.Yours sincerely,PROFESSOR JH LAZARUS
Professor Lazarus,I hope you can help. I am a 27yr old female currently undergoing IVF treatment ( I have PCOS) I have had tests done on my thyroid following 2 miscarriages earlier this year.My 1st test came back at TSH <0.02..2nd test came back at TSH 5.84.3rd test came back at TSH 2.87.There was about 12 weeks from the date of 1st to the date of the 3rd test.On my 3rd test I had my thyroid antibodies tested also and they came back at 670.I am on no medication at all for my thyroid problems and never have been. My Dr has only suggested I get it checked at least every 3 months. I am concerned however that this is what has caused my miscarriages as all other tests came back ok. In your opinion, to achieve & maintain a healthy pregnancy, should I be on any medication? Many thanks for your time! Nikki Burkhill Dear Ms Burkhill, You do seem to have positive thyroid antibodies and these are actually associated with miscarriage. There is a relatively recent paper which suggests that in your situation it would be reasonable to take thyroxine. This would reduce the chance of having a miscarriage. In the paper, patients like yourself were treated with thyroxine 0.1 milligrams (100 micrograms) a day. I am not sure why your TSH levels were so variable. It may well be that you could have the so called TSH receptor stimulating antibodies (the sort that cause an overactive thyroid). The antibodies you have had tested are probably those that are associated with an underactive thyroid.PROFESSOR JH LAZARUS
Dear Dr.
Lazarus, I have been
diagnosed with Hashimoto's after having a severe
allergic reaction to a sulfa drug, Batrim. I have elevated
tpo and ana tests. I have had a
burning sensation in my thyroid which i annot get to
stop and wondered what i could do. I am on an
appropriate dose of armout thyroid based on the blood
tests. I would very
much appreciate any help on this as I am concerned the
burning is indicative of more of the thyroid being
destroyed and want to stop it if I can.thank you
very much,Susan
L Gold <susanlgold@yahoo.com>
19/12/2006 07:15
______________________________________________________________________________________-
<Wbydddg@aol.com>
19/12/2006 03:59:35 >>>Dx with
Graves in 09/05. RAI 10/05. TSH is still undetectable with normal FT4 levels -
12/06. Is this sub-clinical hyperthyroidism? I was told that it is normal
for TSH to stay suppressed after RAI for a period of months but am concerned
about suppression after 12 months. Glenda B.
<EFCathome@aol.com> 12/12/2006 03:36 >>>Could you please advise if ear pressure is to be expected after a total thyroidectomy? I had Papillary cancer and removal of my thyroid and 24 lymph nodes about five months ago. It has been 6 weeks since I had the RAI treatment. Thank you. As far as I know there is no relationship between total thyroidectomy and a feeling of pressure sensation in the ear. However, if this continues you should arrange an Ear, Nose and Throat consultation.PROFESSOR JH LAZARUS ____________________________________________________________________________________________ Rita Johnson <rajmct01@yahoo.com> 08/12/2006 19:58 >>>I am a 54-year old female with a family history of Diabetes. I was diagnosed with Type II Diabetes in 2000, which is under excellent control. I follow a low-carb diet. I was also diagnosed with Graves Disease 6 years ago and followed a course of treatment with Tapizole. When I was no longer able to remain euthothyroid, I received low dose radiation treatment 3 years ago. Over the past year my weight has risen. Two years ago I was 145lbs and now am 176lbs. My blood work shows a range of 5.0, which is in the normal range. I don't remember is this is the TSH or the T3/T4 reading. My doctor just started me on Synthroid at a dose of 50mcg on Monday. I have taken it for 5 days. This morning I noticed a wired feeling, which reminds me of symptoms I had on Tapizole. Is this normal? Will it ease out over a few weeks? Should I be on Synthyroid if my blood work shows a normal range? I did experience mild heart palpitations only once the evening of the second treatment day. I have read it is best to start at a low dose like 25mcg. Is my dose too high? Rita Johnson Dear Ms Johnson, I presume that your doctor decided that the radiation treatment (which I presume was radioiodine) has eventually caused the thryoid to fail and you need to be on replacement thyroxine. If however your blood tests show normal results then normally there is no reason to give you the thyroxine. When starting thyroxine (Synthroid) most people can indeed start on 50 mcgs a day. If you have heart disease or symptoms of heart disease then it is usual to start on 25 mcgs. 50 mcgs is not a high dose, but blood levels of thyroid hormone should be checked after six weeks.PROFESSOR JH LAZARUS
