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2007 Patient Questions

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TREATING HYPERTHYROIDISM12/1/2007

Question

My mother had been diagnosed as Hyperthyroidism and she is now having her medication to controlling her thyroid hormone for 3 months which will be continue for a year if her thyroid level still in high risk, what I want to ask are : 1.how to gain her weight since she is so underweight (her BMI is only 19)? 2.what supplements should I give her that wouldn’t interfere her current medication? 3.Did she need any special diets? because I found on online journals that hyperthyroid patient should consume any diary products, spinach etc 4. Is Hyperthyroidism curable or just treatable?

Thank you,

Amelia Pranatio

Response

1.If her hyperthyroidism is controlled, she should be able to gain weight by consuming more calories than she usually needs. 2.Perhaps extra vitamins would be useful, but basically she just needs a healthy diet. 3.She should avoid large amounts of iodine- milligram amounts- but I do not think any food would be a problem. 4.The last question is complicated. Probably the autoimmunity to the thyroid persists, but for the vast majority of people, treatment is effectively curative.

L De Groot, MD


TREATMENT OF HYPERTHYROIDISM

Question

I would like to ask a question for the thryoid disease manager web site. I am 58 and have Graves disease being controlled by carmbimazole daily. I am feeling very well and able to live a full and active life. Last test results l.4 TSH : 11 T4: 4.4 T3. I have tried coming off twice but symptoms return and will continually try to reduce or come of this drug if blood test results allow. If this is not possible what are the long term consequences of staying on cambimizole compared to the multitude ofcases I have heard of and read about that have had disastrous results for RAI treatment and the resulting hypothyroidism. I understand the risk of a sore throat and the need to have a immediate test but would like to know what other risks are involved in long term use of this drug. Does diet and stress reduction play any part in reducing symptoms?

Many thanks,

Jane Sinclair

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. 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. 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. 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. 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. My labs before the surgery were:

  • 08/29/07
  • TSH 0.98 (0.46 – 4.68)
  • T3 Uptake 27.20 % (23.50 – 40.5)
  • T4 11.2 (5.53 – 11.0)
  • FTI 3.04 (1.65 – 3.89)

My labs after the surgery were:

  • 09/27/07
  • TSH 1.91 (0.46 – 4.68)
  • T4 9.1 (5.53 – 11.0)
  • SED Rate 54
  • Thyroid Peroxidase < 10 (0-34)
  • 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?? 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. I do not believe your complaints of sore throat etc., are necessarily related to Hashimoto’s thyroiditis. I think it possible that you do have an unassociated mild infection and I am surprised that the antibiotics have not helped. Although I would say that thyroxine is not indicated it may be that a trial of thyroxine for six weeks at 0.1 mgs a day may be worthwhile. I do not think the other side of your thyroid should be removed.

Yours sincerely,

Professor JH Lazarus


THYROID ANTIBODIES AND THE RISK OF MISCARRIAGE2 Apr 2007

Question

I found your excellent Home-Page when browsing the internet concerning a question, which is very important for me. I’m pregnant in week 20 and suffering from hypothyroidism. It is unclear, whether I have Hashimoto thyroiditis, since antibodies were never detected, the ultrasound images of the thyroid gland were normal (no reduction of the echo or other abnormalities), the only thing was that the gland is asymetric and small with a volume of 10 ml and my Tsh was over 3,5. I’m taking Thyroxin-substitution every day and the dose was also controlled and increased during pregnancy. My questions: 1. Does autoimmune thyroid disease like Hashimoto increase the miscarriage rate only in first trimenon of pregnancy or also in the second and third? (I’m a bit afraid about that) 2. If having Hashimoto : is there also an increased risk of having antiphospholipidsyndrome? I knwo that when having APS the risk for miscarriage is quite high in the second and third trimestre and I heard, that there is an association between APS and Hashimoto?? 3. Can Hashimoto or other autoimmune thyroid diseases present a echonormal picture in ultrasound? What could be the cause for my hypothyroidism if not an autoimmune disease? Because of the possible impact of autoimmune thyroid disease on pregnancy I would “prefer” – of course – a non autoimmune cause for my hypothyroidism Thank your very much for your answers! You see that I’m a bit afraid about possible pregnancy complications linked to autoimmune thyroid disease. I already read your related text on the home-page but the questions above remained. Would you be so nice to write me a mail to MH.

Response

I will try to answer your various – and legitimate – queries: First, your hypothyroidism seems to be extremely mild since the only diagnostic proof was a serum TSH above 3.5 mU/L. This, in itself, classifies you in the category of ‘subclinical’ hypothyroidism (meaning with normal thyroid hormone levels). You did not mention however whether the slightly elevated TSH was discovered once you were pregnant, or already known before. I would also have liked to know your serum thyroid hormone levels and the dosage of thyroxine you take now. Question 1: miscarriages are increased mainly in the first trimester in women with Hashimoto’s disease. Question 2: there is an association between the APS and Hashimoto’s disease. Question 3: normal ultrasound patterns can be found in Hashimomoto’s disease, either because the chronic ‘inflammation’ process is very mild or so diffuse that it cannot easily be seen. Also, thyroid echography is operator-dependent and therefore the conclusions depend in part upon the experience of the radiologist. Hypothyroidism can be due to several other causes, and this is not the place for a sientific discussion about those. Finally, having reached 20 weeks of gestation, taking the thyroxine correctly with adeqaute controls and monitoring of thyroid function tests should reassure you concerning the remainder of your pregnancy which I wish you to be uneventful and highly successful.

Prof Daniel GLINOER


PREGNANCY AFTER RAI TREATMENT24 MARCH 2007

Question

My husband had a diagnostic scan of 111MBq (3mCi) of RAI in December 18,2006.I am presently in the 9th week of pregnancy.My question is- I am very much tensed whether my child will have any problem,due to the effect of RAI. How safe was it to conceive now?

Thanks.

Elizabeth.

Response

While there are suggestions that it is wise to wait at least three months after RAI to initiate pregnancy, there actually are no data proving that you have any increased risk.

L De Groot, MD


TESTS DURING PREGNANCY14.02.07

Question

My pregnant daughter was refused a scan at 20 weeks by NHS even although she is taking thyroxine. Is a scan not advisable to check the baby’s growth? She did, however, pay for this privately but should a 20 week scan not be automatic under these circumstances?

Kathleen Armour

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 HYPOTHYROIDISM08.02.07

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 you 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 TSH07.02.07

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.

Response

Dear Mrs Fisher,

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 TSH07.02.07

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 NODULE21.01.07

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. I questioned my consultant about ‘draining’ the liquid, but he said it wasn’t possible and instead said I have two options: either to leave it or have partial thyroid surgery which isn’t very helpful.

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!) As a “by-the-way”, I will not be going back to this consultant! Thank you once again for your website and I will definitely look out for that book “Thyroid Manager”. I look forward to hearing from you.

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 THYROXINE17.01.07

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 NODULES04/01/2007

Question

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


03/01/2007

Question

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

Response

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


Question

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 thisyear.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 amconcerned 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

Response

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


19/12/2006

Question

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

Response

Dear Susan,

You indicate you have Hashimoto’s disease and that you are being treated with armour thyroid. You also indicate that you have had a severe allergic reaction to Bactrim. Armour thyroid is not normally recommended as it is a combination preparation of T4 and T3 which is not normally necessary for the treatment of hypothyroidism. In addition it is itself a porcine extract, and the possibility of allergy in yourself should be considered. It may be worthwhile switching to regular thyroxine therapy, e.g. Synthroid or Levoxyl or other synthetic thyroid preparation. Unfortunately whatever you do the immunological process relating to progressive thyroid destruction and failure may in fact continue even though you are taking thyroid hormone.

Professor JH Lazarus

Follow up 19/12/2006

Thank you for answering.

I was taking armour thyroid (very low dose) before the Bactrim incident happened and I never had any trouble with the armour. Is it problematic to be on armour even though it supplies t3 and t4? I had preferred it over the synthetic brands previously.

Susan L Gold

Response

Dear Susan,

Thyroid physicians do not recommend armour, because there is no evidence that a combination of T4 and T3 is any better than T4 alone. In addition, armour is an extract of porcine thyroid and, although manufactured in a rigorous way, still has that potential problem. Synthetic thyroxine is probably easier to manufacture to tight specifications. In addition the T3 which armour contains can cause an elevated T3 level in some people which could be a health hazard. However, many people are on armour and do say they prefer it, although the reasons are often not very clear.

Professor JH Lazarus

Follow up 22/12/2006

Thank you so much for answering.

Could you tell me what sort of health hazard is an elevated t3 if the armour were to cause that? also, is it possible to get Hashimoto’s to stabilize or is this a progressively destructive disease to the thyroid?

Susan L Gold

Response

Dear Susan,

An elevated T3 affects the heart (causes palpitations etc). It also will accelerate bone loss.Hashimoto’s is normally a progressive, destructive disease, but it proceeds at variable rates and can indeed stabilize on occasions.

Professor JH Lazarus


19/12/2006

Question

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.

Response

Dear Glenda,

You are correct that it is indeed normal and usual for TSH to stay suppressed after radioiodine for quite a long time, anything up to two years. Technically you could regard this as subclinical hyperthyroidism, but there is nothing to do at the moment, providing your T3 level is normal.

Professor JH Lazarus


12/12/2006

Question

Could you please advise if ear pressure is to be expected after a totalthyroidectomy? 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.

Response

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


08/12/2006

Question

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

Response

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


Question

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

Response

Dear Ms Adelman,

Thank you for your letter. I am not quite sure which column you were reading! At any rate the short answer is that you should not be worried about a low T3 uptake. It is not a test that is done very often now. Low or high readings of this test can be normal in patients in certain situations or taking other drugs. If your T4 and TSH are normal then you are euthyroid (normal thyroid status). I should not worry.

Professor JH Lazarus


06/12/2006

Question

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

Response

Dear Sandie,

I am sorry to hear that you had a miscarriage. It is probable that you have thyroid antibodies (antithyroid peroxidase antibodies) because you have been diagnosed as having hypothyroidism. These antibodies are associated with miscarriage, although this would be expected to be less if you have on the thyroxine treatment. It is not true that 200 mcgs is the most that you can take. The dose is dependent on what your TSH level is, if you need more to get your TSH level to the normal range that is fine. Another point is that if you do become pregnant you should increase the T4 dosage by 50 mcgs in the first instance. This is because most pregnant women on thyroxine need more when they are pregnant.

Best of luck.

Professor JH Lazarus


05/12/2006

Question

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

Response

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


04/12/2006

Question

I was diagnosed with Grave’s Disease in 2001. At the time the only symptomsI 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

Response

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 LEVELSwere 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


03/12/2006

Question

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)

Response

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. It is true you gain weight after radioiodine; this is because when you were thyrotoxic your weight was probably less than it would otherwise have been. Some of your symptoms are clinically suggestive of an inadequate thyroxine replacement.

I hope these comments are of help.

Professor JH Lazarus


28/11/2006

Question

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

Response

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


28/11/2006

Question

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 hereduced it to two tabs- he said the latest test was slightly up so heput me on 3 tabs.He is talking surgery- but I am really wanting another baby as timeis ticking.Should I delay surgery and ttc or have the surgery (NOT WHAT I WANTIN THE BEST OF ALL POSSIBLE WORLDS OBVIOUSLY) then try to ttc number 2?

Regards,

Maree

Response

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


26/11/2006

Question

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

Response

Dear Jim,

The normal therapy for thyroid replacement is a commercially manufactured pure preparation of the hormone thyroxine, that is what levoxyl is. The thyroid community consider that these preparations are the most satisfactory as they are carefully manufactured to precise limits and standardised.There are thyroid preparations known as thyroid extract which are made from animal thyroids and, although made to strict specifications, they are not as standardised as the synthetic variety. Hence they are not recommended for routine use by thyroid physicians in the world. It is true that originally in 1896 thyroid extract was used for the first treatment of an underactive thyroid, but as you can imagine this preparation was crude and for the last 50 years or so commercial synthetic thyroxine has been the mainstay of treatment. In summary I would not recommend any other treatment other than levoxyl and would confirm that there are really no useful natural remedies to take instead of the drug.

Professor JH Lazarus


22/11/2006

Question

I had a partial thyroidectomy (left lobe) in 2004 due to a growth in thethyroid. 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.

My question is: All medical professionals indicate that the other half of 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?

Response

Dear Ms Mak,

You had a partial thyroidectomy and the question is what is the function of the remaining lobe? If the remaining lobe is normal (which in your case it probably is), then you will have a normal TSH and T4 and will not require any thyroxine replacement therapy. However, it is true that some surgeons routinely ask their patients to take thyroxine after surgery, although in my opinion there is no definite evidence that this is required. It would be useful to know whether you have any thyroid antibodies present in the serum, as this may indicate the progression of thyroid disease in the remaining lobe. The answer to your question is that the remaining thyroid can function quite normally after thyroidectomy and will indeed compensate. The best tests of thyroid function we have at present are indeed TSH and T4 and they are normally accurate at providing information on the health of a patient.

Professor JH Lazarus


DIAGNOSTIC DOSE OF 131-I21 Nov 2006

Question

Can you please answer my questions regarding RAI dose of *111MBQ for a 30ys old male* How many days should the person stay separate from others ?(especially from pregnant person) As per our doctor this is a diagnostic dose to check for the spread of cancer. One year back the same dose was given and it was found that there is no spread of cancer in the body. So is there a possibility that there will be spread after one year? Is this a high dose?

Thanks Elizabeth.

Response

This is not a high dose. It is a diagnostic dose that will not cause significant exposure to other people including pregnant women. Regarding the possibility of subsequent spread after a negative diagnostic WBS, it depends from the original TNM stage, the age of the patient and the type of initial treatment. However, the diagnostic WBS is poorly sensitive in detecting local or distant recurrence. The best method of follow-p is measurement of serum stimulated thyroglobulin (that must be undetectable) ands neck ultrasound (that must exclude regional disease).

Sincerely,

F. Pacini MD


SUB-CLINICAL HYPERTHYROIDISM AFTER RAI TREATMENT7 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, PREGNANCY17 OCT 2006

Question

I am 29 years old female (weight: 143lbs (pretty constant for the last 5 years; height: 5’-3”) currently residing in India. I have been diagnosed with hypothyroidism since 2001, and I have been on thyronorm (thyroxine sodium) on and off. I had 0.25mcg thyronorm continuously for one year in 2004. Recently, when I got my blood profile done, my TSH value was 8.5, and was put on 50mcg Thyronorm. 2 months later my TSH levels dropped to 0.02. Suspecting that there was some problem with the results, doctor suggested a retest. But now the TSH levels have dropped to 0.01.At this time, my doctor asked me to do a TPO antibodies test, which showed the result as >1300 (range <34). He is asking me to continue the Thyronorm for next 3 months (50mcg). Other than the abnormalities in the blood test, I do not have any major symptoms of either hypo or hyper thyroidism other than difficulty in losing weight. I have no lethargy/ tirdness/ fatigue etc. I am attaching my historical TSH values for your reference. We are trying to get pregnant, and the doctor has asked us to wait for 2-3 months.Is there anything else that I need to recheck? Should I ask for a second opinion?Myself and my husband are really concerned about this issue, and we would be very grateful if you could please advise us on this issue.

Shilpa

T3 (ng/dl)

T4 (ug/dl)

TSH (UIU/ml)

TPO ANTIBODIES

10-Oct-06

167

12.1

0.01

>1300 IU/ml

Range

70-204

5.2-12.5

0.35-5.5

<34

07-Oct-06

215

12

0.02

Range

60-200

4.2-12

0.3-5.5

26-Jul-06

136.4

8.7

8.52

Range

70-204

5.2-12.5

0.3-5.5

09-Jul-04

90

9.54

Range

80-180

0.4-5.5

28-May-04

110

8.63

Range

80-180

0.4-5.5

04-Jun-01

83

5.99

8.54

Range

70-200

4-13

0.3-0.6

06-Apr-01

160

11.94

0.02

Range

70-200

4-13

0.3-7.0

03-Jan-01

123

9.91

5.65

Range

70-200

4-13

0.5-0.6

Response

Dear madam, the only reliable parameter to monitor appropriate thyroid hormone substitution is the TSH value. T4 and T3 parameters are insensitive to this end. Your TSH should be between .04 and 2.0. This means that you are using a little too much thyroid hormone. I suggest to take alternatively 25 and 50 microgr per day. There is no problem to try to get pregnant already now, even if your dose is a little too high. This does not hurt. Be aware that during pregnancy many women need about 30% more thyroid hormone. I suggest that as soon as you have conceived to increase the dose by 30% of what you are using. Have your TSH tested 3 weeks after this increase and subsequently every 6 weeks during pregnancy. After delivery most women can go back to the pre-pregnancy dose.

Georg Hennemann, MD


POSSIBLE HYPERTHYROIDISM10 OCT 2006

Question

I’m a 34 year old female. On a routine blood test, my doctor discovered a slight case of hyperthyroidism. My TSH is below .01, and my T4 and T3 are elevated ( as are FT4 and FT3), both slightly, but the T4 is elevated more, relatively speaking. My doctor says my ratio of these factors points towards it not being Graves. After a patient history, physical exam,and an EKG to check for any arrythmia ( it wasnormal), my doctor decided it was likely to related to an excess of dietary iodine ( a supplement with 150 mcg and excessive amounts of dairy), and too much caffeine ( I am, or was, until this happened, as he termed it, a caffeine abuser). I was told to watch the iodine and caffeinefor 8 weeks and return for repeat testing. The only other significant factor in my history is that after 11 years of being either pregnant or nursing continuously, I stopped in May of this year ( but my child is older than a year). I asked my doctor about Graves, and he is unconcerned about it. I had a late term pregnancy loss ten years ago, and underwent extensive testing at that time, and have continued the testing atfuture pregnancies. I have had four negative thyroid antibody tests, and he declined to do another one at this time. My only finding from all of my repeated autoimmune testingis a one timelow positive anticardiolipin antibody, but it was later attributed to a case of CMV, and never occurred again. I have no family history of Graves or autoimmune disorders. I have absolutely no symptoms at all. No weight loss,no palps, no skin or hair changes. Nothing. I feel just fine, and can exercise and complete my daily work with no trouble at all.Is my doctor right to advisethis course? Watch and wait?

Jessica

Response

Your thyroid hormone data point to hyperthyroidism. It is not possible to judge from these data if it is caused by Graves’ disease or some other condition, such as nodular goiter or thyroiditis. The fact that you have no family history of Graves is a weak argument against Graves, but more significant be it not conclusive, is that you have no thyroid auto antibodies. If you have no serious complaints and no anatomical thyroid abnormalities, such as goiter, the option “to wait and see” is a good one. If you happen to have the painless type of thyroiditis, this resolves spontaneously in 70% of cases. However in these patients hypothyroidism may develop in later life. Your doctor could measure thyroid uptake of radio active iodine that is low or absent in thyroiditis but normal or elevated in Graves and nodular goiter. If iodine would be the cause of your hyperthyroidism, then it might resolve after reducing intake. This implies that you might risk hyperthyroidism at some time later, even without excessive iodine intake.

Georg Hennemann, MD


MEANING OF POSITIVE ANTIBODY TEST10 OCT 2006

Question

I had hyperthyroidism about a year ago and it was very severe, I lost about 30 pounds weighing about 100 and could not do anything without almost fainting but I ate like a horse. My thyroid got very low after some time on tapazole and I finally got off of it. Once my thyroid levels became normal I have had elevated antibodies. This scares me and makes me think there could be something else raising my antibody levels, but my doctor seems nconcerned. My thyroid gland is enlarged and I have had several ultra sounds on it and there is nothing showing up.The doctor said normal antibodies are at 35 and mine have been 165.This seems abnormally high. Could this mean I have some other unrelated problem in my body like cancer or an immune problem? –sciple l m

Response

I agree with your doctor that this is hardy anything to worry about. In the first place your antibody level is only mildly elevated. Strongly elevated levels are in de many hundreds or may be thousands. The presence of these antibodies is only a risk factor that at any time in your life you may develop ether hyper- or hypothyroidism. A yearly check of your TSH is there fore mandatory.

Georg Hennemann, MD


THYROXIN TREATMENT AND URTICARIA

Question

I am a patient who has underactive thyroid and have been on medication for a long time. I just develped uticaria out of the blue. Never heard of such a thing. went to the dr. He put me on Prednizone, Zantac and Zyartec which are all antihistamines. Can this be due to my throid changing. All of a sudden. Are there any diets you can go on. I appareciate your answer. My dr. took all blood tests. He thinks it is a virus that hit the immune system. Is that possible.

joankjoank@msn.com

Response

Very rarely patients become allergic to the thyroid medication. Not so much because of the thyroid hormone it contains, but to the other material in the tablet. In such case changing to an other thyroid hormone preparation is usually sufficient. Again this situation is really verry rare. It can certainly not be due to a change in thyroid function. Of course there are many other more frequent causes of urticaria.

Georg Hennemann, MD


THYROXIN DOSAGE AFTER PREGNANCY 26Sep 2006

Question

I have been taking synthroid 50mcg for years. I then became pregnant and my dose was upped to 75 mcg. after having my baby and nursing for 4 months i was feeling extremely awful and all my hypo signs returned. My tsh was tested and came back 14.78. The doctor ordered and additional TSH and it came back 17.48 in one week it went up from 14 to 17. My goiter has also become enlarged. My doctor upped my Synthroid to 150 mcg and ordered additional blood work in 6 weeks. I am afraid she doubled it and that may be too much.Do you think 150 is too much of a jump from the 75?

Response

You may be right. However you are most probably suffering from post partum thyroiditis. This condition may occur in women who have thyroid antibodies (anti-TPO) in the circulation. It usually develops in the first year after delivery. It can cause either hyper- or hypothyroididm. You apparently were already partially hypothyroid before pregnancy. This has now aggravated after delivery. The following process may occur. Either the severity of your present hypothyroidism remains permanent and may become even worse, or resolves to the pre-pregnancy level. The increase in dose, considering your TSH level may certainly be too high for the present time. A jump in dose of 50 would probably have been better. However if your thyroid is going to be damaged even more the dose may have to be again increased further. Note that for appropriate dose finding only the TSH level, and not the T4 and or T3 levels, is important. The TSH should be in the range of 0.4 and 2.0. Can breastfeeding cause the TSH levels to rise so high? No How quickly do you feel side effects from synthroid? If appropriatly dosed there are no side effects. If the dose is too high, side effects, in the sense of hyperthyroidism, may ensue after 1 to 3 weeks. How soon do you feel improvement after taking higher dosage? This may start between a few days and 1 week.

G Hennemann, MD


HASHIMOTO’S THYROIDITIS AND MANY PROBLEMS26 SEP 2006

Question

I am a 34 year old mother of 2. About one year after my first child was bornI was at a health seminar were I had a health screening. Being a Physical Education teacher and avid fitness buff, I thought they had sent me incorrect results from my cholesterol test. It came back high and with a warning to see a Doctor. I ignored the test andthe next year became pregnant with my second child.I had a much more difficult pregnancy with my second. I had severe fatigue, a strange skin condition around my mouth, my eyes and my ears and gestational diabetes (which is not prevelant in my family at all, and my pregnancy weight was totally normal). MyOB chalked it up to being a mother of one and hormones. (I have a wonderful OB).Approximately 6 months after the birth of my second child I experience major weight gain, severe fatige, dry skin, scruffy voice and hives. I was immediately sent to an endocronologist after my TSH levels came back high at my yearly OB visit. Too make a long story short (TOO LATE) I was diagnosed with hashimoto’s. I am taking Synthroid .111. I feel much better then last year, but I still have some conditions that are interfering with day to day activity. First of all the strange dryness around my eyes and ears are gone, but is still around my mouth all the time. Every 2 to 3 weeks I have these episodes where I become completely irritable and unable to control my temper and emotions, my vision gets blury, I become forgetful, bloated and my periods are out of control. My mother who also has thyroid issues (not as severe as mine) often says give the medicine another year. I don’t think I can. I call my endo. regularly, but his nurses seem to blow me off and on the rare occasion I do talk to him I don’t feel like I get any answers.He has sent me for lab work, all of which comes back fine. My question is this. Are there answers out there to get or am I losing my mind. I feel crazy and am beginning to wonder if I am ever going to feel normal again. Just curious if I should pursue a different route or stay the course. I hear wonderful things about my endo. from other people and I certainly don’t want to complain about him, however, I really need to get back on track and even if one person could tell me that I will be back to normal one day soon it would make me feel so much better. I greatly appreciate any response you might have time to give me. I can tell by reading the thyroid disease manager website you are very busy, but I am very impressed with all the responses.

Thank you for your time.

Katie

Response

Dear Katie,

In the first place the question is if you are appropriately treated with thyroid hormone. The only correct way to dose this is on the basis of the TSH value that should be between 0.4 and 2.0. T4 and T3 are unnecessary and even sometimes misleading. Check with your endo if this is really the case. You should know that all! abnormalities and symptoms, caused by Hashimoto, revert to normal after correct treatment, This may sometimes, in long term severe cases, even take a year indeed. However in that year there has to be a continues improvement, So, if complaints remain, one have to think about other causes. As Hashimoto is an auto-immune diseases, one has in the first place to think of other auto-immune conditions that may play a role, For instance dry mouth and eye problems may occur in Sjögren’s disease. Psychological problems can certainly exist in inappropriate thyroid hormone substitution and generally in people who feel awful for any reason. Talk to your doctor!

Georg Hennemann, MD


TREATMENT OF PAPILLARY THYROID CANCER26 SEP 2006

Question

My son is 23 yo who was diagnosed with papillary carcinoma of the thyroid in 1995. He had a total thyroidectomy and a right radical neck dissection. He was treated with 83.2 mCi of I131 post surgical ablation.In 1996 he was again treated with another 29.5 mCi of I131 for an elevated TG of 450. TSH was 51.1. Post therapy scan revealed a single small uptake of iodine in the right upper lung. Six months later 1997, he was treated again with 29.4 mCi of I131 for an elevated TG of 2200. TSH was 144.2. Post therapy scan revealed that the single area of uptake in the right upper lung has resolved. However, there was diffuse uptake seen throughout both lungs, which was interpreted as microscopic metasatic papillary carcinoma. Six months later in 1998, he was treated again with 178.13 mCi of I131 for elevated TG of 1300.TSH was 217.6. Post therapy scan showed no significant change from the prior whole body scan six months ago. Six months later in 1998 he was again treated with 161.77 mCi of I131 for an elevated TG of 1121. TSH was 185.9. Post therapy scan again showed no significant change from the previous. Chest X-Rays were all normal and Chest CT’s showed diffuse lesions mainly in both lower lobes largest being 10x11mm. Most of the lesions are 7x6mm or smaller. CT findings have been relatively the same as well as the I131 whole body scans. A recent PET CT fusion scan revealed the same findings. In 1998 it was theopinion of the attending Nuc Med physician that we stop and watch the disease due to the accumulativeI131 doseof over 500 mCi and my sons age of 15 yo. Since then we have followed the disease by TSH suppression and TG. Results have be shown to have a slight increase from 85 in 1999 to 141 in 2006. Currently, his physician has recommending another I131 therapy treatment utilizing dosemitry for the maximum dosage which is scheduled for Oct 18, 2006. Last year when the question was raisedof therapya Nuc Med physiciansuggested banking bone marrow. This time, on multiple occasions his endocrinologist has been calling him and informing him of the high risks on sterility and complete destruction of his salivary glands. I have been in the Radiology field for 30 years and through all the lititure I can not find anything to support the extent of these risks. I do findthe risks to be classified as “suppressed” rather than complete destruction. Other concerns are leukemia and pulmonary fibrosis. My son is raising questions of quality of life. Few physicians when asked why do therapy if it is stable? Most jump to the guns and say treat with I131 despite knowing he has had 5 therapeutic doses of I131 for a total over 520 mCi.Some after learning the history of my son say that being conservative is also an option. Some have talked about future medical advances which may cure this disease. We again are having mixed feelings about this therapy. Getting a good experienced second opinion is very hard to come by. We are in search for an unbiased good experienced second opinion. I have readsome of your publication and feel you are the most experienced that I have found in the 11 years of searching. Could you please give us your thoughts, suggestions, and recommendations.

George Miladinovich

Response

I have reviewed the facts in your son’s case carefully. Although it is difficult to comment on the decisions made by others in retrospect, it does seem that the administration of radioactive iodine was done with reason and for contemporary indications. Generally your son would be considered to have a good prognosis as he was diagnosed at a young age. Individual progression is difficult to predict but there is some indication that his thyroglobulin is rising despite TSH suppressive therapy. It is likely, given the diffuse nature of the apparent disease in his lungs that surgery is not a viable option. As such his physicians may be balancing the risk of progression of the thyroid cancer versus the down side of additional 131-I treatments which do include the risk of salivary gland damage, and higher risk of secondary malignancy such as leukemia. The comments about transient bone marrow and testicular suppression are valid and indeed some patients have experienced bone marrow failure (risk is likely greatly lessened with dosimetry) and infertility. The banking of sperm has been recommended for those undergoing higher dose 131-I therapy and I would think that bone marrow banking might seem reasonable as a measure to utilize in the case of marrow failure or the development of leukemia. I do not believe that marrow banking is generally recommended in current guidelines. So what to do? If there is evidence of anatomic progression, further treatment with 131-I would seem reasonable if the post (or pre for that matter) treatment scans indicate that the 131-I was taken up into the tissue. If the post-treatment scans show no uptake however, consideration of chemotherapeutic protocols currently under investigation would be reasonable if there is evidence for progression of disease.

James Hennessey, MD


FLUID RETENTION, ? CUSHING’S, ESTROGEN TREATMENT, EXCESS WEIGHT23 Sep 2006

Question

I`ve been to several endocrinologist in the UK over the last 20+ years, who don`t seem to be up to speed.I initially had increased prolatin some 20+ years ago I was prescribed T3 which helped with fluid retention. However after 3 months it stopped working. I found out many years later that after 2 to 3 months T3 causes a rebound reaction..I was then prescribed a narcotic thename evades me at the moment.. It made my blood pressure drop like stone.Then about 10 years ago I had 2X 24 hour urine samples and I appeared to have 11 Hydroxycortisol missing along with one or two other elements.The endocrinologist I saw were I am very much afraid out of their depth…They were only concerned I might have Cushings.They did not want toentertain I might have adrenal hypoplasia.I did get some dexamethose for a private GP and natural path which seem to help.and some saline solution.But since then I got myself off the dexamethsone.I`ve been borderline diabetic for many years, but the endocrinologist did not want to know..I`ve gone into early menopause at about 37.. I was found on a private test some 3 or so years later myoestrogen level had dropped below so called normal menopausal levels.I think it was 8%..I`ve been on oestrogen of various kinds for the last 8 years or so.So I still have periods… But my weight keeps increasing.. I am about 20 stone and don`t eat much.Is there any help you could suggest? Like experts in the UK who know what their doing.

Carol J.R. Rae

Response

If you do not have Cushing’s disease or thyroid malfunction, the increase in bodyweight can only be due to an imbalance between energy intake (food) and energy expenditure (exercise etc). The only solution is to decrease the first and increase the second.Regards.

Georg Hennemann MD


HYPOTHYROIDISM AFTER OPERATION23 Sep 2006

Question

I’m a 51 year old regularly menstruating female.Irecently had a total thyroidectomy for possible Hurthle cell ca found on biopsy of one dominant nodule (multinodular goiter with previously normal free T4 and TSH). The final path report was thankfully negative, and I began my exogenous hormone replacement at 75mcg four days postop, not feeling particularly fatigued. At 4 weeks (9/8), my Free T4 was 1 and my TSH was 24.5, and the fatigue has set inI’m now on a 150mcg dose daily, but feeling significantly more fatiguedeach day. This increasing fatigue made me suspect that my “homemade” supply has been exhausted and I’m now solely relying on my RxMy questions are– (1) How long does the body “hold on” to its T4 and T3 post total thyroidectomy, and how long does it take for the Rx to “take hold?” If a “total” thyroidectomy is really total, usually a minimal remnant stays, thyroid hormone levels disappear from the blood in about 6 weeks. (2)How often do you recommend TSH monitoring before a euthyroid state is achieved?

Thank you for your expertise and your time!

Response

Erica B That depends on the time periods that the dose is increased until the desired amount. I suggest that after each increase in dose, the TSH should be checked about 4 weeks later. Note that for optimal dose finding and maintenance the best test is that of the TSH. In patients on thyroid hormone treatment it should be between 0.4 an 2.0. The values of FT4 and T3 are irrelevant in this respect.

George Hennemann, MD


MANAGING A THYROID CYST23 Sep 2006

Question

I read on your site that cystic growths may not be visible on MRI. If draining of the cyst is a treatment option, then (a) How do you ascertain the location of the cyst (and where to drain it from) (b) Is draining sufficient for a total cure (if it is fully liquid)?

Thank you.

ggopal@mba04.rsm.nl

Response

Cyst are best visualized by ultrasound. Draining is done under ultrasound control by needle puncture. The best results, about 30% complete and in 60% partial disappearance, are obtained, when after draining the cyst is rinsed with ethanol.

George Hennemann, MD


HASHIMOTO’S THYROIDITIS AND MANY SYMPTOMS5 Sep 2006

Question

I am a 39-year old white female who was diagnosed as having Hashimoto’s thyroiditis 7 years ago. At the time I was hyperthyroid and received medication to treat that for 1 month, but have since then be euthyroid. My latest TSH levels were 1.7 in January and 1.3 in June. My thyroid is enlarged and has been since prior to diagnosis. I have had a series of thyroid sonograms that do show several small insignificant nodules that are not changing in size. I have also had an uptake scan done which is normal. My problem is the body aches and fatigue that have accompanied the initial thyroid symptoms have not dissipated. I have had an endocrinologist and an ear nose and throat specialist tell me that “you have an autoimmune disease–deal with it”. My general practitioner frequently runs all types of blood work and has no answers. Because I am currently euthyroid, I am told that I do not require treatment, but I am very frustrated with the fatigue and body aches. The endocrinologist that I was seeing has since retired and there is at least a 6 month wait in my area to get an appointment with one. I am currently being treated for high blood pressure, endometroisis, anxiety and TMJ.

Any suggestions?

lscrawley@verizon.net

Response

In Hashimoto’s thyroiditis, we usually use thyroxine tablets when patients have decreased thyroid function, and we call this is the replacement therapy. Sometimes drug is used to suppress TSH in order to decrease the thyroid size or to inhibit the growth of thyroid nodules. In latter case, some patients complain heart palpitation, hand tremor etc., just like you, due to slightly increased serum thyroid hormones. Initially you might have this condition. It seems unlikely that there is functional difference among different brand tablets. Hashimoto’s thyroiditis gradually develops into hypothyroid condition and your current treatment with 0.1mg of Levoxyl is appropriate since your TSH 1.47. Anti-thyroid peroxidase antibodies (TPO -Ab) keep their high titers for life long and are not disappear and just show continuation of thyroid autoimmunity. However, TPO-Abs have no biological activities. Liver function tests are influenced by abnormal thyroid function but slightly increased ALT in your case may not be related to thyroid problem since your thyroid function seems to be normal due to suitable replacement therapy. Your feeling of fatigability may not relate to thyroid problem since your thyroid function is normal.

N Amino, MD


THYROXINE DOSAGE FOR CONGENITAL HYPOTHYROIDISM1 Sep 2006

Question

My daughter, who is nine months old, was born with congenital hypothyroidism. It was caught because of the heel prick test and she began taking Synthroid in her second week. She has been on a dose of 25mcg pills of which she takes 1.5 pills per day. We have been to several dr appointments and her med levels have not changed. She went to another appointment this week and they want to adjust her to 1.5 pills one day and 1 pill the next, alternating. Her TSH level was 1.65 and her T4 level was 0.05. The doctor said the the T4 level was a bit low but the TSH level was good and that she wanted to decrease the dosage just a bit. I have seen the normal levels on your site but wonder are these levels the same for infants. She is developing normally and the doctor says there are no problems. She did ask me if she was restless sleeper. What would this mean and how do I know what restless is. She has been sleeping through the night since she was 1 month old and very rarely wakes up. Is restlessness an indicator of something? Also what sort of signs should I look for that may indicate that there is a problem with the dosage of medication. She only goes to the dr every three months currently.

Thank you for your help.

Janice McKinstry

Response

A dosage of 37.5 mcg (i.e., 1 ½ 25 mcg tabs) is a common dosage for babies with congenital hypothyroidism. Visits every 3 months are OK. One of the signs of thyroid hormone overdosage is difficulty sleeping which your baby definitely does not have if she sleeps through the night.Are you sure that it is not the free T4 that is 1.65 ng/dL and the TSH 0.05 mcU/mL? If so, then decreasing the dosage would be reasonable.

Sincerely,

Rosalind Brown MD


RAI TREATMENT IN A 14 YR OLD WITH MINIMAL CANCER(25 AUG 06)

Question

My name is Sheila( from UK)and my 14 year old daughter underwent hemithyroidectomy in April 06 to remove 3.5cm tumour, which was found to be microinvasive follicular carcinoma.She subsequently had the second half of her thyroid removed in July 06, and this was found to contain a tumour <1cm in size. Now her surgeon is considering RAI ablation, but says he is not keen on this type of treatment, and that my daughter and I have to decide whether or not she should have it.My questions are- what are the risks of radioactive iodine for a girl this age, and could measuring her thyroglobulin levels indicatewhether or not the cancer may have spread?

Sheila

Response

Although the prognosis in this situation is very favorable, the usual response would be to ablate the residual thyroid tissue with RAI. There is probably no detectable risk with this treatment. Alternative but less satisfactory approaches would be to 1) follow thesituation with imaging and blood tests, or 2) delay RAI until age 18. But I doubt that either is quite as satisfactory as to treat now.

L De Groot, MD


TREATMENT OF RAI INDUCED HYPOTHYROIDISM25 Aug 06

Question

I had been diognised with
Hyperthyroidism — Graves Diseasefor years with Tapozle. Then my endocrinologist suggest me to take RAI. After RAI, I still hyper, so continue to take Tapozle. After 1 year of RAI, right now I am
Hypothyroidism — after RAI treatment. AndI am on Synthroid 0.088mg for 3 months, then my doc change to Eltroxin 0.05mg now.I am searching for the better treatment for myself because I don’t think these chemical medicine is good for the body. I regret that I took RAI without knowing the serious side effect for my rest of my life. From what I had experienced I will NOT sugguest people to take RAI !! I suffer lots of symtoms after got Hypo. after RAI. Not sleep well, no energy, hair loss, dry skin, feel cold..and I am only 23 years old! I feel helpless…but I believe the natural herbal may be can help me..I found a site
http://www.greenlife-herbal.com/and want you comments. What do you think I should do?? What do think about the western medicine and tradiational herbal treatment?

Waiting for you answer. Thank you a lot!!

Kelly

Response

RAI treatment is the best treatment for Graves’ disease. Appropriate treatment with thyroid hormone is easy and people feel 100%.For dose finding the only important thing is to check serum TSH that should be between 0.4 and 2.0. Both Eltroxin and Synthroid are perfect medications for hypothyroidism. Alternative treatments do not work and life is not possible without the availability of thyroid hormone!!

Georg Hennemann MD


STAPLES IN THE NECK AFTER THYROID SURGERY24 AUG 06

Question

At least ten years ago, I had a goiter removed, surgery went well, no complications. About five years after that, I had to have xrays taken on my neck, and found out by the technicianthat I have staples where my goiter surgery was, actually it is more to the left up the side of my throat! Is this common, or did the Doctor just want to do a “quick” job to get done, or did he forget to remove these? I have since relocated from the area that this surgery was performed, but many times this has been an unanswered question in my head. Can you enlighten me on this matter?

Thank you

Lynn

Response

It is normal to have staples present in the area of prior thyroid surgery, and harmless.

L De Groot,MD


HYPOTHYROIDISM AFTER REMOVAL OF HALF THE THYROID24 AUG 06

Question

I am a 40 year old female. My doctor discovered a tumor on my right thyroid lobe in 2002. I immediately underwent surgery due to results of the ultrasound, uptake and scan. When the surgeon removed the gland tests indicated the tumor was benign, so he left the left lobe in tact.Since this time I have been taking 100 mcg of synthroid daily. I’m not sure how I feel. I have not felt like myself since prior to the surgery. I do know that I feel better when I take the Synthroid than when I’m not because I stopped taking the meds before.I began seeing a new doctor 3 weeks ago. I had not taken the synthroid for approximately 3 weeks so she ordered blood work at that time. I went back today and she told me that my blood work confused her because my TSH was 7.4 and my T4 was 5. and the T3 was 2.4. She wants to repeat my blood work again in two weeks 24 hours after I have taken my synthroid.I don’t understand any of this and I have never asked about my blood work results in the past. I just let them draw the blood and took the meds the Doctor prescribed. I do know that I feel fatigued and catch every virus and cold that I’m around. I also believe that something is affecting my mental health. Can thyroid disease effect all of this and do you have any answers based on the small amount of information I can provide?

Sandia

Response

If one lobe has been removed by surgery, the other lobe usually compensates for the whole thyroid function. In other words, there is usually no additional thyroid hormone substitution needed. It may be that, because you used thyroid hormone that you recently stopped, your thyroid is resuming function that was suppressed by the thyroid medication. I therefore think that is too early to conclude that you need permanent thyroid hormone medication because your TSH is elevated at the moment. I would suggest to wait at least another 8 to 12 weeks before taking a decision about treatment with thyroid hormone for permanent thyroid failure.

Georg Hennemann MD


QUESTIONING THE DIAGNOSIS OF GRAVES’ DISEASE24 AUG 2006

Question

I am a 40 year-old female who has been diagnosed with Grave’s disease, but I am questioning this diagnosis for the following reasons. I have been hypothyroid for 10 years and taking thyroid medication. When I switched to this Dr. she had my blood tested for antibodies, which came back positive. These were my results in 12/04. FT4 was normal at 1.0, TSH was abnormal at 11.584, anti-thyroglobulin AB was 125 (<40 IU/ML) and antithyroid peroxidase was 553 (<35 IU/ML). She put me on thyroid replacement (Synthroid) at that time and told me that I had Grave’s disease because I tested positive for antibodies. I came home and read all that I could find on Grave’s disease, but could not find anything that supported treating GD with thyroid hormone replacement. The next test I had she only tested me for TSH, which was 9.473 in 7/05. Then just recently, she only tested for TSH again, which was 8.023. She has increased the dosage of my medication. Can you please tell me if this is a correct diagnosis? Most of what I have read would point me towards Hashimoto’s Thyroiditis as opposed to Grave’s disease. However, as far as I can tell I do not have a goiter. Is it possible to have autoimmune thyroid disease without having Hash. or Grave’s, or is that for sure what the antibodies are predicting? I would appreciate it so much if you could help me with this. Each time I told my Dr. that I couldn’t find any literature to help back up what she has diagnosed me with, according to my labwork, she tells me that I had hyperthyroidism at one time, but that my thyroid burned out and doesn’t work any more and that is why I am taking thyroid replacement. Is this possible? I have always been very cold, low temp, suffer from bouts of depression, and very tired. I’m just questioning this diagnosis. Thank you for any help you can give.