I read your
column and wondered if I should be worried about a low T3 uptake blood
result. My T4 and TSH were
normal--actually right in the middle of recommended results, but my T3 was
only 22%. What does
this mean? I am a fairly
healthy 44-year-old woman of normal weight. Look forward
to hearing back from you, Laurel
Adelman
<Sandieduffy@aol.com>
06/12/2006 18:41:02 >>>I am a 31
year old mother of two healthy boys. In Nov 2002 I was diagnosed as having an
underactive thyriod, obviously I started on a low dose but now am on 200mcg
daily. I have just recently suffered a miscarriage and I'm hoping it was
nothing to do with the thyroid, but obviously the thought is there. I understand
that this could be just a chromosone problem, but it is still in the fore
front of my mind as I would like another child and my TSH levels were fine
when I had my boys. I have been told that 200mcg is the most that I can take, is
this true? Please help as I dont want to have to go through this again. Sandie
>>> <Heartofgold002@aol.com> 05/12/2006 16:47:44 >>> I am currently taking 100MG of Levothroxine due to the fact that I had a thyroidectomy in August of 2000. Here in the past two months I have gain 26lbs and my eating habits are no different than before. Is there any kind of medicine that I can take to help me lose weight? I am currently walking for and hour in the morning and an hour in the evening but this doesn't seem to be helping me control my weight. I am not used to being the size in which I am at and it's killing me to weigh this much. Please help me if at all possible.Debbie Dear Debbie, I understand you had a thyroidectomy and you are now on 100 micrograms (not milligrams) of levothyroxine and you are concerned about significant weight gain. It would help if we knew what your thyroid function was while taking the 100 mcgs of thryoxine. There may be room in the results of the thyroid function tests for you to increase the thyroxine and this is the first thing I would go for if this is possible. In this regard the serum thyroxine level could be above the normal reference range quite satisfactorily and safely in somebody taking thyroxine. As long as the serum T3 is within the normal reference range you are entitled to an increase in T4 dosage.PROFESSOR JH LAZARUS
"Kate Walker" <kwalker@dgatpa.com> 04/12/2006 19:12:37 >>> I was diagnosed with Grave's Disease in 2001. At the time the only symptoms I had were shaky hands and fatigue. I took Tapazole for a short period of time. The shaky hands stopped and instead of fatigue, I had sleeplessness. All this time my T3, T4 and TSH levels were elevated but I felt fine. I stopped the Tapazole and for 3 years never had another external symptom although the blood tests were still high. Recently, I started having the shaky hands and heart racing. I went on PTU. The shakiness is gone, my heart is fine but I have a terrible time controlling my body temperature. Approximately every 10 days, I get severe chills (it is cold where I work) and once I am chilled to the bone I can't get warm or stop shivering. Not long after this I will get a fever with the chills and I have to leave and go lay down. It takes a couple hours and then I feel fine. I thought it was a storm but several people on-line said I am having a reaction to the PTU. I asked my doctor about switching to methimazole but she believes it is a storm and not the PTU. In order to experiment, I went off the PTU for a week, I took one pill and had an episode. I stayed off for 10 more days and tried again and had another episode. I abstained for 10 more days, took a pill this morning and I am not doing well right now. Do you think it could be the