Anita

Response

You do not have Graves’disease , but auto-immune hypothyroidism. The misunderstanding however is that Graves’ disease and auto-immune hypothyroidism are from the basic causal point of view not very different. Graves’ disease is caused by thyroid auto-antibodies that stimulate the thyroid to hyper function. These antibodies are called Thyroid Stimulating Immunoglobulins ( TSI ). However in Graves’ disease, also thyroid damaging auto-antibodies are being produced, i.e. anti- TPO and anti- Tg . It depends on the ratio of the present stimulating and damaging anti bodies what the clinical picture will be, hyper- or hypothyroidism. If stimulating antibodies prevail hyperthyroidism will ensue, but at the long run the thyroid will be damaged by the concomitantly present damaging antibodies, resulting ultimately in auto-immune hypothyroididsm . If the damaging anti-bodies are initially dominantly present the primary picture is that of auto-immune hypothyroidism. Thus both diseases are caused by the same basic process, but differ in clinical picture.Your doctor has to increase the thyroid medication on the basis of the TSH level that should be between 0.4 and 2.0.


HYPERTHYROIDISM AND WEIGHT GAIN19 AUG 06

Question

I have gained 10 pounds in the last year and haven’t felt myself. Went to Dr. and they tested my thyroid – much to my surprise-they are telling me I am hyperthyroid even though I have a lot of hypothyroid symptoms – My bloodwork and RAI uptake test all came back – over an 8 month period, my TSH has continually been 0.01 and now my Free T3 is high – my endo is recommending that I have a treatment of Iodine Therapy and then take PTU 48 hours after the treatment. Is this the correct approach? I am very nervous. I don’t know what to do.

Tracy

Response

It is exceptionally rare to have weight gain during hyperthyroidism, but it happens indeed! Only if your thyroid is not or only slightly enlarged it is worthwhile trying to treat you for at least one year with an anti-thyroid drug. However relapse occurs in the majority op patients. More and more the first line of treatment is administration of radio-active iodine. It is harmless except for the thyroid that is intentionally being damaged. Hypothyroidism will ensue in due time, frequently already in the first year. But treatment with thyroid hormone is easy. In fact even after (successful) treatment with ant-thyroid drugs, hypothyroidism develops ultimately in many patients, but over a longer period of time.

Georg Hennemann MD


THYROGLOSSAL CYST(16 AUG 2006)

Question

Hi, my name is Dianna and my son has a thryo glossal cyst. He is only 2 years old and I was told that it needs to be removed along with the hyoid bone. Will this cause him any danger getting the hyoid bone removed? Will he still be able to talk normal and be a normal 2 year old. Please help me because he is due to have the surgery soon. Thank you fortaking time to read this.

Thank you,

Dianna

Response

The suggested operation is thecorrect procedurefor this boy. There should be no significant difficulties with swallowing or speech after surgery. The central part (Sistrunk) of the hyoid is removed. If it is not removed, recurrence can occur. If the patient does not have surgery, there is the possibility of a recurrence.

If I can be of further assistance, please let me know.

Edwin Kaplan, MD


HYPOTHYROIDISM AND HIVES

Question

I am scratching myself crazy. I am getting hives several times a day and it’s pushing me over the edge. The hives are coming more often and spreads to a larger area with a burning and crawling sensation. At the end of last year my doctor put me on SynthroidI started out at 100 and elevated to 150 mcg. I stopped taking it @ January after only being on it a cpl of months due to a lost of insurance. In the past several months the hives are back Big Time, I have went from 180 to 255 in 6 months ( I barely eat and my fiancee and daughter are constantly on me to eat—-but I’m getting scared to because of the incredible weight gain;I am 6′ tall so 165-180 is my normal weight – I am 43 yrs old), I am losing hair like there is no tomorrow, my blood pressure is extremely low always, I have absolutely no energy, my periods are extremely irregular and very heavy ( I go through 2-3 boxes of tampons & 2 bottles of Pamprin Max each period- passing ALOT of clots), my face is puffy and at times it is a bit sore, and as weird as it may sound when the hives come my tongue gets fat and it seems with each episode it stays fatter, headaches are constant at this point and it seems to effect my vision alot, and unless I take something – I am constant constipated…am I going crazy? Menopause from hell? or is my thyroid wacked out? My mother died @ 25 years ago, however, I know she had major issues w/her thyroid and even at one point had goiter surgery. My daughter has borderline TSH levels and I have several nieces w/thyroid issues and are on constant medication. Can this be dangerous or just extremely annoying and uncomfortable….I do not have insurance and know retesting and meds are extremely high. My doctor moved to FL at the time I ran out of meds and insurance so I would have to find a new one…..Guess I just want to make sure this isn’t dangerous, as well as, is there anything I can do that isn’t going to put me into financial hell.

Donna Gillstrap

Response

Your complaints and symptoms sound very serious and are quite compatible with severe hypothyroidism! I am compelled to say that going on like this may be life threatening! You may even be in a situation that immediate full replacement with Synthroid may be dangerous too and that substitution has to be done carefully in a graded manner, for instance every for week an increase in dose of only 25 microgram and starting with this dose as well. Appropriate treatment should aim at a TSH level between 0.4 and 2.0. T4 and T3 levels are absolutely unnecessary and cost only money. It is only the TSH that matters.I am really sorry about your financial situation but this is life priority!I can’t exactly explain your hives problem but there may be a connection with your present state of hypothyroidism.

Georg Hennemann, MD


HYPOTHYROIDISM AND HIVES20 JUL 2006

Question

I am a 37 year old female who is experiencing urticaria x 3-4 years. My hives have been progressively getting worse. I recently went to an allergist to be tested, hopefully to receive immunology injections to alleviate this problem. He ordered a series of blood work to determine if my thyroid was normal. My lab results came back with my TSH High at 5.37, my Anti-thyroid ABS–TPO AB is High at 1335,Antithyroglobulin AB High at 77. My IGE, total and Immunoglobs A/G/M QN were all in the normal range. After researching hypothyroidism I have almost every symptom there is–low body temperature, dry/breaking hair/dry eyes/fatigue/weight gain/low bp/irregular periods/increased snoring and unexplained anemia, etc. My other concern is my mother to my knowledge has not had any thyroid problems but she had multiple sclerosis which is another autoimmune disease. Could this autoimmune disease be related to MS?

Thanks,

Pam

Response

Although rare, thyoid auto-immunity (positive for TPO- and Tg antibodies) maybe related to hives. Your thyroid is starting to fail and that will certainly worsen looking at the high level of your TPO antibodies. There is no doubt in my mind that you should start with thyroid hormone (levothyroxine) treatment.

Georg Hennemann, MD


CONCEPTION AND HYPOTHYROIDISM20 JUL 2006

Question

I had missed two cycles on menses, was advised a TSH which turned out to be high. Have got T3 and T4 done. My question is does this affect the chances of me getting pregnant ?how much time would the drugs to get TSH normal and me to start ovulating ? Thanks Fatema Bangalore

Response

It may take several months before you start ovulating again, at least if this symptom is not due to anything else other than your thyroid problem. Patients on thyroid hormone substitution should have a TSH that varies between 0.4 and 2. T4 and T3 levels are not important for dose finding! When you have conceived be aware that you may need about 30% more thyroid hormone during your pregnancy. This is very important for optimal development of your child, in particular the nNervous system. I would advise to start immediately with this increased dose after conception and adjust the dose after 4 weeks to the required TSH interval I indicated. Regular check of your TSH during pregnancy is advised. A TSH during pregnancy no higher than 1.0 is even better. After pregnancy you can reduce the dose to the pre-pregnancy amount.

Georg Hennemann, MD


POSITIVE THYROGLOBULIN ANTIBODIES AND NORMAL TSH

Question

Hi,

I’m so glad I found your site! I’m 41 and feel like I’ve been struggling with fatique for a very long time. I’m a medical technologist so have the ability to run most routine blood work at will. Nothing came to light. Then 2 years ago I learned of estrogen dominance and determined that was part of my problem so I started using natural progesterone cream with great relief(P:E ratio improved too). Now, however, the fatigue has returned somewhat but the bigger battle is with constipation! My TSH has pretty muchrun above 2.5 for the last six years with the exception of one 2.33 value in 2/2005. My highest reading to date was in May at 3.47. I stumbled across something that said kelp could help decrease fibrocystic breasts (it hasn’t!) so about 4 weeks ago I added 225 mcg to my supplements. I ran my TSH last week and it was lower than usual at 2.42…which I attibuted to the kelp. I finally sent my thyroid antibodies off and low and behold my TPO is negative but my Thyroglobulin antibody is high at 91 (lab ref range <20). Is this a common findiing? From what I’ve read it’s usually the opposite. So, could there be a chance that the kelp is causing the high anti-thyroglobulin antibody? If so, please explain b/c I can’t put reason to that. I’ve since stopped the kelp b/c I didn’t realize there is 1mg in my multi-vitamin. I guess there’s always the theory that the 1mg of kelp in my multi-vitamin has been keeping my TSH lower all this time. I feel I’m hypothyroid based on my symptoms and TSH tending to run above 2.5 plus the antibody. My mother is also hypothryoid but not sure if she’s ever had antibodies tested. I’d be curious to hear your thoughts before I head off to an endocrinologist to tell me I’m nuts! I’m a very healthy, active, health conscious person who used to be an energizer bunny. I know age slows one down but geez! Thanks for all you do!

Tracey

Response

Your TSH has always been in the normal range. The variation in values is also quiet normal. It is mostly that when thyroid antibodies are present, it is the TPO that is elevated and not the TG antibody. Having anti TPO increases the risk of future development of hypothyroidism. Your value of 3.47 tends into that direction but not quite. It has been shown that iodide may induce hypothyroidism indeed in susceptible subjects. As your mother had hypothyroidism, and most probably also thyroid antibodies, you probably have that susceptibility , What is your FT4? If that is not lowered, there is no reason to start with thyroid hormone, considering your values. Do not take kelp anymore and test your TSH and FT4 every half year.

Georg Hennemann, MD


NORMAL TSH IN AN INFANT2 Jul 2006

Question

Is the normal reference range of TSH in an infant the same as that for an adult? If not, what is the normal range? Background:- 5 month old girl TSH .473 and I’m getting conflicting information on whether that’s normal but a little low, or something to be concerned about. (And in case you wonder why I don’t ask my doctor: he thought low TSH meant hyPOthyroidism.)

Ariel Shkedi

Response

The normal TSH value is higher particularly in the first few days of life ; <25 mcU/mL on the first day; <20 mcU/mL 2nd day, <10 mcU/mL after the first week. After the first week a value up to 9.1 mcU/mL is normal up to 20 weeks according to the Quest normative data. As you know, it is hard to get one’s hands on good norms. Quest reports the normal TSH from 21 wks to 20 yrs as being 0.7- 6.4 mcU/mL. Another reference gives a range of 0.8-6.3 mcU/mL in the first year of life (progressively lower thereafter), so, at least for a 5 month old, I think that there appears to be good agreement. More information can be found in Chapter 15 of Thyroid Manager.

Rosalind Brown MD


POST-PARTUM HYPERTHYROIDISM

Question

I am a 40 year old female, who gave birth to my third child in January of 2006. Following my pregnancy, I have developed a thyroid problem. Slowly of time, it continues to get slightly worse…my T3 is now 277 and my TSH is <0.01. I was referred to an endocrinologist, who put me on 5mg of Tapazole, but I developed bad hives from it. So, I have since stopped the medication. I also have a “lump” on the right side of my thryoid, that seems to move when I swallow. My doctor seems to have the lets wait and see mode…I have also lost a bit a weight. He says if I loose four more pounds to call him. Am I wrong to tell him that I want an ultrasound to be on the safe side?

Cheryl

Response

It is unfortunately not uncommon, that women develop thyroid problems within one year after delivery. This condition is called “post partum thyroiditis”. It is caused by antibodies that circulate in your blood that are directed against your thyroid. They can cause both hyperthyroidism (increased thyroid function), but also hypofunction of the thyroid (hypothyroidism) or alternatively both conditions. In your case apparently hyperthyroidism. This condition may disappear spontaneously in weeks or months. If you are allergic to tapazole, your doctor has the following options for treatment. Treat with PTU, that also inhibits thyroid function but in 50% of cases that are allergic to Tapazole also induce allergic symptoms. You can try it and if it also is allergic to you, propranol is the best alternative. It does not affect thyroid function but suppresses the symptoms of hyper function. If your hyperthyroidism does not subside over a few months, I would advise treatment with radio-active iodine. If your hyperthyroidism does resolve spontaneously then regular thyroid function tests, throughout your whole life, are obligatory as you have a risk of ultimately developing hypothyroidism any time in your life. If spontaneous resolution occurs, the risk of developing hyper- or hypothyroidism during or after a next pregnancy is increased and regular thyroid testing should be performed during that time. Ultra sound of your thyroid will be of little help in this problem. However a lump may point to a hyperactive nodule. If this is the case than your hyperthyroidism is caused by this node and this condition is not related to your pregnancy. It may have developed coincidentally. To investigate this, a radio-active scan would appropriate to establish the diagnosis. In that case it should be treated by operation, ethanol injection or laser therapy. Treatment with drugs is useless.I hope this answer is of some help to you.

Regards,

Georg Hennemann, MD


THYROID MEDICATION AND HAIR LOSS

Question

I am trying to understand my current condition of HYPOTHYROID. My biggest concern is excessively falling hair. The situation is quite bad. I have tried everything from homeopathy to chinese medicine but no success.I list below my blood test of date 1. What is your blood test result most recently?















































Feb 24-06 June 06-06
FT3 3.7 2.9
FT4 18.6 14.0
TSH 0.11 1.10
Anti Thyroglobulin Abs 3.7 2.6
Anti Thyroperoxidase Abs 61.4 424.4
Iron 7umol/L 15
Folic Acid 51.5
Red Cell Folic Acid 885

Between Feb-06 to June-06 my dosage has changed. Till Feb-06 I was taking 125mcg per day. From June and now, I take Mon, Wednesday, Friday, Sunday take 100mcg. On Tuesday, Thursday and Saturday I take 150 mcg. My Iron was low, so I take natural snowdonia water to help get over my iron deficiency. I have just started to take KELP as you will notice that my AntiTHyroperoxidase Abs is very high which means I am seriously Iodine deficient. I also take Multivitamin with minerals, Vit A 7mg and Betacarotene -1 a day. andVIT D + Calcium 1250mg – each tablet – taking 2 tablets a day.If there is anything you can suggest to improve myhair falling problem woudl appreciate it. Ihave: no fatigue, no constipation (never did), good sleep, good energy. Sometimes less concentration, falling hair – handfuls , cold hands and feet,swelling on top of my eye lids in the morning and swelling under my eyes – more on the right hand side.I am going to a homeopath also but it has not helped at all.Pleaselet me know if there is anything that can help me reducemy hair loss.

Kind regards,

Gohar

Response

You were overdosed indeed with 125 ug, but on 100 ug T4 you are OK. I can see this from the TSH values. My advise is that your TSH should be kept between 0,4 and 2. If your falling hair were to be due to variations in T4 dosing then it will surely recover if your present TSH stays between the range that I indicate here. This may take some time even a few months. If it does not normalize then there must be another reason, for instance varying iron levels sometimes dropping below 10. What is the reason for this low iron level. Do you suffer from heavy menstrual blood loss? If not, you may discuss this with your doctor. The thyroid antibodies will not hurt you and there is no reason to take extra iodine. You are now taking thyroid hormone and you are not anymore dependent on iodine. I can hardly believe that iodine deficiency would still occur in the US. Extra iodine may however affect your thyroid if there is still some functioning left. It may aggravate the hypothyroidism but also induce hyperthyroidism.A last advise. Why don’t you use iron tablets? It is probably cheaper and contains a constant amount of iron.

Georg Hennemann, MD


Thyroglossal cyst

Question

Thyroglossal cyst When I was a child I had a thyroglossal cyst removed from under the neck, it returned and a second surgery removing the hyoid bone and soft tissue around the neck and throat were removed because of the cyst’s “track.” I am 32 years old now and when I get a cold it immediately turns into pain and mucous in the throat. I have trouble removing the mucous, and swallowing during this time, and my neck glands become sore and swollen. My doctor’s say by looking in the throat they see nothing. Is this a normal occurrence for people who have had a cyst removed?

Dana Clary

Response

Removal of a thyroglossal cyst and twice operated for, is such a rare event, that I think that nobody has any experience such to tell you if your complaints are ‘common’ for this surgery. It seems to me that your complaints are directly caused by the cold, for which they are certainly ‘normal’, rather then anything else. However your second operation was certainly relatively extensive and may aggravate these symptoms.

Georg Hennemann, MD


THYROID ANTIBODIES AND QUESTIONABLE HYPOTHYROIDISM6 June 2006

Question

Hi, I am a 50 year old woman. Since age 12, I’ve experienced repeated bouts of over activity followed by under activity, the duration and recovery of each bout has also increased over the years. I’ve been unable to return to work since 1993. I heard about Hashimoto’s and requested tests in March 1996, TSH 2.3 and T4 80 (previously 1.1 and 94 respectively in Jan 94).

April 96

October 1996

Antithyroglobulin

Neg

1:100

Antimicrosomal

1:400

1:25600

I started on 25 mcg Thyroxin, increasing over 15 months to 100mcg, but could not find a dose that returned me to ‘normal’, my TSH also fluctuated – 1.4/0.2/1.5/0.2/1.2. I was concerned about taking replacement T4 when antibodies can also increase T4, but both my GP and Endo said not to worry. I settled on 75mcg for the next 3 years, even though I still experienced fluctuating symptoms I felt overall much better with a clearer mind and sleep down to 8-10 hrs. I was still not able to work but was able to start an OU physics degree course.

T4

TSH

T4

TSH

Dose

T4

TSH

T3

20-1-99

1.8

22-5-02

31.6

0.1

75mcg

9-5-03

18.6

<0.1

2.1

29-3-99

22.1

0.3

30-8-02

22.3

<0.1

50mcg

2-6-03

17.4

<0.1

1.8

6-4-00

30.7

0.1

9-12-02

24.9

<0.1

25mcg

23-9-03

1.0

24-8-00

1.9

18-3-03

24.4

0.1

0mcg

23-1-04

1.2

9-3-01

28.5

10-8-04

1.22

By May ‘02 I felt so hyper that I started to decrease my dose of Thyroxine and have had none since March ‘03. In May 2003 Anti-TPO was 1212 u/ml. I believe the low TSH was due to the antibodies but GP thinks it was over-replacement – What is your opinion? I have continually deteriorated since and now am unable to concentrate on my coursework and sleep 12-16 hrs a day (as well as other symptoms). GP won’t put me back on replacement but has referred me to Endo. I’ve been reading about T4/T3 combo for people who continue to have symptoms on replacement T4 only. What is your opinion and what tests should I expect the Endo to do? My latest TSH was 2.65 in Dec ‘05. I am not sure if you reply by e-mail or only on your site. It would therefore be appreciated if you would e-mail me as to whether you are able to respond to my questions or not.

Thank you in anticipation.

AJ McGowan

Response

It strikes me, if correctly understood, that you started on thyroxin while you were not hypothyroid? I agree that you have high titers of thyroid antibodies, but that does not automatically imply underactivity of the thyroid! Or did you have an elevated TSH at that time? At any rate, your present situation shows that your thyroid is normally functioning without medication! Consequently meaning, that the antibodies have not damaged your thyroid to the extent that it can not function normally. A point of note is the fact that even a low dose of thyroxin. i.e. 25 microgram suppresses your TSH which does not occur in subjects without thyroid affection. In normal subjects the TSH stays in the normal range with this dose. In your case this is probably explained by the fact that you have also an other thyroid antibody circulating named TSI which stands for Thyroid Stimulating Immunoglobulin. This antibody contrary to the other ones does not damage, but stimulates the thyroid and can not be suppressed by thyroxin. Hence the lowering effect on your TSH. My suggestion is that you keep discontinuing thyroxin usage, but keep a close watch on your TSH. My guess is that ultimately you really will develop Hashimoto and then it is time to start with thyroxin. Be aware, and not all doctors realize this, is that when on thyroxin, you have to keep your TSH between 0.4 and 2. The values of T4 and T3 are not important in the dosing of thyroxin in those situations.

Georg Hennemann, MD


RAI TREATMENT, FERTILITY, AND EYE PROBLEMS3 May 2006

Question

I am a patient I have been fighting Graves disease for almost 4 years I have almost gone into remission 2 times using tapazole. This last time I came closer then ever and was put on synthroid because my thyroid level was low. They took me off the synthroid for6 weeks and when my thyroid levels didn’t normalize they did an ultrasound and uptake and discovered the graves had come back and now my doctor wants to do RAI and I am very worried about the side effects Namely thyroid eye disease and difficulty getting pregnant as well as the possibility for the disease coming back. I have detached retinas in both eyes that have been operated on and I am legally blind I am worried if I do the RAI my eyes will get worse. I have also had Cerebral palsy since birth and I am worried how these conditions may be effected. My doctor says RAI doesn’t effect fertility is this true. How will my other conditions be effected by the RAI and can it come back after the RAI? I want to go back on the tapazole because RAI terrifies me? Please respond if you can do so thanks.

Eidwriter@aol.com

Response

I think that I understand your problem fully. 1.RAJ does not affect fertility 2.There is no side effect of RAJ treatment established so far in the many million patients treated as such, despite scrutinized follow up over more than 50 years, but for one exception and that concerns you in particular. That is that in a minority of patients eye problems may be induced. In essence these signs involve an increase in volume of the tissue behind the eyeball causing bulging of the eye outwards. This process may consequently lead to increased intra-occular pressure that probably may increase the risk for a 3 retinal ablation. It is possible to prevent this complication by administration of prednisone before treatment and for several weeks thereafter. However this scenario seems to be equally risky for you as prednisone may raise intra-occular pressure as well. My conclusion is that there are 2 remaining options for you. 1.Start again with tapazole. However this treatment does not always prevent eye problems, especially if it is not performed with a full inhibiting dose of tapazole on thyroid function in combination with a dose of thyroid hormone that keeps the TSH in the low-normal range. Even then eye signs, though rarely, can not always be prevented 2.So my final advice to you is to have your thyroid (near) totally removed by a very experienced surgeon. The less thyroid tissue remains, the lower risk of developing eye problems in the future. I suggest that this operation should be done by a thyroid surgeon experienced in operating patients with thyroid cancer as they are used to perform total thyroidectomies.

Georg Henneman, MD


THYROID TUMOR WITH NEGATIVE IMAGING AND POSITIVE TG18 MAY 06

Question

I’m a 30 year old male who has PTC and has had: A partial thyroidectomy (right side tumor ~10cm and attached to all surrounding structures, with lymph node metastis which were removed), Surgery to remove the remainder of the thyroid (no tumor, but left lymph node metastis which were removed), I-131 treatment on two occassions with 150 mCu on each occassion, Numerous I-131 WBS with negative results, Numerous US with negative results, Numerous chest and neck CT’s with negative results, One whole body PET scan with negative results. However, my Tg is significantly elevated (not sure of the exact level). My questions are: Given that no tumor can be found through imaging, what are my options for next steps? Where could the residual tissue be located? Will further I-131 treatments are required? Would a neck dissection be required?Thanks.Any help would be appreciated as this has been a two year ordeal and I see no end in sight.

B Woodford

Response

Your problem is, unfortunately, not rare, and causes both the patient and physician a great deal of distress. There is no perfect answer. To begin, I assume that your antibody test is negative, so that the TG assay is meaningful. If so, to some extent the answer depends on how high the TG is with TSH suppressed, and with TSH stimulation, and whether the TG level is rising, stable, or even falling,over time. Another question is whether the post therapy scan with that 150mCi treatment was negative, or not? So long as there is no identifiable tumor lesion on any modality, and in view of your prior therapy, there is probably little to do except for continued follow-up with TG, US, and sometimes 131-I scan and PET scan. More specific answers to your questions should come via discussion with your own MD, who knows you, your exam, and your treatment history. L De Groot, MD.

THYROXIN THERAPY IS FOREVER?16 MAY 2006

Question

I am wanting to know if once you are diagnosed Thyroid problems does it ever go away.Meaning once you are on Synthyroid do you ever stop meds or does it mean you have this problem for life or does it get betteras the doctors here are telling methat you can get better with time.??? As I had always been on meds for a while then moved to the UK-military doctors took me off when I got here said i was in the normal range…but I have all my symptoms that it is not better. I am suppose to see internal meds this month and they are going to look into futher but when i was in the states when to Endo doctor and with my low pulse and all the other symptoms was put on Synthyroid it helped lots. But now i have stuggled since Jan 04 with doctors here as they say i am in the normal range isnt everyone normal range different from one person to the next? And sometimes some of the doctors would not even do any more than a TSH test no T3 or T4. I am waiting to get those test back now. Please if you can possibly answer any or some of my questions it would be greatly appreciated. I am so in need of help and for someone to let me know if I am in the right direction.

Thanks so very much,

Beth Wray, Military Wife

Response

Presumably you are on synthroid because of an underactive thyroid. This almost certainly will not go away and you will need to stay on thyroid replacement therapy for ever. There are a few people in whom it does go away and this can cause a lot of confusion.If the blood tests suggest a very overactive thyroid while on synthroid it would be advisable to stop it for at least 1 month and then be retested. Please note this is a rare event Normally you should have a TSH and a T4 measurement done for routine evaluation of Synthroid therapy. The TSH level in your case should ideally be in the lower range of normal but if it is a bit lower than that it probably doesn’t matter. I hope these comments are helpful.

John Lazarus, MD


CHANGING SOURCE OF THYROXIN14 MAY 2006

Question

I have been on thyroxine for 9 years and take 200mg daily for an under active thyroid. My question is that I have recently shifted from New Zealand to Australia and have changed the medication to oroxine and would like to know if there is any difference in the composition in the making of the tablets. I have developed un explained headaches – all the usual reasons have been eliminated by scans etc. I am trying to eliminate all possible causes and was hoping that you would be able to answer my question. Many thanks.

Maree Wright

Response

There may be some difference between these medications, predominantly by differences in absorption from the gut. This is however easy to solve. Take just that dose of oroxine that keeps your TSH between 0.4 and 2.0uU/ML. It may take some time to find the proper dose. Do not change dose sooner than once a month. The values of T4 and T3 do not matter for dose finding.

Georg Hennemann, MD


RAI TREATMENT AND PREGNANCY10 MAY 2006

Question

My husband who is 30 years now was diagnosed with Papillary carcinoma of thyroid two years back(2004).In Sep 2004 a total thyoidactomy was done and he was adivsed to have 300mcg of Eltroxin. In Nov 2004 he had RAI.While this iodine treatment was going on i was 20 weeks pregnent and 4 weeks later i had to go in for an MTP due to the child having TOF(Tetrollogy of Fallots). Since the doctor advised us to wait for one year after the radiation for another child, i didn’t conceive for one year. In Aug 2005, he started getting giddiness and the doctor found that Eltroxin intake was high and reduced the dose to 200mcg. After two months in October 2005 again he had RAI and found that no spread of cancer in the body.The Eltroxin tablet was increased to 250mcg subsequently. The doctor again advised us to wait for one year after the second radiation to conceive.

My questions are the following:

1. Can i conceive after one year (by September 2006).Is it safe?

2. If i conceive will the child have any defects since he had two RAI?

3. Will there be any infertility problem for my husband ? or do we need to go in for a sperm test before conceiving to check the whether radiation is still present in the body.

4. I am assuming that my first child had ToF because when my husband had RAI i had accompanied him to hospital and also during the time of his surgery (Sep 2004) i was with him in the hospital inmy 8th week of pregnency for a week after the surgery.

5. If i conceive and in case ny husband has to undergo another RAI what steps do i need to take.

6.Do i need to check my husbands T3,T4 and TSH levels before conceiving.

Thanks,

Elizabeth

Response

1. Yes. Generally it is advised for males to wait 6 months after RAI before starting a pregnancy, but there is no hard datato supportthis suggested time period.

2. There is a 4 percent chance of a fetal abnormality is all pregnancies. The added risk related to prior 131-I treatment is very low, and is usually ignored. However the occurrence of a previous abnormality raises a concern that you should discuss with your Obstetrician. I do not think the occurrence of the Tetrology could be related to your husband’s treatment when you were in the 20th week of pregnancy.

3. Fertility could be reduced. There can be no RAI left at this point. I do not think there is any practical test that can be done to answer the question you raise.

4. See above.

5. You must discuss this carefully with the therapist. Mainly you need to avoid close contact for about a week. 6. The dose of medication that he is on probably makes him mildly hyperthyroid. While not dangerous, it might be reduced toward a more normal level.

L De Groot, MD


T3 FOR WEIGHT LOSS

Question

For years I have tried to loose weight. I have a small goider but nothing serious with no changes. My T3.T4. TSH, Free T3, etc. always come back within normal range. My hair is falling out, I am always cold, plus other symptoms that point to thryoid issues. I am close to putting myself on a trial of a T3 thyroid medication. What are your thoughts?

Thank you for your time and attention,

TPerk1211@aol.com

Response

Using T3 to loose weight is dangerous. It mainly decreases your body protein meaning that your organs like muscle, heart, liver etc are being damaged, while your body fat is hardly affected.

G Hennemann, MD


EYE PROBLEMS, ON STEROIDS

Question

I have been on prednisone for over 4 months. I was put on it for my eye lidswelling and bulging with severe pain. A CT showed the muscle in the back of the eye and right side of the eye not working correctly.Every time we try to get off the prednisone, it swells again. I had T3,T4, and TSH done and all came back normal.I went to a new Dr and he did thyroid antibodies and it came back none. I had another CT done today. Can you give me any clue has to what this can be?

Kathy

Response

Usually eye signs are decreasing spontaneously over time, what may take years. Mild and moderate eye signs are at present not routinely irradiated by X ray. However if eye signs are more severe irradiation should be considered seriously. Also when eye muscles are not functioning well in the sense that they do not move precisely simultaneously, they may be infiltrated by fibrous tissue, which stays there more or less permanently. This may lead to squinting. In this situation I advise orbital irradiation under supervision of an experiencedendocrinologist and radiologist. Good luck!

Georg Hennemann, MD


CONCERNS ABOUT THYROID DAMAGE3 Apr 2006

Responses by G Hennemann, MD

Do you know of any medications that can cause your Thyroid to be over active? Iodine in susceptible people Also do you know if a person has had surgery in that area C 5 C 6 Fusion. Could there be signs of scar tissue that could shoot off the Thyroid hormones into the Blood stream?

Highly improbable

If so could this cause the T3 T4 levels to change?

See above

Why would you need an Biopsy of the area with aspiration of small needle of the gland?

Because a small needle is much simpler and less damaging than a thru cut biopsy

Can this also cause voice problems?

Not if properly done.

Thanks,

Carolgammon1@aol.com


THYROID CYSTS AND THYROXIN TREATMENT13 March 2006

Question

Good day to you Doctor. I’m Juvy C. Garcia here in Guam, USA, 42 years old. Two years ago (March 09, 2004 to be exact), I underwent a Thyroid Ultrasound Test. The findings was “There are two focal lesions. In the superior pole of the right lobe, there is an entirely anechoic lesion measuring 7 x 4 x 5mm. There is quite hypoechoic sharply demarcated 4 x 2 x 3 mm lesion in the extreme interior aspect of the right lower pole. The background thyroid stromal echotexture is normal. There are no other focal hepatic abnormalities. There are no areas of abnormal stromal echotexture.IMPRESSION: THIS IS A NEAR NORMAL EXAMINATION. THE TWO LESIONS IN THE RIGHT LOBE OF THE THYROID GLAND HAVE EXTREMELY BENIGN CHARACTERISTICS. My questions are as follows: 1. When I had vacation in the Philippines, I had it biopsied and Thank GOD, it turned out to be negative for malignant cells. Doctor my question is, if it was diagnosed non-malignant the first time, will it turned out to be malignant after two years? 2. Sometimes, I feel pain but not too much? It’s like feel that it has grown or it’s just in my mind. What is this Doctor? 3. My Doctor prescribed me Eltroxin? Is this a good medicine? And what are the side effects of this medicine? 4. Will it be good to just continue taking it because I stopped it for awhile.

Thank you so much.

Juvy

Response

I get the impression that the focal lesions are cysts. A cyst is defined as an entirely an- or hypoechoic lesion with a sharp demarcation all around. You do not mention anything about the demarcation of the lesion in the upper part of the right lobe. But as this lesion is anechoic I presume that this is a cyst as well. Thus probably you have 2 cysts in your thyroid. Cysts are by definition non-malignant, because they have no cellular lining on the inside and if there are no cells, then there is obviously no malignancy present. There is usually little effect of thyroid hormone treatment on cysts. Cysts usually do not cause pain, so it may be in your mind. If they cause pressure feelings in the neck and or are disfiguring the first line of treatment is aspiration of the fluid and subsequent rinsing of the cyst with alcohol. This procedure can be repeated say 3 times in a period of 3 months. They may disappear completely or partially that may be often considered as sufficient. If there is no effect at all, operation is the only remaining option. There is little chance that thyroid hormone treatment will have a sufficient effect, but there is noting against it to try this. To do this optimally the dosage of thyroid hormone should be chosen such that your TSH comes down just above the lower normal level oh the assay. If after half a year there is no effect. You may discontinue thyroid hormone gradually in a 2 week period. However if there is an effect you should not be surprised if the cysts relapse.

Georg Hennemann, MD


MAXIMUM DOSE OF THYROXIN10 MARCH 2006

Question

My query is what is the maximum dose per day of l- thyroxin in adults?

khanhasinkhan@hotmail.com

Response

There is no specific ‘maximum dose’. You have reached the proper maximum dose when the TSH of the patient stabilizes between 0.4 and maximally 2.0 uU/ml.

Georg Hennemann, MD


THYROXIN DOSE AFTER PREGNANCY8 MARCH 2006

Question

Not a physician but in need of assistance. I was diagnosed as having Graves disease in ’97. I chose radio active iodine as my solution. I went off to college and had a horrible 1st year not being able to get back in touch with my Endo who did not inform me and my parents of the need for continued meds. In early 2005 I finally got pregnant. I had been going steady on 88mg for about 2 yrs and got increased from 125mg to 112mg during the pregnancy. I gave birth in Oct. and my dose was decreased to 100mg in December. in mid Jan my TSH was @ .43. Now in early March my TSH is .088 and my T4-Free is 1.98. My Dr. advises to decrease back to 88mg. My question is will this be a sufficient decrease? Can this affect my child in any way in regards to affecting the quality and amount of breast milk? I originally thought the dose needed to be increased as I seem to be having the same symptoms as when I did the radioactive iodine e.g.. significant hair loss, weight gain despite working out three days a week(I have always been skinny), lethargic, depressed etc. I read an earlier response also about cold medicines not affecting properly managed individuals. I have found that I get palpitations and shortness of breath when taking them. I’ve just settled for OJ and water as my cures. Any other suggestions?

Coleen Jackson

Response

Probably you will need to go back to the same dose you took before pregnancy, if your weight is about back to normal. The tiny excess hormone (if present) certainly will have no adverse effect on your infant. Mild hyperthyroidism could relate to palpitations, but I hesitate to relate it to your other symptoms.

L De Groot,MD


HAIR LOSS AND NORMAL THYROID TESTS21 Feb 2006

Question

What do you know about Wilson’s Thyroid Syndrome and T3 & T4 treatments? In July, 2005, I had my thyroid levels tested. Everything was considered “in range”, except Antithyroid Peroxidase which was 46 when range should be <35 Iu/ml. As a result, I was diagnosed as Hypothyroid and began the Wilson’s Thyroid Syndrome regiment (T3/T4 compounds) in July, 2005 (for about 7 months now) where I take my temperature every morning, evening. Starting with 7.5 mg, If my temperature is below 98.6, I would escalate up another 7.5 mg etc. up to 37.5 mg. My temperature is steadily around 97.9 – 98.1. I have felt an increase in my energy level and able to sleep much better at night, plus my night sweats were eliminated. However, I am experiencing an abnormally severe hair loss. I am 50 years old, and have always had issues with hair breakage—but they were short pieces, spurts of growth and then slight breakage (due dry hair and possibly peri-menopause). Now I am losing full, long strands with white bulbs on the tips to a point of bald patches in the back and sides of my head. Additionally, I am experiencing severe thinning in the top —you can see clear through my hair to see my scalp. I do not have a perm or use chemicals on my hair. I do use hair coloring, but brands with no peroxide. It’s winter where I live, but my skin is dry and is very itchy and stings. I am frantically scratching—but there is no rash. I have not lost any weight as I was expecting. My metabolism seems to still be slow. In August, 2005, a sonogram indicated a large mixed nodule on the left side w/ no abnormality—2.0cm x 2.7cm in diameter. A biopsy showed it was not malignant. I am not experiencing any pain—so I have not made a decision to have removed at this time. What do you recommend my next steps should be? I have made the decision to stop the T3/T4 regiment as I only experienced this drastic hair loss since being on the medication. My dermatologist is baffled. My thyroid surgeon recommended I see a Doctor of Internal Medicine—I’m confused. Do I need to see an Endocrinologist or Hormone specialist? Is there something else I should be taking for my hypothyroidism, or to generate hair growth? I want so much to solve my hair loss problem and am not sure what’s causing the loss. Will it grow back? Can you give me some general direction where to begin? T3, Total – in range at 1.2 Reference 0.6 – 1.8 ng/ml T3 Uptake – in range 29.53 Reference 24.4 – 39.1% TriiodoThyronine Free 2.6 Reference 2.3-4.2 pg/ml T4, Total – in range 7.2 Reference 6.5-10.5 mcg/dl Free Thyroxine Index 7.1 Reference 6.0-11.4 Free Thyroxine (FT4) 1.0 Reference 0.8 – 1.8 ng/dl TSH (3 Generation) 1.620 Reference 0.35-5.50 mciu/ml Anti-thyroglobulin AB <20 Reference <40 iu/ml Thyroglobulin 23.7 Reference <=55.0 ng/ml AntiThyroid Peroxidase Out of Range 46 Reference <35 iu/ml Even though I was primarily “in range”, my symptoms were low energy, low sex drive, wintery skin, restless nights, irritability, inability to lose weight, night sweats, stiffness, hot/cold intolerance. My doctor felt it was better to treat the symptoms. There has been some improvement as noted below. But no weight loss (not 1 lb), low sex drive, wintery skin, hot/cold intolerance is still a factor

Diane Peoples

Response

You had a thorough set of thyroid tests, and they are all normal. Thus it is not possible to attribute your symptoms to a lack of thyroid hormone, no matter what your arm-pit temperature is.The predicament you have is similar to that bothering many middle aged women.There are many causes for hair loss, so you need a careful medical evaluation, which unfortunately often ends up “negative”. Hair loss is certainly associated with alterations in thyroid hormone levels, especially when changing from hyper- to hypo- and back again. Hair loss is common with aging, serious illness, psychological stress, excess androgens, and can be due to autoimmunity. You apparently have low levels of anti-thyroid antibodies, so to some extent, Hashimoto’s thyroiditis. This could possibly be related to hair loss, but in view of normal thyroid function, does not offer an approach for treatment. So probably the best advice is to have a thorough medical exam to rule out other illness, consult your dermatologist about possible treatments, but notexpect miracles to recover the hair.

L De Groot, MD


PAINFUL HASHIMOTO’S THYROIDITIS10 FEB 2006

Question

I am not a doctor, but am in need of advice. If you cannot reply, I understand. I am a 40 year old female that was diagnosed with hypothyroidism six years ago. I was placed on levothyroxine and up until one year ago, was doing fine. In January of 2005, I started losing weight. Then in June of 2005, my thyroid became enlarged, with significant pain. My doctor sent me to an endocrinologist, who diagnosed subacute painful thyroiditis. At this time, my TSH was low, and FT4 was high and my T3 number was so high that it did not register. I had all of the symptoms of hyperthyroidism. I was placed on a beta blocker and was taken off of my levothyroxine. The enlarged thyroid and pain persisted, and in July I was placed on 40 mg of prednisone per day. At this time, I also went back on the levothyroxine, at 125 mcg. After a month of prednisone, they tapered my dosage, but as soon as I got down to 10 mg, the inflammation and pain would come back. I was then sent to the University of Michigan Health Center, where they diagnosed me with Hashimoto’s thyroiditis. After one month, I was to again told to taper my dosage of prednisone and again when I got down to 10 mg, the inflammation and pain would come back. We tried to taper the dosage eight times, with no success. I went back to the University of Michigan in January 2006. The ultrasound confirmed the Hashimoto’s and the thyroid is still enlarged. At this time, I was taking 5 mg of prednisone per day and I was instructed to stop taking the prednisone on 1/27/06. Two days off of the prednisone, I had severe prednisone withdrawal symptoms along with a very enlarged thyroid, and extreme pain. I am back on 5 mg of prednisone. They have also placed me back on a beta blocker, as I have episodes of heart pounding and tremors. I am currently having weekly flare ups and the thyroid is still quite enlarged. There are days that you can see it from across the room and it has been extremely tender. During these flare ups, I have difficulty swallowing, and the pain radiates up into the ears. U of M told me that I have two options. One is to stay on the prednisone for another 6 months to a year or the other is to have a thyroidectomy. The side effects from the prednisone have been horrible. I have a history of ulcers, and take Prevacid daily. My bones are becoming brittle. I broke a rib from coughing. I have bad leg cramps and weakness. I am told that because of the enlarged thyroid, and because it has been enlarged for so long, surgery risks are increased. Is this true? My question is, are these my only two options, or should I get another opinion? I am afraid about the risks of surgery, but am desperate to get my quality of living back to what it should be. Any insight that you can provide would be greatly appreciated.

Julie Lofgren

Response

Assuming everything you say is “as is”, and that the diagnosis is really painful Hashimoto’s thyroiditis (and not subacute thyroiditis), thyroidectomy sounds like a conservative answer to your struggle. We have reported this problem, treated with surgery, and sometimes RAI in addition.(Go to PUBMED on your browser and search for “degroot lj AND painful thyroiditis”)

L De Groot,MD


FLUORIDE AND THYROID FUNCTION6 Feb 06

Does fluoride indeed affect the thyroid levels? I have Hypothyroidism and take Levothyroxine.137 1x daily. I am a Dental Hygienist and I would like to know for myself and for my patients. I use a fluoride toothpaste and I recommend it to my patients. I also give every patient a fluoride treatment after a cleaning. So any information would be very helpful.

Thank You.