PTU or a thyroid storm? I live in a small town and there are only 2 endocrinologists in the neighborhood. The one I went to just moved to the city and the one left doesn't have an appt till March. Kate Walker walker111@comcast.net Dear Ms Walker, Overall I think the reactions you are describing may well be due to the PTU. PTU can produce an immune reaction. You should have your anti-nuclear cytoplasmic antibody (ANCA) measured. I doubt whether this is a thyroid storm. I do not think you should be untreated if your thyroid hormone levels are high. However you indicated that at one time your T3, T4 AND TSH LEVELS were elevated. If this is the case it is quite possible that you never had thyrotoxicosis. You should carefully check these levels again, because the TSH level should be low or suppressed in somebody with hyperthyroidism associated with a high T4 and T3. If this is not the case the diagnosis is not secure.PROFESSOR JH LAZARUS
>>> <tom51@tiscali.co.uk> 03/12/2006 13:58:32 >>>I am writing to you in the hope that you can point me in the right direction with my thyroid. July 05 I was diagnosed with an over active thyroid - My treatment was firstly on MRI scan (for peturity gland) then raido iodine for a growing thyroid.Consequently I was put on 75 mcg of thyroxine for an under active thyroid and told by my doctors that the levels are right and I am on the correct dose. This is where I part ways with my doctor, I am sure he is doing everything within the recognised box but I know my body and it still feels like it did before I underwent any treatment. My symtons are Nearly two stone weight gain.Swollen feet Palpitations Swollen all over feeling and this is hard to explain but a flu like feeling all over my body. My Doctor says I am on the correct dose of thyroxine so where do I go from here.? Any advice or comments would be very much appreciated.Mrs Lesley Smith (Age 53)
Dear Mrs
Smith, I understand
you have had radioiodine for hyperthyroidism and this caused under activity
of the thyroid and you are now on thyroxine replacement therapy. The
question is how much therapy you should be on and what are the exact levels
of thyroid hormone, while you are on 75 mcgs of thyroxine. My own
recommendation is that the TSH level can be low or even suppressed in some
patients on thyroxine. The T4 level can be above the upper limit of the
quoted normal reference range, but the T3 level should be within the normal
range. There is an issue with suppressed TSH in that theoretically there
may be a risk of cardiac irregularities and it may affect the rate of bone
loss (and this is especially important in a post menopausal woman).
However, I would imagine that increasing your dose to 100 mcgs a day would
probably not be a major problem, but I cannot firmly recommend this as I do
not have sight of the blood levels.
>>> "The Metauro's" <wollastonlakers@sympatico.ca> 28/11/2006 21:09 >>>Hello Doctor looking for your opinion on the following results from my thyroid scan.(the following is the report as given to me) "Describing a complex left thyroid nodule and a small solid nodule centrally in the submental region.The thyroid scan demonstrates patchy uptake bilaterally. There is inhomogeneous uptake on the right lobe , with a large area of decreased activity laterally. There is a well defined focal area of no activity in the lower pole on the left, which is likely due to the underlying nodule In addition, there is decreased uptake in the upper pole, but in a less foacl fashion. The uptake in the midpole is relatvely increased. There is no uptake specifically in the submental region to indicate ectopic thyroid tissue."All my blood results have come back normal and I also have a cyst in the lymph node under my chin.This was the reason I originally went to the doctor.Angela, Canada Dear Angela, Your thyroid scan suggests that firstly your thyroid gland is not normal, secondly it suggests you have multiple lumps or nodules in the thyroid, some of which take up the radioisotope and some of which do not. Although your blood tests of thyroid function have come back normal, the main question is whether any of these nodules have serious disease (i.e. malignancy in them). Overall this is unlikely, but you should consult an appropriate endocrinologist who could do a needle test on one or more of these nodules if necessary.I am not sure about the significance of the lymph node under your chin.PROFESSOR JH LAZARUS