Robin Carney RDH

Response

I have never heard that the concentrations used in toothpaste en the tablets given to children affect the thyroid in any way.Below you find a report of a study in workers contaminated with fluoride because of their work that do not affect thyroid hormone blood levels. I do not know what amount you use after teeth cleaning. Is that really necessary when you use fluoride also in toothpaste? You may know that fluoride in toxic doses may cause bone abnormalities.

See also abstract below.

Georg Hennemann, MD

Epidemiologic assessment of worker serum perfluorooctanesulfonate (PFOS) and perfluorooctanoate (PFOA) concentrations and medical surveillance examinations.

Olsen GW
,

Burris JM
,

Burlew MM
,

Mandel JH
.
J Occup Environ Med.2003 Mar;45(3):260-70. Perfluorooctanesulfonyl fluoride (POSF, C8F17SO2F) is used to create applications for surfactants and paper, packaging, and surface (e.g., carpets, textiles) protectants. Such POSF-based products or their residuals may degrade or metabolize to PFOS (C8F17SO3-). PFOS concentrates in liver and serum and results in hypolipidemia as an early effect of cumulative dosages. Male and female employees of two perfluorooctanyl-manufacturing locations (Antwerp, Belgium and Decatur, Alabama) participated in a periodic medical surveillance program that included hematology, clinical chemistry, thyroid hormone, and urinalysis testing. Serum concentrations of PFOS and perfluorooctanoate (PFOA, C7F15CO2-, used as a fluoropolymer emulsifier) were measured via mass spectrometry methods. The mean serum PFOS and PFOA concentrations for 263 Decatur employees were 1.32 parts per million (ppm; geometric mean 0.91, range 0.06-10.06 ppm) and 1.78 ppm (geometric mean 1.13, range 0.04-12.70 ppm), respectively. Mean concentrations were approximately 50% lower among 255 Antwerp workers. Adjusting for potential confounding factors, there were no substantial changes in hematological, lipid, hepatic, thyroid, or urinary parameters consistent with the known toxicological effects of PFOS or PFOA in cross-sectional or longitudinal analyses of the workers’ measured serum fluorochemical concentrations.


HYPOTHYROID AFTER TREATMENT FOR TOXIC MULTINODULAR GOITER

Question

I am writing you for help. I have been a thyroid patient in some form for the last 8 years. The reason I am stating in some form is that I have had several thyroid related issues in the last 8 years. My first abnormal TSH test came back in August of 1998 with a level of 0.32. After a couple of other blood work ups I was sent for an uptake and scan. At that time my scan showed a large hot nodule and an increased uptake. My PCP at that time thought I had subclinical thyroiditis. They placed me on a high dose of prednisone to be tapered off with in four weeks. After two weeks I went in for a follow up and my doc decided to taper me off quickly as I had gained 12 pounds in that two weeks and my symptoms showed no change. At that time I began having more symptoms of hyperthyroidism with the rapid heart rate, hot flashes, insomnia, and inability to concentrate. Unlike most hyperthyroid patients I had an increased weight. It took me until April of 1999 to began being taken seriously for my symptoms as my doctor noticed that the right lobe which had the hot nodule was becoming larger. At that point I had an ultrasound done and another uptake and scan. The ultrasound showed a cold nodule with no blood flow. The uptake and scan again showed increased uptake and a hot nodule that was slightly larger than the original scan. I do not know the exact levels of the uptake. I then was referred to a general surgeon as my symptoms had increased. I had neck pain, difficulty swallowing, rapid heart rate, hot flashes, insomnia,mood swings,muscle weakness, and severe fatigue. At that time my surgeon diagnosed me with Plummer’s Disease (Toxic Nodular Goiter). I was scheduled for surgery two weeks later. Surgery took longer than expected due to the size of the nodule once the surgery was under way. My doctor told me it was golf ball size so that I would be able to understand opposed to millimeters. I began to notice a remarkable difference almost immediately. I lost all of the 40 pounds I gained in total and felt great.

About a year and a half later I began to feel bad again. I had problems again with weight gain, muscle weakness, mood swings, heart palpitations. I had them run my labs and the only abnormal result was my T3 which at that time came back as 291. Since I had already had the right lobe of my thyroid removed they thought that maybe I was beginning thyroid decline which I had been warned might happen. At that time they put me on .25 synthroid. My symptoms worsened, I began sleeping all the time and had no energy. They changed it to 25 of cytomel to see if maybe there was a conversion issue. I felt better and had a little more energy. I stayed this way for close to another year. As I continued to gain weight and feel worse, I just thought it was me and this is how I was supposed to feel. I went to the doctor in May of 2003 and had labs drawn. Again my TSH and T4 were normal. My T3 again was 246 still way above normal. My doc at the time refused to do anything stating they weren’t abnormal enough to worry about even with my history. I began to see another doctor who was a little more progressive. He suggested a new uptake and scan. The scan showed increased uptake on the left side that remained and some residual growth on the right side. At that time my TSH was back into the hyperthyroid stage again. I was sent to a endocrinologist who did a physical examination, and review of labs and the uptake and scan, as well as new blood work. My TSH at that point measured 0.17. I was diagnosed at that time with Grave’s Disease and due to increased risk due to scar tissue it was suggested that I have RAI. I went in two days later for the RAI of 17 microcurions (sp?). Within 2 days I began to have symptoms of radiation thyroiditis. My endocrinologist considered it the worst case he had ever seen and that I was lucky at that point to only have half of my thyroid as it was severly swollen. Within 6 weeks I had a TSH of 79. I began levoxyl at that time. I began at 127 then moved down to 112 back up to 127 then 137 to 150 and finally to 175. At that time I was asked to come back in 6 months. I did not have insurance 6 months later and my doctor would not refill my levoxyl without new labs. I ran out of levoxyl and was off of it fora month. I ended up in the emergency room where my TSH was over 300 the point where the lab stopped measuring. They gave me a prescription for 150 levoxyl. I was able to get insurance and see a doctor in August. She ran new labs at which time my TSH was still high I believe it was close to12 and she wanted to see if it came down in a month due to my being off of it for so long. When I ran new labs my TSH was up to17 but my T4 and T3 were normal. She thougth this was indicative of possible pituitary problems so she had the office endocrinologist see me the following week. He said he did not think that there was an issue with my pituitary and ran a full panel of pituitary tests. Again they raised my levoxyl this time to 150 one day and 175 the next alternating. Well I went in a couple of weeks ago and had my TSH and T4 drawn again. My T4 came back at 1.10 which is mid-range. My TSH however went up again to 20.9.

After going through all of this for so many years I have gotten to a point where I do some of my own research. I know most docs don’t like this, but you can only feel bad for so long before you start to look for answers. Right now I have a variety of symptoms besided feeling awful. I am have gained 30 pounds again. I am have severe dry skin, fatigue, headaches, difficulty concentrating, muscle weakness, and visual problems (I have had since grave’s diagnosis). My question is am I losing my mind? I have no thyroid function and I thought that as long as my T4 and T3 were normal my TSH should be too. The only thing I can find that fits what my labs are showing and I am feeling is a TSH Secreting Pituitary Adenoma. My doctor doesn’t want to run an MRI or CT. Is it within my rights to demand one? Do my symptoms truly match those of someone with a TSH pituitary adenoma? I am looking for help, any advice is appreciatedand words are never a diagnosis I am aware. So any thing you can offer me is appreciated.

Stephanie L. Jackson

Response

On the basis of the supposition that your story is exactly how all happened (I have not heard the standpoint from your doctors), the least that I can say is that I am not impressed by some aspects of the medical expertise that you were confronted with. I feel no urge to go into detail about this comment. I just like to say that you are now (most probably) permanently hypothyroid. It is far from true that the TSH value is not important as long as the T4 and T3 is normal. In contrast, the reverse is true, i.e. as long as the TSH is in the range that is the best when treated with thyroid hormone, which is between 0.4 and maximally 2.0, the value of T4 and T3 are of little importance. The TSH is by far the most sensitive measure to monitor optimal thyroid hormone substitution. I am almost convinced that if you guard your own lab results and fulfill this criterion, no matter what your doctors say, you will ultimately (this may take some time) feel normal again. I agree that that is no reason for a MRI or CT of your pituitary, because your thyroid hormone values are ‘normal’ for a person who is still under substituted with thyroid hormone.

Georg Hennemann, MD


HYPOTHYROIDISM TREATMENT, SOY, AND PREGNANCY12 JAN 2006

Question

I have been looking at your site and hope that one of the experts has time to consider the below and provide some answers. I was diagnosed with hashimoto’s earlier this year (July) following a positive test for antibodies and an ultrasound of my neck (which showed a number of small nodule). I have had a noticeable goiter (about twice the normal size)for about 15 years (it was first noticed when I had glandular fever as a child)and my TSH level has been regularly checked (and always been within the ‘normal’ range), this year I was tested for antibodies for the first time. Since diagnosis I have been on ‘oroxine’ (600mcg / week). My TSH levels have dropped (from 3.3 in July to 0.68 in November),my FT4 has increased slightly (16 to 19) and my FT3 is pretty stable (4.7 to 4.6). Following my diagnosis my Mother has also been diagnosed with hashimotos (she has no symptoms) and I know that my Grandfather (on the other side of my family) had thyroid problems and had his thyroid removed in the early 1940s. Two months before the hashimotos diagnosis I had a miscarriage at ten weeks (the baby was only 6w2d – my TSH levels were ‘normal’ during pregnancy). We have been trying to conceive again since August (last time we got pregnant on the first cycle). Since I started on the ‘oroxine’ my periods have been getting longer (from having always been 27-8 days now up to 32 days last cycle) and I am worried that the hashimotos or the oroxine is interfering with ovulation. Is my lengthening cycle just coincidence or could it be a result of the hashimotos or oroxine and if so, what does that mean in terms of trying to conceive?

What levels should my TSH, FT3 and FT4 be to allow conception and maintain pregnancy? When we do conceive, other than regular TSH tests, are there any tests or treatments that I should request? I’ve never had any thyroid symptoms (other than the goiter and indigestion problems) but have read that I should be avoiding salt and soy products (I am intolerant to lactose and fat so I have a lot of soy products), is this true?

I have recently moved countries and feel very much in the dark as I don’t have a specialist or Doctor here yetto consult with and would really appreciateany advice you might have on managing hashimotos, particularly in relation to conception.

Thank you for your consideration.

Kind Regards,

Gemma.

Response

The “normal” levels of TSH of people using thyroxine, is different from that in the normal population, in that it is between 02-04 and maximally 2. The FT4 under these circumstances is in the high normal range. In fact as long as the TSH is OK, the values of FT4 and T3 are not important. Under these conditions there is no influence on the ovulation, cycle, or conception

There is no specific reason to avoid salt. Soy however is an other story. Soy interferes with absorption of thyroxine from the gut. To avoid this you should take your thyroxine on an empty stomac. It is not known how long you should wait before taking soy to avoid this problem. I would guess at least 3 hours, if complete avoidance is possible at all!

In almost all women the dose of thyroxine has to be increased during pregnancy. This is very important for optimal brain development for the child. As soon as you have conceived you have to increase the dose you are using at that moment, by 30%. Then have your TSH checked every month during pregnancy to keep it around 1. After delivery you may go back to the original dose.

Georg Hennemann, MD


CONFLICTING OPINIONS ON A NODULAR GOITER12 JAN 2006

Question

Glad to come across your ad so I’d be learning more about my thyroid condition.I’m Ryanna,female,34, from the Philippines.I’ve been under medication for nodular goiter for 2 years.I started with eltroxin 100mg for about three months but when I went to a new a new doc, my medication was changed to euthyrox. T3 =1.62 nmol/1, T4= 92.90 nmol/1, TSH= .75uIU/mL as of June 2004 result. My first ultrasound was done 6-1-04: Right thyroid gland enlargement with a cystic nodule.R thyroid gland is enlarged measuring 4.9×2.5×3.0cm with a cystic structure measuring 1.8×1.0x1.8cm with a volume of 3.8cm. Euthyrox dosage started from started from .25mg and gradually raised to .50, .75 and now to 100mg. Ultrasound as of 6-14-05 shows Right Thyromegaly stable in size with progression of the cystic nodules. A new cystic stucture was noted inferior to the previously noted nodule. FNAB as of June 2005 = Negative for Malignant Cells. My ultrasound as of 10/24/05 shows a .56x.42x.23cm(LWH) with a volume of .03ml hypoechoic solid mass in the superior aspect of the isthmus, solid mass with cystic changes in the right lobe of the thyroid gland measuring 4.19×2.7×2.42cm(LWH) with a volume of 14.21ml. The cystic structures measures 1.82×1.5×1.19cm(LWH) with a volume of 1.7ml and 1.27×1.03x.51cm(LWH) with a volume of .35ml.I was then advised for an operation.I sought for a second opinion then,.The new doc asked for another FNAB and the result shows cells suspiscious for malignancy, of papillary origin, and was also advised for an ops.I was then alarmed so I thought of taking another opinion.TSH result = less than 0.05 uUI/ml as of January 2006. I’m still watiting for the ultra sound result as of this moment.My concern here is that if I could get well through medication and not undergo an operation,then the better…Do you think it’sok that I change doc for the third time?Aftyer all, it’s a patient’sprerrogative , right? I’d be very glad to hear from youso I could better decide whether i should really submit myself to the operationas the doctors here suggested.

Have a great day(*?*)

Ryanna

Response

This is not an easy problem! If I understand the situation correctly then you have partly solid and partly cystic lesions in the right lobe and the isthmus. They are progressive despite treatment with thyroid hormone. You have one FNA negative and one positive for malignancy. If the pathologist is experienced then I think operation should follow. If he is not that experienced in FNA’s, I suggest to have both FNA’s evaluated by a third pathologist with a nationwide experience in FNA’s. I am sure that my good friend Dr Mazzefari, who is a world known specialist in thyroid carcinoma, can help you further. I send him a copy of this e-mail.He will certainly advise you too what to do and if his advise goes against mine, do follow his!

Regards,

Georg Hennemann


ANTITHYROID DRUGS VS RAI OR SURGERY6 Jan 06

Question

Dear Sir/Madam-

I’m not a physician, only a 28 year-oldlady aspiring tostudy graduate medicine.I was previously a consultant in audit risk management. In October 2004, I was diagnosed with Graves’ Disease: T3 >12.0 (1.57- 2.59 NMOL/L);T4 >90 (9.6- 19.1 PMOL/L);TSH <0.006(0.36- 3.24 MU/L); andTSH Receptor Antibody >40.0 (0.0- 1.5 IU/L). Iwas given Lugol’s iodine mix fora weekand started on antithyroid drug of 20mg. Currently, my dailyCabimazoledosageof 10mg hascontrolledmy T4 at 12.42 (10.00- 20.00 pmol/L).TSH is 0.014 Low(0.290- 3.770 mU/L). I still have a goiter which occassionally becomes painful in the evening.The problemarose6 months after medication, when my doctor recommended me for RAI. My parents felt that it wasn’tthe best option for me and we switched physician, hoping to find a dedicated doctor who cares for patients more than the number readings. Nevertheless, my current doctor also seems to be gettingimpatient on me and hasbeen pursuading me into RAI, otherwise surgery, for the past 3 months (or 1 year since the onset of Graves’ disease).Although my T4 of 12.42’s within the lower normal range, I’m already experiencing the hypothyriod symptoms such as muscle aches in my body, retardedness,decreased concentration and weight gain. Comparing the hyper and hypo stages, I definitely function better in a slightly hyperthyriodone. No way wouldI trade my body for a life-time hypo plus hormone replacement.My doctor claimed that “it would be much easier to taking only1 pill after RAI” butI could foresee the difficulty of adjusting to the right amount of thyroid hormoneafter the body enters the permanenthypostage.The body will be fighting against the hypo symptomsat onepoint or another as the thyroxinehormonecan never be accurately prescribed.It will not be me when I cannot push myself to perform to my full potentialand concentrate in my studies, muscle pains, lethargyand weight gain. The outwardphysical ills are secondary, the body has to cope withlife-long hypo symptoms which decrease the quality and momentum of life.For an olderwoman entering menopause, the body would not adjust as well with fluctuating hormonal changes and slower metabolism.How many patients actually thank their doctors after gulping down mouthful of RAI? Why wasn’t proper informed consent presented to the younger patients about the after-years effects of RAI? Why are doctors rushing patients into irrevocable options when 1- 2 years of antithyroid drug trials are not up? Wouldn’t a patient on medication be given a higher chance of remission of illness? This can be easily achieved bydoctors without having to adjustthe standing antithyroid dosage much.

If my physician bugs me in March again, I am prepared to sack him for another doctor. Is this the practise at your side too and for what reason, or is this only happening in Singapore? I am thankful that antithyroid medication at leastgives me hope for a miraculous recovery–to be free ofmedication one day. This would not be possible with RAI. The option of surgery, on the other hand,has its shared amount of risk.What do you reckon is the best option in the patient’s interest?

Yours Sincerely,

Celeste Yeo

Response

The vast majority of patients seem to do well after RAI therapy, or surgery, but of course some have problems. Often it is difficult for the physician to know whether the problems are due to the thyroxin replacement, or another situation in the patient’s life. Life is complicated, and everything interacts with how a person “feels”. You can continue to take antithyroid drugs for years, and unless you have a reaction there is no absolute reason to stop. MDs typically suggest RAI or surgery after one or two years of pills, if there has been no sign of remission. This is because usually life is simpler on replacement therapy than on antithyroid meds, and because, as I note, most patients feel well and normal on the pills. I suspect that if you discuss this with your MD, he/she will agree to follow you on the pills until you remit, or grow tired of the process.

L De Groot, MD


THYROID AND WEIGHT GAIN, REDUX!

Question

hi my name is louise i have had under active thyroid for about 13 yrs now i feel ok most of the time but sometimes i feel i cannot eat anything because i gain weight so fast and very easy.I cannot eat fruit or veg or i would is there anything i can eat that won’t give me a bloated stomach every other day

thanx

Louise

Response

You have to be treated with thyroid hormone, if this is not already the case. Your doctor has to see, in order that you get the appropriate amount of thyroid hormone, that your TSH blood level is between 0.4 and 2.00If the latter is the case, any weight gain is not caused by your thyroid problem.

Regards,

Georg Hennemann, MD


BULIMIA AND EXCESS THYROXIN

Question

I am sorry to bother you with this question, but I have researched my question on the internet and cannot seem to find an answer. I am bulimic, and in addition to purging and laxatives I take 10 x 100mcg Oroxine tablets a day. I know that this is a bad habit, and I am working out my problems with a therapist, but I would just like to know the exact repercussions that I may face if I continue taking this kind of dose. At the moment I am continually restless, my legs ache and I get some pretty bad pains in my chest… Can you tell me exactly what might be happening?

Kind Regard,

Jean

Response

Oroxine is the Australian brand of thyroxin, and if you actually absorb all of 10 X 100ug of thyroxin each day, you will become dangerously hyperthyroid. (“thyrotoxic “). That is 6 to 10 times the usual dose, and could cause heart failure and death. I hope I have been clear about the danger.

L De Groot, MD


SPONTANEOUS VARIATION IN TSH LEVELS

Question

I am not a physician. I am 45 and started suffering from severe menstrual irregularities about 4 years ago. After an abalation, I switched to another GYN closer to me who happened to be a reproductive endocrinologist. She couldn’t understand why tissue taken during the ablation was from both before and after ovulation and apparently neither could the pathologist. That and the fact that my sister has Grave’s and my mother has Addison’s and a hypoactive thyroid prompted her to do a TSH. My TSH history is below.Ablation May2003 Jan05 TSH=3.087 July05 TSH=0.67 July05 TSH=0.61, t4=9 Aug05 TSH=4.255, 1.198 Dec05 TSH=2.77 Lab normals for TSH =0.3-5.5 Any ideas on the reasons for the TSH fluctuations? In addition to periodic sweating and palpitations and a dizzy spell or two, which are resolved now, my menstrual cycles are all over the place (20-54 days) and the GYN says this is not due to perimenopause based on other tests she’s done. My GYN said to come back in another couple of months for a repeat TSH.

Thanks much!

Michelle

Response

Certainly your genetic heritage suggests you are prone to multiple endocrine autoimmune diseases. I would guess that, assuming the TSH levels are accurate, you have Hashimoto’s thyroiditis, and that your thyroid produces variable amounts of hormone from time to time. Another explanation might be related to adrenal autoimmunity (much less common), which could affect the thyroid. I suggest that you MD check anti-thyroid antibodies, and adrenal function. On the other hand, all of the TSH levels , save one, are in the normal range, so there does not seem to be any acute problem.

Leslie J De Groot, MD


TSH REMAINS ELEVATED20 Dec 2005

Question

Hi,

I have been experiencing elevated TSH levels on my last 2 checkups, even though I never miss a dose of the Synthroid. I had been having normal levels but 6 months ago my first TSH was 22.0. I attributed this to having taken the medication approximately 2 hours before having the labs drawn. A follow up was much lower. A few weeks ago, the first level was 12.0 and it was 9.0 when re-done. I am not having considerable fatigue. My doctor does not want to adjust the dose as of yet but I am just wondering what would cause this elevation regardless of the fact I’m taking the meds correctly.

Wrosebush@wmconnect.com

Response

There could be many reasons. Have you gained weight? Are you pregnant? Do you have Hashimoto’s thyroiditis? Did you change brands of thyroxin? Are you on another medication, iron, or other material that might alter your dosage? Maybe you just do not have quite a big enough dose. If none of these factors are present, and your TSH remains elevated, you most likely need more hormone.

L De Groot, MD


THYROID HORMONE DOSE AND WEIGHT GAIN11 Oct 2005

Question

I HAVE BEEN DIAGNOSED WITH THE ABOVE ABOUT 2 YEARS AGO. I HAVE A QUESTION ABOUT TRIGGER FOODS. ARE THERE FOODS THAT TRIGGER THE MY PROBLEM TO MAKE THE WEIGHT GAIN COME ON? WHEN I AM FUNCTIONING FINE I CAN TAKE THE WEIGHT OFF PRETTY EASY. I HAVE HAD A CONTINUALLY FLARE UP SINCE THE SECOND WEEK OF AUGUST. ALL THE WEIGHT I TOOK OFF HAS CAME BACK.. IT IS A UNUSUAL FEELING OF EXTRA WEIGHT. (SQUISHY FAT AND IT IS ALL IN THE MIDDLE) IT IS VERY HARD TO EXPLAIN. ONE OF THE THINGS THAT MADE ME MAKE MY DOCTOR PERSUE THIS WAS I WENT FROM A 7/8 SIZE TO A 12/14 IN THREE TO FOUR MONTHS.

PLEASE HELP.

PAHARRIS@MANDTBANK.COM

Response

As long as you are being treated with the proper thyroid hormone dose and consequently your TSH is normal (not higher than 2.0) the thyroid hormone dose can not cause increase your bodyweight. There is one exception and that is that if you still have a partially functioning thyroid, excess iodine can further suppress its function. However if you are on a full dose of thyroid hormone iodine can not hurt you either.Discuss this with your doctor.

Georg Hennemann, MD


PROPER DOSE OF THYROXIN23 Sep 2005

Question

I am a 34 year old female. In late May this year, the doctors discoverered my T4 level to be low. I was placed on 25 mg of Synthroid. In July, the dosage was raised to 50 mg, because the T4 level was still low. I have recently startted to gain weight rapidly-12 pounds in 2 months and I am very active. I am wondering when or if this will stop. I want to stop taking the Synthroid, but it is working for my other symptoms. What shall I look for?

Dawn

Response

The only way to check if substitution with thyroid hormone is OK is to measure blood TSH. This should have a value no higher than 2.0, preferably 1.5. The level of FT4 is of secondary value.

Georg Hennemann, MD


VERY ELEVATED TSH LEVEL24 Sep 2005

Question

March my TSH level was checked and was in the approx 780. My doctor wanted to recheck before putting me on medicine..so in April my level was 895. The doctor, before putting me on medication, wanted to have the ultrasound and subsequent radioactive iodine scan. Which came back normal. So I started Synthroid at .25mcg with the doctor noting that the medicine would most definitely need to be increased, but wanted to wait a few months to see the effects. So I just did my bloodwork and the doctors office called that the TSH level is 1200. I know this is way out of range and will be going in to see the doctor, but am very curious at why with medicine my TSH has increased. To note, my symptoms that persisted prior to medication are gone (constant menstruation, inability to tolerate cold, etc….) The only symptom I seem to have developed recently are dizzy spells and muscle cramps. Any help would be greatly appreciated.

Thank you

Sherri

Response

Your TSH results are almost certainly an artifact in that these values are most probably caused by circulating anti-bodies against TSH in your blood, interfering with the test.This can be easily sorted out by the laboratory chemist. He should perform so called “dilution curves” of your blood TSH and of the standard TSH of the test and compare parallelism of these curves. This phenomenon has no health consequences for you. There is no reason to continue using thyroid hormone. This assumption is based on the presence of a normal FT4. If this value is also elevated then it is theoretically possible that your pituitary produces too much TSH. To investigate this, a MRI of the pituitary can give the answer.

Georg Hennemann, MD, PhD, FRCP


REACTION TO ANTITHYROID DRUG

Question

I hope that you will find a time to answer my question although
I am not a physician. I am a pharmacistand recently I have been diagnosed with hyperthyroidism, precisely with Grave’s disease. I live on a small tropical island and I would have asked my physician what to do but the problem is he is out of the island and there is nobody else available. I started taking Methimasole 20 mg 2 times a day on 25 of May 2005, and I started feeling much better (my hair stopped falling, my pulse became normal, excessive sweating and shaking has been decreased) but yesterday when I got my blood results I noticed that liver enzymes have increased which left me in doubt
what should I do next-decrease the dosage of the medicine or discontinue it because of possible hepatotoxicity?
Grave’s disease was diagnosed based on the following results: 20 may 2005FreeT4…….4,12 ng /dl (0,9-1,9),TSH………..0,007microUI/ml (0,18-3,4) TRAK (antibodies for tsh receptor)……4,4 (n<1,5 IU/L) Dimensions of the gland were normal and without any nodules, ultrasound results pointed possibility of Hashimotos.I had almost all the symptoms except that instead of losing I gained weight and there was no goiter. My eyes are notbulging, but sometimes I feel discomfort and redness.
After one month of therapy with Methimasole 20 mg two times a day, I got the following results:Free T4…..2,3 ng/dl,Free T3…..5,0 ng/ml (1,40-4,40), TSH………..0,005microUI/ml
GOT(AST)………42 U/L (0-40), GPT(ALT)………89 U/L (0-38)Alkaline Pho……80 U/L (37-137) Bilirubin –di…….0,0 mg/dl (0-0.8) Bilirubin-to………0,4 mg/dl (0,2-1,6) GGT………………..29 U/L (0-60) Bilirubin ind……..0,40ml/dl (0,10-1,0) CBC with film was normal except LYM%……50,8% (13-50) I would very much appreciate your advice, because there is nobody else that I can ask at the moment, I am 29 years old and haven’t had any major health problems in the past, in my family there are 2 cases of hypothyroidism as I know, and I have to mention that I had some major stressful events in the past years (including death in the family).

Vesna Nastovska, Pharmacist

Response

Methimazole can certainly cause liver function abnormalities on the basis of allergy and/or of toxicity. These abnormalities are very rarely serious and then especially of the cholestatic type. In your case only ALAT is mildly elevated. Apart from allergy or toxicity these abnormalities may also be due to the hyperthyroidism itself. The high normal count of lymphocytes is due to the Graves’ disease per se. A toxic reaction is likely less probable because the cumulative dose used is so far very low. Most probably the abnormal tests are due to the hyperthyroidism itself. As your hyperthyroidism has been successfully (partially) blocked by methimazole, I would suggest to decrease the dose to 20 mg daily. Check your liver function tests for the time being twice a week and stop the methimazole if they do not normalize in a few weeks and if they increase stop immediately. If you have to stop, I would not advice to try propylthiouracil as there is considerable overlap in side effects, but start with propranolol, 40 mg 3 or 4 times per day and have yourself treated with radio-active iodine eventually abroad. You can even use prednisone in addition if necessary.

Kind regards,

Georg Hennemann


HYPOTHYROIDISM AND JOINT ACHES

Question

Is there a relationship between inflammation of muscles/ligaments and thyroid problems.

I had total thyroidectomy1 year ago (actually 2 partials) for follicular cancer. Lately I have had pain in the achillies tendon which passed. This week it is in my knee, I do exercise but I have done nothing for a few days and suddenly this afternoon pain in my knee. I can harldly lift my leg but there is no radiating pain of visible inflammation. I took 600mg of Motrin which has given me some relief. Someone told me that ligamament inflammation can be related to the thyroid. Is this true?

kfrebo@comcast.net

Response

If you are properly treated with thyroid hormone to suppress your TSH, your complaints are most probably not related to your thyroid condition.

G Hennemann, MD


ESTROGEN AND HIGH T3 LEVEL24 MAY 05

Question

I have now been taking Diane35 (estrogen) for 6 months following the doctor’s advice for treatment of PCO (poliquistic ovaries). Now I have the results of a recent blood analysis showing high levels of T3, while T4 and TSH remain normal. Values are as follows: Triyodotironina (T3): 3.58 (ref. values 0.90-2.79) Tiroxina (T4): 150.3 (ref. values 24.5-171.6) Tirotropina (TSH): 1.94 (ref. values 0.35-5.50) I am wondering if the high T3 levels are caused by the estrogen pills, and what effect this might have. I am supposed to stop taking those pills in September to control PCO.

Thanks!

Victaria Mengual

Response

Estrogen raises TBG, which raises bound hormone, but not active free hormone. This appears to be the situation since your TSH is normal. The test should normalize when the estrogen is stopped, but it is not a problem anyway.

L De Groot, MD


HYPERTHYROIDISM AND PREGNANCY27 Apr 2005

Question

Hi I am in my 29th week of pregnancy. I have my thyroid levels checked once a month and am on PTU’s I currently am taking 150mg a day. My question is this every time have my thyroid levels checked my TSH is less than .001 and my t4 is highly elevated. I think around mid 20’s. My question is this. What affect will these levels have on my unborn child and what affect will the meds that I am taking have on my son. I have had one ultrasound at 14 weeks and they said it was a boy and everything looked good, and he is growing like he should but I am not sure if anything could be happening to him because of how long my hormones have been so messed up while I am pregnant and the doctors dont seem to have an answer. I really would like to know if there are complications or possible birth defects that I could expect so that I can prepare myself for these.

Michelle Rhodes

Response

Your thyroid overactivity should be controlled to the normal range as soon as possible. Hyperthyroidism can definitely cause difficulties in maintaining a normal pregnancy. PTU is the usual treatment, and is not anticipated to cause trouble with the fetus unless relatively high does are required. It is best that you discuss all of these issues with your MD.

Regards,

L De Groot,MD


ARMOUR DESSICATED THYROID AND SYMPTOMS24 Apr 05

Question

Does Armour thyroid medicine, or the condition of hypothyroidism cause a fast heart rate? I have been diagnosed with hypothyroidism about 3 months ago and am now on 90 mg of Armour. I check my heart rate during the day and after resting for 15 minutes my heart rate is usually around 90-100 but sometimes it is higher. My doctor seems to think it is NOT from the medicine but it sounds like the logical explanation to me.

Thank you,

Alica Rutherford

Response

Dear Madam,

I have personally no experience with Armour but can tell you that as long as your TSH blood level is within normal range you are not using an overdose. In overdose situations TSH is below normal or even totally suppressed.

Regards,

Georg Hennemann


THYROTOXICOSIS AND PREGNANCY21 APR 2005

Question

Hi. My husband who is 27 was diagnosed with ‘grave’s disease’ in February of 2004. He is currently on PTU and Propranolol, and his endocrinologist has recommended he has the iodine therapy done, as the medication is not working successfully. Weare trying to fall pregnant,and I am concerned about the affect (of any) of the iodine on a males sperm and reproductive system. Should my husband consider freezing some sperm before he has this done? Also, There seems to be lots of information regarding women’s fertility but not mens! Does having an overactive thyroid cause infertility? If so, why? If infertility happens when your thyroid is overactive, when the levels settle down, will fertility ‘come back?’ We would really appreciate any advice you can give us.

Thank you for your time.

Response

Thyrotoxicosis can reduce fertility, and it should return to normal after treatment. RAI can damage sperm formation. Freezing sperm is possible. Often males are advised to wait several months after RAI treatment before planning pregnancy.

L De Groot,MD


HYPOTHYROIDISM AND PCO

Question

I am 28 years old hypothyroid patient, married 4 years back. We are trying to conceive from the last 3 years and 2 years back we found that I am hypothyroid and have polycystic ovary also. From the last 2 years I am having 100mgm Thyroxine sodium ( Electroxin from Glaxo) and ovary ruptured ( one year back) by laparoscopy as per infertility specialist direction to reduce PCO. But I am not yet conceived and the doctor says my LH level remains too high during the initial period of my cycle and hence the eggs are not growing or producing. Recently I tested my blood, blood sample collected on 3 day of my period, the LH value was 19,( Reference range is 1.1-11.6) and the FSH is within the reference range. Doctor please advise me on the following:

A. Is there any relation between Hypothyroid and Poly Cystic Ovary?

B. Is there any relation between Hypothyroid and LH surge on the initial days of period?

C. What are the probable cause of LH surge, other than hypothyroidism, and treatments for a successful conceive?

Thanking you.

Rachel

Response

As far as I know, there is no relationship between polycystic ovaries and thyroid diseases including hypothyroidism. Neither, certainly when substituted adequately with thyroid hormone, between hypothyroidism and the LH surge, as you indicate. The elevated LH levels in polycystic ovaries are a characteristic feature of this syndrome but not fully explained. Other causes of elevated LH are the post-menopause state and a benign tumor of the pituitary gland.

Georg Hennemann, MD


FACTORS ALTERING THYROID BLOOD TESTS4/2/05

Perhaps you could have the following questions answered in “the patient asks” section of
www.thyroidmanager.org.

  1. For a patient who’s hypothyroid because of autoimmune thyroiditis and taking thyroid meds, what effect could transdermal estradiol have on total T3, free T3, and TSH?.
  2. What effect might SHBG below normal (e.g. .5 (range 1-3)…hyperandrogenism) have on metabolism of thyroid meds and thyroid blood tests?
  3. Is atrophic autoimmune thyroiditis (nongoitrous) resulting in hypothyroidism a distinct entity compared to goitrous Hashimoto’s disease?
  4. What effect could the presence of anti-TG antibodies in the absence of anti-TPO antibodies have on thyroid blood tests for someone who’s hypothyroid?

Thank you.

Idlle Port

Response

  1. It will probably cause some increase in total T3 and temporary decrease in free T3, but in time the latter should return to the pre treatment level.
  2. Should not influence it.
  3. There must be some difference in the pathogenesis (immunology) of the conditions, but at the practical level treatment is the same.
  4. Unless the TG antibodies included the rare anti T4 antibodies, it should not make any difference.

L De Groot,MD


CONTINUED HYPERTHYROIDISM AFTER SURGERY

Question

I don’t know if it’s proper for me to show my case here, but I’m in argent need 4 help. My name is Salar Hesen Omer Berwari, I’m 28 years 28 years, male, single & I work as a constructions engineer. I live in Duhok- northern Iraq, in my city we don’t have expert in thyroid diseases so I was going 2 another city 2 have treatment, but under the bad situation of security in that city I couldn’t meet physician any more, & it seems that I’ll not be able 2 go there till a long time. I got Hyperthyroidism in 1997 & used 2 have carbimazole in deferent doses starting from 12 tablets of 5mg/ day. But the size of the gland still increased & the excretion of T3 & T4 was on, there I did a surgery in Oct. 2002 & removed the great % of the gland (270 g). & all features of Hyperthyroidism disappeared, & tests didn’t show any kind of cancer in the removed gland. I was going on taking carbimazole after the surgery for about a month, & after 3 months features of Hypothyroidism appeared, but I didn’t take anything against that, after about 5-6 months features of Hyperthyroidism appeared again 7 the test of T3 & T4 show that there was a great increasing. I started taking carbimazole again, 12tab.s for about 2 months, 9 tabs for 45 days, 6tabs for a month & then 4 tabs till now, that with inderal & Predizolon according 2 the physicians recommendations. But after that the size of the gland started increasing under unknown reasons ( I was taking 4 tabs that time) & after that features of Hyperthyroidism started again (pulse increasing, high temp.) & now I don’t know what 2 do. Can u plz help me & show me what can I do till I meet my physician again?? Why I was back 2 Hyperthyroidism after the surgery?? & why going on taking carbimazole can’t stop increasing the gland & the hormones?? For information I don’t have any family history of thyroid disease and/or diabetes.

Thank u so much.

Salar Barwari

Response

From what I understand is that you have relapsing hyperthyroidism despite thyroid surgery and continuation of carbimazole . You also had an increase in thyroid size for unknown reason. My general impression is that the dose of carbimazole that you are using are higher than usually necessary. We know that high doses can lead to goiter formation. However if at the same time or soon after an increase in goiter size during carbimazole hyperthyroidism relapses, the increased volume is probably related to the persistence of the hyperthyroidism. I think that it is very important to establish if you still have hyperthyroidism. If that is the case the best treatment is administration of radioactive iodine. Would that be possible in your circumstances? If that is not the case you have to continue with carbimazole in a dose that normalizes your thyroid function properly until you can get permanent treatment. I would strongly advise you not have a second operation as in that case complications causing paralysis of your vocal cord(s) and or inadvertent removal of your parathyroid glands are possible. If you can have your TSH and T4 being measured periodically, I am quite happy to advise about the dose of carbimazole that you have to take until you can consult your doctor again. I am not very happy about the fact that you use prednisolone . Inderal is OK for the time being.

Georg Hennemann, MD


Question

I have had a multinodular goiter for at least 5 years, although I suspect its been more like 10 years.. I am 30ish female with multiple symptoms on NO meds, cause my doctor likes voodoo medicine. The body canheal itself, etc…..I have ultrasound once a year. Fine needle biopsy ,have lost up to sixty pounds in a two month peroid, massive hair loss, periods have dissapeared,6 months no period. dizzyness…singular pvcs,tremors.heat intolarance cold intolerance,memory loss with personality changes, TSH is .48…t4,9.8 my question is my dr says labs are fine perfect do you think I need meds?

JL Shearer

Response

Voodoo medicine is potentially dangerous for any patient. My advice to patients is to turn away from doctors who practice this kind of quackery.

The complaints that you have are typical for someone who’s thyroid functions too rapid. It may be so that your lab results are (just) within the normal range. However this does not mean that they are normal for any subject, as the normal ranges of TSH and T4 are rather wide.

Your doctor apparently has not determined your blood T3 concentration. T3 is another thyroid hormone that is much more active than T4 and I would not be surprised, considering your symptoms, if this would be elevated. But even if this is not the case than I still think that your thyroid is (borderline?) overactive. This expectation is on the basis of the combination (1) of your typical complaints, (2) the fact that you have a longstanding multinodular goiter that very often develops into hyperfunction and (3) the combination of a low normal TSH and high normal T4.

Even if hyperfunction is borderline it can produce substantial symptoms on the long run, which is possibly the case with you.

My advice is to consult an endocrinologist who practices regular medicine.

Kind regards,

Georg Hennemann


ELEVATED T3 LEVEL AND ESTROGEN

Question

I am not a doctor but I have a medical question (I am going to a doctor. soon) I had a thyroid profile II because i was having problems with anxiety (the doctor checked for graves because my sister has it) my test results were the following: TSH 1.217, T4 12.9, T3 uptake 21,Free Thyroxine Index 2.7, T3 241. My doctor is concerned about the T3 results and told me to go see my regular Dr (the first Dr is a Dr at my school) I did some research and found that a high Estrogen level can cause an elevated T3 level (I have been telling my doctors for years that I thought I was producing to much estrogen) my question is can High Estrogen cause an elevated T3 level or am I in early stages of Graves and if it is the estrogen how do i get my doctor to test for that I have been trying for years to get my hormone levels tested and not just by one doctor.

Erika

Response

The normal TSH gives a strong indication that you do not have thyroid hormone excess. Estrogen does increase the TOTAL levels of T3 and T4, but estimates of the free level are normal when there is no thyroid disorder. You do not give the units or reference ranges for T3 and T4, but the T3 concentration, if high, will correct to normal when the low T3 uptake is taken into account. If you are taking an OCP it would explain these tests. Hope this is helpful.

Jim Stockigt, MD


THYROXIN DOSE AFTER THYROID CANCER SURGERY QUESTION

Hi I am a 46year old female being treated for papillary carcinoma. In 1997 I had a partial thyroidectomy and was told that my biopsy revealed follicular neoplasm. I was told everything was okay. InApril 2003 I was not feeling to well and visited my doctor. I have an existing B12 deficiency and thought that might be my problem but I also stopped sweating(I usually sweat alot) and was just not feeling to well. My T4 was checked and my levels were to low according to my doctor. I went from 75mcg to 100mcg and started feeling better. But in August I started noticing changes in my voice and a lump in my neck. My voice started to sound shaky and the lump was preventing me from swallowing properly.. I went to my doctor and he ordered a ultrasound of the thyroid. There appeared to be a mass in the left side of the thyroid. The right having been removed in 1997. I went for a FNA to biopsy the mass. The biopsy revealed changes of either a follicular variant of a papillary neoplasm or a follicular neoplasm. I had surgery in February of 2004. The report reads as follows. The specimen was sectioned in its entirety. The sections show multiple nodules of varying sizes and the nodules contain follicles of varying sizes some of which are very large. Some small nodules are composeds of very small follicules. The largest nodule, witha nearby long black suture, is also mainly composed of follicles but show a fairly large component of papillae fomations.These papillae are arborizing in areas and have a fibrous and fibrocascular stalk. The lining epithelium is composed of columnar cells which are medium to large in height. A few show nuclear grooving and a rare cell shows internuclear vacuolization and some cells show clearing the nuclei. The findings are those of a papillar carcinoma. This focus occupies approximately .7cmin the center of this nodule which is approximately 1.5cmindimension. This case represents papillary carcinoma.. I was told 6 weeks later of this finding. I was also told by the surgeon not to worry it was no problem because it was all removed. On seeing my endocrinologist he informed that I would be needing treatment and this was not to be taken lightly.. I was put on a low iodine diet and taken off my levothyroxine. I was without my thyroid meds. for 11 weeks and was treated with I-131 and then given a body scan 2 weeks later. My body scan showed 3 foci’s. Two in the area of the jaw and one in the lower left region of my clavicle. Four months later my TSH levels and other blood work was done. My TSH levels were to high and I was put on 150 mcg of levothyroxine as the Endocrinologist informed me that cancer could come back. I wanted to know if the 3 foci’s were of concern and my doctor just shrugged his shoulders and told me he would be keeping an eye on it. Now it has been 5 weeks since my dosage was increased. I am experiencing blurred vision, heart palpitations I am urinating about every 1/2 hour I also feel agitated, numbness in the hands and feet and excessive sweating. I also feel like my mind is racing and I am more irritable than normal. I am 5’1″ and weigh 114 lbs. I do not know if the amount of levothyroxine is to much for someone of my size. I do not see the endocrinologist until Feb 2005. Should I be concerned with the amount of levothyroxine I am taking?