>>> Maree
Jaeger <mcm@unite.com.au> 28/11/2006
09:32 >>>I am female-
just turned 37 I was
diagnosed in 2002 (I
think..who can keep track of these things!) I had NO
symptoms whatsoever just woke up one morning and my throat
was swollen like a football!! Having a really high
allergy rate I thought it was an allergy. I went to the
dr who sent me to a specialist who ordered
tests- which confirmed Graves. i did have heart
palpitations but only a couple of days after my throat
swelled up. My specialist didn;t believe that I had no
symptoms prior to my throat swelling up that was how it
was.I had my
first child when 35-I had a flare up again 18 months (usually
apparently its sooner than this) after my daughter was born. He put me on
6 tabs (carbimozle) then my results improved and he reduced it to
two tabs- he said the latest test was slightly up so he put me on 3
tabs.He is talking
surgery- but I am really wanting another baby as time is ticking.Should I
delay surgery and ttc or have the surgery (NOT WHAT I WANT IN THE BEST
OF ALL POSSIBLE WORLDS OBVIOUSLY) then try to ttc number 2?Regards,
Maree Dear Maree, You had two episodes of hyperthyroidism due to Graves' disease, which suggest to me that the tablets are not a suitable option in the long term. If you are wanting another child you could easily have surgery and recover relatively quickly from this. You would then almost certainly require to take thyroxine. If you became pregnant the thyroxine dose would need to be increased during the pregnancy.If you stay on tablets I would suggest you switch from Carbimazole to Propylthiouracil because the latter are a little safer during pregnancy.If your thyroid is as swollen as you say, I think it suggests that surgery is a reasonable option and it will not delay you particularly in becoming pregnant after the thyroid has been removed. PROFESSOR JH LAZARUS
>>> "PATTI
WEBER" <fennimore4@msn.com>
26/11/2006 14:46 >>>my wife is
taking levoxyl for the rest of her life because she had her thyroid removed
last year are there any natural remedies to take instead of the drug
levoxyl? sincerely her husband jim
>>> "Diana Mak" <dmak@headplay.com> 22/11/2006 19:51 >>> I had a partial thyroidectomy (left lobe) in 2004 due to a growth in the thyroid. The test result of the removed thyroid tissue was benign. There was another question on the website titled HYPOTHYROIDISM AFTER REMOVAL OF HALF THE THYROID (24AUG 06). The writer described the exact same symptoms that I experienced as well after the surgery. I was not given any medication because I was told that the other half of the thyroid will compensate. However, about 6 weeks after the surgery, I was experienced mood swings and felt tired all the time. I thought it would go away but it didn't so I went on Synthroid. (My family physician had previously prescribed Synthroid before I had decided on the surgery. When I took this before surgery, I had too much energy and with the physician advice, I did not take it anymore.) I felt better after taking the medication. However, on a follow-up appointment at the surgeon's office, I was told off for taking the medication because my TSH and T4 results were in the normal range. I was even told I probably have other mental conditions such depression and that I should go see my family physician. With the family physician's consent, I ignored the surgeon's advice and continued with the Synthroid medication for about 6 months. I felt better during that time. After the 6 months, I decide to stop the medication and see if there may be changes. Towards the end of the 1st month after I had taken the medication, I was experiencing the same symptoms. By the 4th month, I could not handle being tired after 10 hours of sleep and not being in the 'right state of mind' and continued with the Synthroid. I'm feeling better now but still do
not have the
same energy as before the surgery. the thyroid will compensate for the lost of the other part. Is this really true? Are the TSH and T4 tests accurate at providing information on the
health of a
patient?