Lilliane Dubois

Response

In brief, yes. You need enough thyroxin to keep TSH near 0.1 when you are on the med, but for you that dose is probably near 125ug . The exact amount can only be determined by trial. Get a blood test now.

L De Groot,MD


HIGH TSH AND THYROXIN TREATMENT QUESTION

Question

After years of vague symptoms attributed to menopause (I am F 52yr.), my G.P. did yet another TSH (previous thyroid panels were all negative) and it was 187. Because it was so high, should I be concerned about the pituitary gland having a problem? And, is it OK to treat hypothyroidism by just monitoring TSH levels? Should Free T4 and T3 also be drawn? I have been on Synthroid 75 for 7 months now, and my TSH is down to 4.3.

Cindy

Response

  1. Meaning of high TSH at diagnosis: A very high TSH value indicates marked hypothyroidism. The value reflects a combination of the severity of the hypothyroidism, its duration and some individual factors. As long as the level has been falling with T4 therapy, there is no need to be concerned about the pituitary gland.
  2. Laboratory follow-up for treating hypothyroidism In most patients with hypothyroidism, it is not necessary to check T4, T3, free T4 or free T3 levels during treatment. As these values can vary widely within the population and the pituitary gland is very sensitive to changes in thyroid hormone levels, monitoring just the TSH is usually sufficient. I would recommend though that you dose be increased to maintain the TSH within a range of 0.4 to 2.5.

David H. Sarne, MD FACP


History of controlled hypothyroidism: now with hives

Question

I have had hypothyroidism for ~ 18 years now. I also have a history of ebstein-barr virus in 1988 which manifested itself with (L) sided weakness and burning- neurlogical symptoms that still remain. I have been on Synthroid 150 mcg po qd and my T3, T4 in Feb 04 was normal. I am 41 years of age. I had a child in October 03. For the last 5 months I have had to deal with hives. Initially, they were on my most dense on my abdomen & back, and some on my legs, arms, lips. My family Dr suggested Benadryl. No help. After they worsened, I went to see a Dermatologist who put me on Zyrtec 10 mg po qd. That did help for about 3 1/2 months. I would have intermittant hives but they were tolerable. For the last 3 weeks, they have been horrible again. Raised, red, itching and burning relentlessly. They are most dense on my legs this time, but also appear on arms, lips, hands, back and abdomen. Dermatologist doubled my zyrtec to 20 mg daily with no improvement. I saw him and he gave me 60 mg of kenalog IM and added allegra 180 mg qd as well. He did bloodwork as follows:

T4 – free, direct tryroxine 1.14 nl(.61-1.76) TSH 1.778 (.350-5.5) T4-thyroxine 8.7 (4.5-12.0) T3 128 (85-205) Thyroid Peroxidase 65 high nl 0-34 Thyroid antithyroglobulin Ab <20 nl 0-40

I have to wait a week to see my family Dr. I am not established with an endocrinologist as I had been stable. Please help me understand what is going on and what the next steps should be.

Thank you,

Dee

Response

I understand how difficult your problem is. It appears that you have been appropriately treated. Generally a search is made for any possible environmental factor that might cause an allergy, for certain genetic traits, for other diseases associated with hives, and for “collagen-vascular” disease, but this is often fruitless. You do have autoimmune thyroid disease , and that is definitely associated with the hives that you have. However to my knowledge that does not offer any recognized different approach to treatment. Typically over time the process subsides, often to recur to some extent at a later time.

Sorry I cant be of more help,

L De Groot,MD


HYPER AND HYPOTHYROIDISM AT THE SAME TIME

Question

Is there a disease related to thyroid hormone that causes one to have symptoms of hypothyroidism and hyperthyroidism simultaneoulsy?

Samantha S Schilling

Response

To my knowledge there is no specific disease that can cause such a condition. Nevertheless it is very easy for anybody to have some symptoms of hyperthyroidism, and some symptoms of hypothyroidism, at the same time, since the symptoms are so common in many other conditions, and so non-specific.

L De Groot,MD


THYROID NODULES AND ACUPUNCTURE11 May 2004

R ecently I was accidentally Dx through an MRI, and later Nuclear med test…with having cold nodules on my thyroid. The left lobe nodule is 2.5 cm x 1.0 cm x 1.5 cm. the right side nodule is only 3 mm. I have had two USGFNB os these noduleswhich are not palpable.Both attempts at USGFNB biopsy came back as inconclusive. My ENT Dr.suggested that I have a partial thyroidectomy done or take a high dose of synthroid for 3 months in an attempt to reduce and possiblymake the nodules disappear. Thosearemy two options from him. My question is, Do you know of any successful treatment studies done on these types of nodules that have been treated through acupuncture and Chinese medicine? And or what are the consequences of not choosing to have these nodules treated, or not treated successfully minus the surgery? Do they ever go away by themselves? I am a 37 y/o/f. My only C/C prior to my MRI has been left ear radiating pressure that increases after singing, talking a lot,eating and my voice becomes hoarse after singing only several songs or I have been talking a lot.

Thanks for any advice youcan give me.

C. Bauchert

Response

The nodule is fairly large and your symptoms could be related to it. Unless you have a good negative result of an FNA, usual practice would be to remove it , and with both sides abnormal, a near -total thyroidectomy by a specialized surgeon would be the approach. Although thyroid hormone therapy might help suppress growth of a benign nodule, the typical natural history of such nodules is slow growth. Obviously if it is in fact a malignancy, it is possibly much more of a problem. You sound too intelligent to waste your time and money and health on acupuncture and Chinese herbal medicines.

L De Groot,MD


SYNCOPE DURING THYROID NEEDLE BIOPSY

Question

Hello,

I found your website while doing some research on thyroid nodules.I recently underwent a thyroid biopsy for a nodule that is a 1.5 cm dominant nodule among several smaller nodules. During the biopsy, I passed out, at which point the doctor discontinued the biopsy. Needless to say – he did not obtain a sample. The doctor is sending me to a cardiologist to rule out a heart condition, but I think will eventually want to rebiopsy. I do not think I have a heart condition (I am in good health and run 3-4X weekly) but I do have a history of passing out during medical procedures (I have to lay down for blood tests). As a result of this episode, I have extreme anxiety about repeating the procedure. Have you had to deal with patients like myself? Do you make special accommodations to prevent this type of reaction?

EB

Response

It is not amazing that you get weak when someone wants to stick a needle in your throat! Actually, in the hundreds of patients I have biopsied, no one has ever passed out. In our clinic we do the procedure with the patient lying flat, rather than sitting up, as some MDs do. But quite a few had to keep flat for a few minutes to recover from the same sort of hypotension that you experienced. I suppose a small dose of Valium prior to the event could be useful. We do that frequently for patients who can not stand being in the closed space of the MRI machine, for example.

Good luck.

L De Groot,MD


WHAT IS THE PROPER DOSE OF THYROXINE?

Hello,

I know you are mainly for professionals but I really need some advice. I am sure your comments would not take long on this if you could please just take a few moments to read this. I am a 34 yr old male with auto immune thyroid (Hypothyroidism). My blood tests (04.12.2003): Glucose, Lactate, Leucocyte count, Erythrocyte count, Hemoglobin, Hematocrit, Mean Corpuscular Volume, Mean Corpuscular Hemoglobin, Mean Corpuscular Hemoglobin Concentration, Trombocyte count, Potassium, Creatinine, Sodium, Alanine Aminotransferase, Amylase, Aspartate Aminotransferase, Calcium, Billirubin, Billirubin conjugate were normal; but TSH was 51.80 mU/l (norm here is 0.6-4.2). Two weeks later my blood test was (19.12.2003): FT4 – 7.2 pmol/l (norm here is 9-20), TyglAb – negative, TymsAb – 6400 (norm here is <400), TSH – 61.50 mU/l. My blood pressure based on averaged measurements made per hour one week was: (a) after waking up, but before standing up: systolic – 99.4+-2.3, diastolic54.9+-2.4, pulse, (b) during the day: systolic – 114+-5.5, diastolic – 67.7+-4.2, pulse – 56.9+-4.3. I have not any symptoms of hypothyroidism. But I have headaches (often). My questions: (1) What is the optimal dosage of thyroxine therapy for me, considering my blood tests and the absence of symptoms. My weight is 63-64 kg (stable over 20 years)? (2) Should I take it all my life, or I can stop when the blood tests will normalized? (3) What is the mechanism for decreasing antithyroid antibodies by thyroxine therapy?

Thank you for your time,

Alexander Fingelkurts

Response

The common dose needed is around 1 microgram /pound of lean body mass, but your MD must determine the exact dose by trial until TSH is in the proper range. Usually you need to take the med all your life. The antibodies commonly stay positive for years or forever even on treatment.

L De Groot,MD


CANCER IN THYROGLOSSAL DUCT

My 40 year old son has recently had a Thyroglossal Ductal Cyst removed and the pathology report was Thyroid Papillary Carcinoma. He was told that it is very rare to find cancer in these Cysts. His head MRI and Chest CAT scan show no evidence of any caner remaining. He will see a radiologist and endocranologist next week to determine what if any followup he needs.Are there other test that should be taken to determine if the cancer has spread to the Thyroid or other tisue? Would you recommend I 131 or followup surgery to remove the Thyroid? I can’t seem to find any information about this type of caner within a Cyst. Could you provide some information?

Thank you in advance,

Daryl McRoberts

Response

Whether to remove the thyroid and look for nodes, or not, is a matter of debate. There is some chance that the tumor involves the thyroid. If the physical exam is negative, the thyroid ultrasound is absolutely negative, and the serum TG is normal, I believed it would be safe to wait and follow with periodic exams, ultrasounds and TGs. If these tests are abnormal, it probably would be best to operate and do a near-total resection of the thyroid.

Leslie J De Groot,MD


Can I take antithyroid meds for Graves Disease for a long time?

Question

Good Afternoon. I have Graves Disease diagnosed in 1996. In 1998 try to leave the antithyroid tablets but my thyroid became over active again. I started the tablets again. Since then I have been taking methimazole tablets 5mg daily and every second. day 10mg (5mg in the morning and 5mg in the evening). I am now normal/stabilized for nearly 4 years, but want to know why I cannot continue with the tablets for life? Thank you.

Kind Regards,

Charlotte Dreyer

Response

There is no specific prohibition to taking antithyroid drugs over a long period, but there is always the small possibility of an allergic reaction. Generally patients and their MDs give up after a year or two or three, because of the inconvenience, and resort to RAI or surgery.

L De Groot,MD


TWIN PREGNANCY AND RAISED TSH LEVEL

Question

I have had my thyroid levels tested twice now with my TSH raising both times. We have found out we are expecting twins. I am 8 1/2 weeks pregnant. My levels were: TSH is 8.66, T3 is 150, T4 is 7.7. I am going to see a thyroid doctor next Thursday. We lost a child last year at 12 weeks. Are a little nervous and wondering if this is a problem we should be worried about. My Ob said not to worry because my T3 and T4 are normal but it is the TSH that is high.

Response

No matter that your T3 and T4 are normal. When your TSH is raised it means that you, and especially your BABIES!!, need thyroid hormone. You have to be treated with L-Thyroxine such that your TSH drops to below 2,0 mU/L.

Good luck

Georg Hennemann, MD


PAXIL AND ELEVATED TSH

Question

I have been taking Paxil or Paxil CR for nearly 3 years now. I have been slowly gaining weight and increasingly feeling tired/unmotivated. I started working out, then ordered some Royal Jelly (Bee product) for energy – then decided before I start self medicating I really should have a physical. My results included TSH at 2X normal levels (per Internist) and an enlarged multinodular goiter per ultrasound of Thyroid. So… I just read a science article from the U of Georgia where they state that they believe fluoxitine inhibits thyroid and so they’ll be looking at that in an upcoming toxicology study re: wastewater and wildlife. I guess the body’s internal pathway of using and recycling hormones is complex and the SSRI’s may inhibit ‘something’ in that pathway. I know only 1 in 1000 of Paxil takers can get hypothyroidism from Paxil. So it’s ‘possible’ that MY Paxil created my Thyroid problem. (I prefer not to be diagnosed and treated based on ‘probabilities’ if specifics can be found!!!) I guess the REAL question clinically is – how would you differentiate what caused my hypothyroidism? Did those ‘rare’ ones who lost their thyroid function from taking Paxil have returned function after ceasing taking Paxil? Is it reversible – do we KNOW? If you believe you can get to the real ‘root’ of this issue better than I’ve tried to parse it here, please feel free to answer as you see best.

Thank you for your time!

Cheryl

Response

Paxil activates enzymes in the liver that metabolise thyroid hormone, thus increasing the requirement. In people who are”normal” this presents no problem. However in, people with a diseased thyroid, it may produce hypothyroidism, and the same in people who take their hormone from a bottle. If you stop the Paxil you may not need hormone, but at this point if you continue the Paxil you need to take thyroid hormone supplementation. I will wager that if your MD does tests for anti-thyroid antibodies, the test will be positive, and that you actuallya have Hashimoto’s Thyroiditis.

Best regards,

L De Groot,MD


HASHIMOTO’S ANTIBODIES

Question

Does Hashimotos thyroiditis reduce or in anyway influence iodine uptake by thyroid gland? I have extremely high levels of TPOAb and I am wondering that since TPO is very essential for iodination of thyroglobulin, wont TPOAb reduce levels available for the iodination? Are there statistics on how Hashimotos patients with DTC respond to RAI ablation compared to DTC patients without Hashimotos? Thanks, Anita

Response

Dear Madam,

TPOAb does not enter intact thyroid cells, hence can not inhibit TPO-activty. TPOAb however kills thyroid cells and thereby reduces the iodine uptake of the whole thyroid gland. A goiter that has developed because of Hashimoto’s disease is hardly that big that reduction is necessary and if so RAI does don’t work because cells are not viable anymore and do not or only minimally take up RAI. I do not know of such statistics that you ask for.

Georg Hennemann, MD, PhD, FRCP, FRCP(E)


HASHIMOTO’S THYROIDITIS WITH VARIABLE THYROID FUNCTION

Question

I have a question about Hashimoto’s? I was diagnosed a year ago. My TSH was JUST above normal, and then I was tested for antibodies which were high. So I have hashimoto’s (my mother has it as well and has been on Synthroid for years). I also have a couple of small nodules. I must have had Hashimotos for about 2 years, which explained the weight gain (about 15 pounds), aches and pains, dizziness, muscle cramps. At the next test, a few months later, my TSH and all the hormones were normal, so my endo ‘monitored’ me and I was tested again in six months. I know that for some people, small fluctuations in the hormones can cause a lot of changes in how you feel. At my last test, while the antibodies were still present (this was in may) my hormones were at normal levels and my endo said my thyroid shows normal function. SO I am not on meds. And I seem to have lost weight and don’t feel as bad as I did a couple of years ago. Does this happen a lot, that you have antibodies but normal function? Can things turn around like that? I have no idea what caused the change. And can you be treated with synthroid or whatever in a case like this, if you have high antibodies but normal hormone levels?

Marlene, Journalist

Response

Thyroid function can fluctuate between normal and high or low in some individuals with Hashimoto’s thyroiditis. Generally if the hormone supply is normal, treatment is not given. However sometimes thyroxine is given in an attempt to decrease the size of the thyroid, and treatment may reduce the antibody levels. Except for their action on the thyroid, the antibodies in Hashimoto’s are thought usually to cause no trouble.

Leslie J De Groot,MD


Thyroid and Hair Loss

Question

I recently stared taking synthroid. I am experiencing fairly severe hair loss. I have been on it for almost 3 months. It has helped me tremendously! I have lost 25 pounds, have more energy, much more interested in sex and basically feel better than I have in 2 years. I am afraid to stop taking it because I feel so much better. What can I do about the hair loss and will it grow back? It has gotten very thin.

Thank you!

C B

Response

Hair loss is common in people who are either hypothyroid or hyperthyroid. Hair loss is also common when one changes the metabolic state. Presumably you were hypothyroid, and hopefully you now are “normal”, and not over-treated. If this is the situation, there generally will be a return to normal hair density over months. However remember that there are many other causes of hair loss, including many serious illnesses, excess androgens, autoimmune problems, and the aging process. Hopefully your problem will straighten out spontaneously in time.

L De Groot,MD


Painful Hashimoto’s ThyroiditisJune 10, 2003

Question

I know you are only for Doctors but I really need some advice i am sure your comments would not take long on this if you could please just take a few moments to read this. I am a 23 yr old women with auto immune thyroid,Hypothyroism & A Goiter. My last blood work done was–TSH – 6.54, Free t3 – 123, Free t4 – 1.4, and antibodies at 135. I have been suffering from Goiter pain and have told my Endo this several times. It was the whole reason I had been referred to him. anyway I called him today to ask for a recommendation on what I could take other then Aleve for the pain as it was not helping and his reply was that it wasn’t my thyroid he thinks I have a sore throat. ok I think after having this problem for 15 years I know the difference but that is what he insists on he told me to go to my reg DR to have it looked at and I plan to go tomorrow just to be sure But I am not sure what to do if my GP says there is nothing wrong with my throat.I mean should this DR,giving my thyroid problems,have blown me off so easily without even looking at things?Should I see about getting a different Endo?or do my test tell him that things are fine and that is how he knows it isn’t my thyroid? as he never even seen me it was a phone conversation in which he told me to take Aspirin that I am allergic to and he knows that I am.I am currently taking Synthroid .175 for the past 3 weeks up’d from .150.

Thank you for any response you can give,

Kyra

Response

You seem to have Hashimoto’s thyroiditis, and according to the TSH you were a bit under-replaced with hormone at the time the test was taken. Pain in the thyroid is unusual in Hashimoto’s, but does occur, and sometimes people even have to have the thyroid removed surgically to get rid of the pain. Your MD might check out an article published in the last issue of Journal of Clinical Endocrinology and Metabolism, entitled “Painful Hashimoto’s thyroiditis”.

Good luck.

L De Groot,MD


MEDICATIONS WHILE HYPOTHYROID10 Jun 2003

Question

I have been searching for cold medicines that are okay for patients with hypothyroidism. Everything I’ve seen over the counter to date includes a notation that one should check with a doctor if one has thyroid disease. I’ve talked with three doctors, and none have any suggestions. Do you know of anything that will dry sinuses or suppress coughs without containing pseudophedrine products? Or suggestions on who to contact next?

Laurie

Response

After your hypothyroidism is treated and your tests are normal, those restrictions on medications no longer apply to you. You are effectively normal, at least in regard to the thyroid.

L De Groot,MD


1/21/03

Question

Hello,

I just found your website and I am hoping you can provide some insight on my situation. I am a 36 years old female and began to notice hair loss in May 2002. The hair loss is diffuse thinning – more in some areas than others – not alopecia areata. I have seen two dermatologists. The dermatologists do not believe that the problem is male/female pattern baldness. They were unable to state the cause.I realize that hair loss can be caused by many things. My question is related to my TSH levels. Here is a history of my TSH: 10/97 = 0.73 (0.3 – 5.1 uIU/mL) 4/99 = 0.99 (0.3 – 5.1 uIU/mL) 8/01 = 2.35 (0.49 – 4.67 uIU/mL) T4 = 13.9 (4.5 – 12.0 ug/dL) 2/02 = 2.53 (0.49 – 4.67 uIU/mL) free T4 = 1.55 (0.6 – 1.85 ng/dL) 4/02 = 3.69 – (noticed hair loss late April early May) (0.4 – 5.5 uIU/mL) 7/02 = 4.09 ((0.4 – 5.5 uIU/mL) 12/02 = 1.90 (0.50 – 5.00 uIU/mL) I showed these results to the dermatologists but they did not mention the changes in my TSH. Are these changes significant enough to cause hair loss? What could cause these levels to change like this? I was on Serzone (350 mg/day) since August 2001 and began tapering off 25 mg/week in March 2002. Could this affect my TSH directly or indirectly? I am completely off of the Serzone.If the hair loss is related to my thyroid, will the hair grow back? How long (approximately) will it take?Any insight would be much appreciated.

Thank you,

Valarie

Response

My answer is “maybe”. The drugs such as Prozac and Paxil, and Serzone, cause increased metabolism of thyroid hormone, which fits with your increase and then decrease in TSH. However the TSH never got out of the normal range. I am unsure that this is enough of a variation to cause hair loss, but it might be. If so, the hair should regrow when you are now back on the regular dose and your TSH is back close to its former level.

L De Groot,MD


13 Jan 03

Question

Two years ago when I found I had Hashimoto’s, My dr. also told me I had autoimmune hepatitis, due to elevated liver enzymes and the ANA was positive. Is it possible that these two disorders could be closely related, i. e. the thyroid has “caused” the liver autoimmune response?

Thanks for your answer!

Carol

Response

Other autoimmune diseases are sometimes associated with Hashimoto’s, and both the ANA and liver disease could be connected in that way. However it is generally believed that these are independent diseases, and not that Hashimoto’s “causes” the other problem. The cause is probably one step farther back for both, some dysfunction in the immune system.