DIAGNOSTIC DOSE OF 131-I
21 Nov 2006
SUB-CLINICAL HYPERTHYROIDISM AFTER RAI TREATMENT
7 NOV 06
QUESTION-I was diagnosed with Grave's disease a year ago
and started treatment with PTU at first and then my doctor put me on
methimazole due to the better
effect according to my doctor. After a couple of months all my hyperthyroid symtoms were gone and my TRAb had also dropped. Unfortunately I got a rash on my feet, knees and elbows which my doctor thought was side-effects of the medication and he referred me to get a RAI done. I had RAI treatment in june this year which was successful until 3 months after with stable T3, T4 and TSH levels. Then my TSH-level started to drop to and jump between 0.05 - 0.14. T3 and T4 are still stable and normal. My doctor says it is my hyperthyroidism coming back, i e subclinical hyperthyroidism and that I need another RAI-treatment. My symtoms are not those of hyperthyroidism though, rather more like hypothyroidism with extreme fatigue and depressive mood. I've also started to get the same kind of rash eventhough I'm not on any medication. I've now read somewhere that depression while having thyroid malfunction can be due to the autoimmunological activity. I think it's in Mary Shomons book "Living well with Grave's disease". In "THE PHYSIOLOGICAL AND CLINICAL RELEVANCE OF THE TSH RECEPTOR IN THE ANTERIOR PITUITARY" by Mark F. Prummel, oct 2003, he concludes the following: "Long-term TSH suppression during otherwise successful treatment of Graves' disease has always been attributed to a delayed recovery of the pituitary-thyroid axis. Less experienced clinicians regard it as proof for still existing "subclinical" hyperthyroidism and act accordingly by increasing the methimazole dosage or decreasing T4 substitution. The above mentioned experiments have clearly shown that prolonged TSH suppression is very likely to be caused by an interaction between the pituitary TSH-R and circulating TSH-R autoantibodies, which can remain present in about half of treated Graves' patients. Low TSH levels in clinically euthyroid patients with normal T4 and T3 levels thus do not indicate persisting low-grade hyperthyroidism, but should instead be seen as an indication for continued TSI activity. A low TSH value in such patients may be regarded as a positive "bio-assay" for TSI activity and explain why decreased TSH values are an independent risk factor for a relapse of Graves' hyperthyroidism after a course of antithyroid drugs." My thought are then if my TSH suppression could be due to a still ongoing autoimmunological activity, rather than a subclinical hyperthyroidism, and if my depressive mood could be explained by raised TRAb-levels or other autoimmune activity? If this is likely, what would be the best treatment? 1. Another RAI treatment as my doctor says, 2. Trying antithyroid medication again since it lowered my TRAb levels last time I took them and it might be so that my rash-symtoms weren't side-effects after all. Maj Sjogren, Karlshamn, Sweden RESPONSE-I note you were treated with PTU and methimazole and subsequently had radioiodine. Your current thyroid hormone levels T3 and T4 are normal, your TSH is currently not suppressed but ranges between .05 to .14. I would agree with you that radioiodine is not indicated in this scenario as there is no definite evidence that you are thyrotoxic. I would continue to get thyroid function monitored every three to four months. If the T3 were to be elevated above the normal reference range then a repeat dose of radioiodine should be considered. Your reading of the Prummel article is correct, and it is correct that there is considerable interest as to the reason for the lowering or suppression of TSH after treatment of Graves' hyperthyroidism and it may well be due to the interaction with the TSH receptor. You are correct that depression can be associated with thyroid autoimmunity but this is usually the thyroid peroxidase antibody and not the TSH receptor antibody. You do not say whether you have TPO antibodies. From my reading of your letter I would not have thought that your depression was particularly related to your thyroid status as it is normal at the moment. It is true that there are mood changes recorded in hyperthyroidism, as well as hypothyroidism. However, these facts are probably not relevant to the treatment of your depression which should be by standard means. I hope these comments are helpful. I do not think your depressed mood is explained by raised TRAb levels, I do not think you should have another dose of radioiodine, I do not think that a further course of antithyroid drugs would be helpful at the present time. Professor JH Lazarus
HYPOTHYROIDISM,
THYROXIN DOSAGE, PREGNANCY
17 OCT 2006
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