L De Groot,MD


11 Jan 03

Question

Hi,I found your names in the internet and decided to try asking you a couple of questions regarding my wife’s thyroid disease. She is scheduled to take the “radio-active iodine” pill next week and we are a little concern about the effects of it. We have two girls and we lost a baby last year. We would like to have another baby, but we were told that after taking the pill, we have to wait at least 6 months. My wife is 31 and we are a little scared about “this pill”. She needs to be away from the children and from me for 3 days, she can not use any metalic silverware, her clothes and the sheets she will sleep in during the first three days after taking the pill need to be laundered separately from the rest of the clothes, etc. etc.. So here are my questions:

  1. Is taking the pill the best option we have today? The radio-active pill is indeed by far the best option. The measures that have to be taken such as you mention are precautions not to contaminate others with radio-activity. However I can assure you, that they are more taken for psychological reasons than anything else as even if contamination would occur this is fully harmless because of the low total dose radio-activity your wife is going to have. Even so the 6 month’s period is mostly for psychological reasons and in fact irrational as it is meant to avoid any irradiation of the ovum (egg) after fertilization and for this a maximum of 6 weeks is sufficient.
  2. Is it true she will still be taking a pill the rest of her life? I mean we are very young yet for this to happen? Is there any other alternative we were not told?

Thanks in advanced for your help and input.

Claudio Martin

Response

The consequence of the treatment with radio-active iodine is indeed that the risk is high that your wife has to take tablets containing thyroid hormone for the rest of her life, because the treatment very often results in permanent thyroid failure and its function has to be replaced by using these tablets. However this also occurs frequently after operation, while long term treatment with tablets to suppress hyperthyroidism is usually inadequate as relapses frequently occur. Furthermore, if your wife has Graves’ disease, then the natural course of the disease is often that after many years thyroid failure will develop anyway. Last but not least, although it is unpleasant to have to take tablets every day, treatment with thyroid hormone to substitute for thyroid failure is easy and does not affect health in any way. The only important thing to remember is that during pregnancy about 50% of women have to take more thyroid hormone for adequate supply to the unborn child. This has to be checked during pregnancy.

Georg Hennemann, MD.


TREATING HYPERTHYROIDISM12/1/2007

Question

My mother had been diagnosed as Hyperthyroidism and she is now having her medication to controlling her thyroid hormone for 3 months which will be continue for a year if her thyroid level still in high risk, what I want to ask are : 1.how to gain her weight since she is so underweight (her BMI is only 19)? 2.what supplements should I give her that wouldn’t interfere her current medication? 3.Did she need any special diets? because I found on online journals that hyperthyroid patient should consume any diary products, spinach etc 4. Is Hyperthyroidism curable or just treatable?

Thank you,

Amelia Pranatio

Response

1.If her hyperthyroidism is controlled, she should be able to gain weight by consuming more calories than she usually needs. 2.Perhaps extra vitamins would be useful, but basically she just needs a healthy diet. 3.She should avoid large amounts of iodine- milligram amounts- but I do not think any food would be a problem. 4.The last question is complicated. Probably the autoimmunity to the thyroid persists, but for the vast majority of people, treatment is effectively curative.

L De Groot, MD


TREATMENT OF HYPERTHYROIDISM

Question

I would like to ask a question for the thryoid disease manager web site. I am 58 and have Graves disease being controlled by carmbimazole daily. I am feeling very well and able to live a full and active life. Last test results l.4 TSH : 11 T4: 4.4 T3. I have tried coming off twice but symptoms return and will continually try to reduce or come of this drug if blood test results allow. If this is not possible what are the long term consequences of staying on cambimizole compared to the multitude ofcases I have heard of and read about that have had disastrous results for RAI treatment and the resulting hypothyroidism. I understand the risk of a sore throat and the need to have a immediate test but would like to know what other risks are involved in long term use of this drug. Does diet and stress reduction play any part in reducing symptoms?

Many thanks,

Jane Sinclair

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. 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. 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. 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. 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. My labs before the surgery were:

  • 08/29/07
  • TSH 0.98 (0.46 – 4.68)
  • T3 Uptake 27.20 % (23.50 – 40.5)
  • T4 11.2 (5.53 – 11.0)
  • FTI 3.04 (1.65 – 3.89)

My labs after the surgery were:

  • 09/27/07
  • TSH 1.91 (0.46 – 4.68)
  • T4 9.1 (5.53 – 11.0)
  • SED Rate 54
  • Thyroid Peroxidase < 10 (0-34)
  • 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?? 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. I do not believe your complaints of sore throat etc., are necessarily related to Hashimoto’s thyroiditis. I think it possible that you do have an unassociated mild infection and I am surprised that the antibiotics have not helped. Although I would say that thyroxine is not indicated it may be that a trial of thyroxine for six weeks at 0.1 mgs a day may be worthwhile. I do not think the other side of your thyroid should be removed.

Yours sincerely,

Professor JH Lazarus


THYROID ANTIBODIES AND THE RISK OF MISCARRIAGE2 Apr 2007

Question

I found your excellent Home-Page when browsing the internet concerning a question, which is very important for me. I’m pregnant in week 20 and suffering from hypothyroidism. It is unclear, whether I have Hashimoto thyroiditis, since antibodies were never detected, the ultrasound images of the thyroid gland were normal (no reduction of the echo or other abnormalities), the only thing was that the gland is asymetric and small with a volume of 10 ml and my Tsh was over 3,5. I’m taking Thyroxin-substitution every day and the dose was also controlled and increased during pregnancy. My questions: 1. Does autoimmune thyroid disease like Hashimoto increase the miscarriage rate only in first trimenon of pregnancy or also in the second and third? (I’m a bit afraid about that) 2. If having Hashimoto : is there also an increased risk of having antiphospholipidsyndrome? I knwo that when having APS the risk for miscarriage is quite high in the second and third trimestre and I heard, that there is an association between APS and Hashimoto?? 3. Can Hashimoto or other autoimmune thyroid diseases present a echonormal picture in ultrasound? What could be the cause for my hypothyroidism if not an autoimmune disease? Because of the possible impact of autoimmune thyroid disease on pregnancy I would “prefer” – of course – a non autoimmune cause for my hypothyroidism Thank your very much for your answers! You see that I’m a bit afraid about possible pregnancy complications linked to autoimmune thyroid disease. I already read your related text on the home-page but the questions above remained. Would you be so nice to write me a mail to MH.

Response

I will try to answer your various – and legitimate – queries: First, your hypothyroidism seems to be extremely mild since the only diagnostic proof was a serum TSH above 3.5 mU/L. This, in itself, classifies you in the category of ‘subclinical’ hypothyroidism (meaning with normal thyroid hormone levels). You did not mention however whether the slightly elevated TSH was discovered once you were pregnant, or already known before. I would also have liked to know your serum thyroid hormone levels and the dosage of thyroxine you take now. Question 1: miscarriages are increased mainly in the first trimester in women with Hashimoto’s disease. Question 2: there is an association between the APS and Hashimoto’s disease. Question 3: normal ultrasound patterns can be found in Hashimomoto’s disease, either because the chronic ‘inflammation’ process is very mild or so diffuse that it cannot easily be seen. Also, thyroid echography is operator-dependent and therefore the conclusions depend in part upon the experience of the radiologist. Hypothyroidism can be due to several other causes, and this is not the place for a sientific discussion about those. Finally, having reached 20 weeks of gestation, taking the thyroxine correctly with adeqaute controls and monitoring of thyroid function tests should reassure you concerning the remainder of your pregnancy which I wish you to be uneventful and highly successful.

Prof Daniel GLINOER


PREGNANCY AFTER RAI TREATMENT24 MARCH 2007

Question

My husband had a diagnostic scan of 111MBq (3mCi) of RAI in December 18,2006.I am presently in the 9th week of pregnancy.My question is- I am very much tensed whether my child will have any problem,due to the effect of RAI. How safe was it to conceive now?

Thanks.

Elizabeth.

Response

While there are suggestions that it is wise to wait at least three months after RAI to initiate pregnancy, there actually are no data proving that you have any increased risk.

L De Groot, MD


TESTS DURING PREGNANCY14.02.07

Question

My pregnant daughter was refused a scan at 20 weeks by NHS even although she is taking thyroxine. Is a scan not advisable to check the baby’s growth? She did, however, pay for this privately but should a 20 week scan not be automatic under these circumstances?

Kathleen Armour

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 HYPOTHYROIDISM08.02.07

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 you 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 TSH07.02.07

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.

Response

Dear Mrs Fisher,

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 TSH07.02.07

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 NODULE21.01.07

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. I questioned my consultant about ‘draining’ the liquid, but he said it wasn’t possible and instead said I have two options: either to leave it or have partial thyroid surgery which isn’t very helpful.

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!) As a “by-the-way”, I will not be going back to this consultant! Thank you once again for your website and I will definitely look out for that book “Thyroid Manager”. I look forward to hearing from you.

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 THYROXINE17.01.07

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 NODULES04/01/2007

Question

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


03/01/2007

Question

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

Response

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


Question

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 thisyear.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 amconcerned 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

Response

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


19/12/2006

Question

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

Response

Dear Susan,

You indicate you have Hashimoto’s disease and that you are being treated with armour thyroid. You also indicate that you have had a severe allergic reaction to Bactrim. Armour thyroid is not normally recommended as it is a combination preparation of T4 and T3 which is not normally necessary for the treatment of hypothyroidism. In addition it is itself a porcine extract, and the possibility of allergy in yourself should be considered. It may be worthwhile switching to regular thyroxine therapy, e.g. Synthroid or Levoxyl or other synthetic thyroid preparation. Unfortunately whatever you do the immunological process relating to progressive thyroid destruction and failure may in fact continue even though you are taking thyroid hormone.

Professor JH Lazarus

Follow up 19/12/2006

Thank you for answering.

I was taking armour thyroid (very low dose) before the Bactrim incident happened and I never had any trouble with the armour. Is it problematic to be on armour even though it supplies t3 and t4? I had preferred it over the synthetic brands previously.

Susan L Gold

Response

Dear Susan,

Thyroid physicians do not recommend armour, because there is no evidence that a combination of T4 and T3 is any better than T4 alone. In addition, armour is an extract of porcine thyroid and, although manufactured in a rigorous way, still has that potential problem. Synthetic thyroxine is probably easier to manufacture to tight specifications. In addition the T3 which armour contains can cause an elevated T3 level in some people which could be a health hazard. However, many people are on armour and do say they prefer it, although the reasons are often not very clear.

Professor JH Lazarus

Follow up 22/12/2006

Thank you so much for answering.

Could you tell me what sort of health hazard is an elevated t3 if the armour were to cause that? also, is it possible to get Hashimoto’s to stabilize or is this a progressively destructive disease to the thyroid?

Susan L Gold

Response

Dear Susan,

An elevated T3 affects the heart (causes palpitations etc). It also will accelerate bone loss.Hashimoto’s is normally a progressive, destructive disease, but it proceeds at variable rates and can indeed stabilize on occasions.

Professor JH Lazarus


19/12/2006

Question

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.

Response

Dear Glenda,

You are correct that it is indeed normal and usual for TSH to stay suppressed after radioiodine for quite a long time, anything up to two years. Technically you could regard this as subclinical hyperthyroidism, but there is nothing to do at the moment, providing your T3 level is normal.

Professor JH Lazarus


12/12/2006

Question

Could you please advise if ear pressure is to be expected after a totalthyroidectomy? 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.

Response

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


08/12/2006

Question

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

Response

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


Question

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

Response

Dear Ms Adelman,

Thank you for your letter. I am not quite sure which column you were reading! At any rate the short answer is that you should not be worried about a low T3 uptake. It is not a test that is done very often now. Low or high readings of this test can be normal in patients in certain situations or taking other drugs. If your T4 and TSH are normal then you are euthyroid (normal thyroid status). I should not worry.

Professor JH Lazarus


06/12/2006

Question

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

Response

Dear Sandie,

I am sorry to hear that you had a miscarriage. It is probable that you have thyroid antibodies (antithyroid peroxidase antibodies) because you have been diagnosed as having hypothyroidism. These antibodies are associated with miscarriage, although this would be expected to be less if you have on the thyroxine treatment. It is not true that 200 mcgs is the most that you can take. The dose is dependent on what your TSH level is, if you need more to get your TSH level to the normal range that is fine. Another point is that if you do become pregnant you should increase the T4 dosage by 50 mcgs in the first instance. This is because most pregnant women on thyroxine need more when they are pregnant.

Best of luck.

Professor JH Lazarus


05/12/2006

Question

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

Response

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


04/12/2006

Question

I was diagnosed with Grave’s Disease in 2001. At the time the only symptomsI 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

Response

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 LEVELSwere 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


03/12/2006

Question

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)

Response

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. It is true you gain weight after radioiodine; this is because when you were thyrotoxic your weight was probably less than it would otherwise have been. Some of your symptoms are clinically suggestive of an inadequate thyroxine replacement.

I hope these comments are of help.

Professor JH Lazarus


28/11/2006

Question

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

Response

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


28/11/2006

Question

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 hereduced it to two tabs- he said the latest test was slightly up so heput me on 3 tabs.He is talking surgery- but I am really wanting another baby as timeis ticking.Should I delay surgery and ttc or have the surgery (NOT WHAT I WANTIN THE BEST OF ALL POSSIBLE WORLDS OBVIOUSLY) then try to ttc number 2?

Regards,

Maree

Response

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


26/11/2006

Question

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

Response

Dear Jim,

The normal therapy for thyroid replacement is a commercially manufactured pure preparation of the hormone thyroxine, that is what levoxyl is. The thyroid community consider that these preparations are the most satisfactory as they are carefully manufactured to precise limits and standardised.There are thyroid preparations known as thyroid extract which are made from animal thyroids and, although made to strict specifications, they are not as standardised as the synthetic variety. Hence they are not recommended for routine use by thyroid physicians in the world. It is true that originally in 1896 thyroid extract was used for the first treatment of an underactive thyroid, but as you can imagine this preparation was crude and for the last 50 years or so commercial synthetic thyroxine has been the mainstay of treatment. In summary I would not recommend any other treatment other than levoxyl and would confirm that there are really no useful natural remedies to take instead of the drug.

Professor JH Lazarus


22/11/2006

Question

I had a partial thyroidectomy (left lobe) in 2004 due to a growth in thethyroid. 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.

My question is: All medical professionals indicate that the other half of 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?

Response

Dear Ms Mak,

You had a partial thyroidectomy and the question is what is the function of the remaining lobe? If the remaining lobe is normal (which in your case it probably is), then you will have a normal TSH and T4 and will not require any thyroxine replacement therapy. However, it is true that some surgeons routinely ask their patients to take thyroxine after surgery, although in my opinion there is no definite evidence that this is required. It would be useful to know whether you have any thyroid antibodies present in the serum, as this may indicate the progression of thyroid disease in the remaining lobe. The answer to your question is that the remaining thyroid can function quite normally after thyroidectomy and will indeed compensate. The best tests of thyroid function we have at present are indeed TSH and T4 and they are normally accurate at providing information on the health of a patient.

Professor JH Lazarus


DIAGNOSTIC DOSE OF 131-I21 Nov 2006

Question

Can you please answer my questions regarding RAI dose of *111MBQ for a 30ys old male* How many days should the person stay separate from others ?(especially from pregnant person) As per our doctor this is a diagnostic dose to check for the spread of cancer. One year back the same dose was given and it was found that there is no spread of cancer in the body. So is there a possibility that there will be spread after one year? Is this a high dose?

Thanks Elizabeth.

Response

This is not a high dose. It is a diagnostic dose that will not cause significant exposure to other people including pregnant women. Regarding the possibility of subsequent spread after a negative diagnostic WBS, it depends from the original TNM stage, the age of the patient and the type of initial treatment. However, the diagnostic WBS is poorly sensitive in detecting local or distant recurrence. The best method of follow-p is measurement of serum stimulated thyroglobulin (that must be undetectable) ands neck ultrasound (that must exclude regional disease).

Sincerely,

F. Pacini MD


SUB-CLINICAL HYPERTHYROIDISM AFTER RAI TREATMENT7 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, PREGNANCY17 OCT 2006

Question

I am 29 years old female (weight: 143lbs (pretty constant for the last 5 years; height: 5’-3”) currently residing in India. I have been diagnosed with hypothyroidism since 2001, and I have been on thyronorm (thyroxine sodium) on and off. I had 0.25mcg thyronorm continuously for one year in 2004. Recently, when I got my blood profile done, my TSH value was 8.5, and was put on 50mcg Thyronorm. 2 months later my TSH levels dropped to 0.02. Suspecting that there was some problem with the results, doctor suggested a retest. But now the TSH levels have dropped to 0.01.At this time, my doctor asked me to do a TPO antibodies test, which showed the result as >1300 (range <34). He is asking me to continue the Thyronorm for next 3 months (50mcg). Other than the abnormalities in the blood test, I do not have any major symptoms of either hypo or hyper thyroidism other than difficulty in losing weight. I have no lethargy/ tirdness/ fatigue etc. I am attaching my historical TSH values for your reference. We are trying to get pregnant, and the doctor has asked us to wait for 2-3 months.Is there anything else that I need to recheck? Should I ask for a second opinion?Myself and my husband are really concerned about this issue, and we would be very grateful if you could please advise us on this issue.

Shilpa

T3 (ng/dl)

T4 (ug/dl)

TSH (UIU/ml)

TPO ANTIBODIES

10-Oct-06

167

12.1

0.01

>1300 IU/ml

Range

70-204

5.2-12.5

0.35-5.5

<34

07-Oct-06

215

12

0.02

Range

60-200

4.2-12

0.3-5.5

26-Jul-06

136.4

8.7

8.52

Range

70-204

5.2-12.5

0.3-5.5

09-Jul-04

90

9.54

Range

80-180

0.4-5.5

28-May-04

110

8.63

Range

80-180

0.4-5.5

04-Jun-01

83

5.99

8.54

Range

70-200

4-13

0.3-0.6

06-Apr-01

160

11.94

0.02

Range

70-200

4-13

0.3-7.0

03-Jan-01

123

9.91

5.65

Range

70-200

4-13

0.5-0.6

Response

Dear madam, the only reliable parameter to monitor appropriate thyroid hormone substitution is the TSH value. T4 and T3 parameters are insensitive to this end. Your TSH should be between .04 and 2.0. This means that you are using a little too much thyroid hormone. I suggest to take alternatively 25 and 50 microgr per day. There is no problem to try to get pregnant already now, even if your dose is a little too high. This does not hurt. Be aware that during pregnancy many women need about 30% more thyroid hormone. I suggest that as soon as you have conceived to increase the dose by 30% of what you are using. Have your TSH tested 3 weeks after this increase and subsequently every 6 weeks during pregnancy. After delivery most women can go back to the pre-pregnancy dose.

Georg Hennemann, MD


POSSIBLE HYPERTHYROIDISM10 OCT 2006

Question

I’m a 34 year old female. On a routine blood test, my doctor discovered a slight case of hyperthyroidism. My TSH is below .01, and my T4 and T3 are elevated ( as are FT4 and FT3), both slightly, but the T4 is elevated more, relatively speaking. My doctor says my ratio of these factors points towards it not being Graves. After a patient history, physical exam,and an EKG to check for any arrythmia ( it wasnormal), my doctor decided it was likely to related to an excess of dietary iodine ( a supplement with 150 mcg and excessive amounts of dairy), and too much caffeine ( I am, or was, until this happened, as he termed it, a caffeine abuser). I was told to watch the iodine and caffeinefor 8 weeks and return for repeat testing. The only other significant factor in my history is that after 11 years of being either pregnant or nursing continuously, I stopped in May of this year ( but my child is older than a year). I asked my doctor about Graves, and he is unconcerned about it. I had a late term pregnancy loss ten years ago, and underwent extensive testing at that time, and have continued the testing atfuture pregnancies. I have had four negative thyroid antibody tests, and he declined to do another one at this time. My only finding from all of my repeated autoimmune testingis a one timelow positive anticardiolipin antibody, but it was later attributed to a case of CMV, and never occurred again. I have no family history of Graves or autoimmune disorders. I have absolutely no symptoms at all. No weight loss,no palps, no skin or hair changes. Nothing. I feel just fine, and can exercise and complete my daily work with no trouble at all.Is my doctor right to advisethis course? Watch and wait?

Jessica

Response

Your thyroid hormone data point to hyperthyroidism. It is not possible to judge from these data if it is caused by Graves’ disease or some other condition, such as nodular goiter or thyroiditis. The fact that you have no family history of Graves is a weak argument against Graves, but more significant be it not conclusive, is that you have no thyroid auto antibodies. If you have no serious complaints and no anatomical thyroid abnormalities, such as goiter, the option “to wait and see” is a good one. If you happen to have the painless type of thyroiditis, this resolves spontaneously in 70% of cases. However in these patients hypothyroidism may develop in later life. Your doctor could measure thyroid uptake of radio active iodine that is low or absent in thyroiditis but normal or elevated in Graves and nodular goiter. If iodine would be the cause of your hyperthyroidism, then it might resolve after reducing intake. This implies that you might risk hyperthyroidism at some time later, even without excessive iodine intake.

Georg Hennemann, MD


MEANING OF POSITIVE ANTIBODY TEST10 OCT 2006

Question

I had hyperthyroidism about a year ago and it was very severe, I lost about 30 pounds weighing about 100 and could not do anything without almost fainting but I ate like a horse. My thyroid got very low after some time on tapazole and I finally got off of it. Once my thyroid levels became normal I have had elevated antibodies. This scares me and makes me think there could be something else raising my antibody levels, but my doctor seems nconcerned. My thyroid gland is enlarged and I have had several ultra sounds on it and there is nothing showing up.The doctor said normal antibodies are at 35 and mine have been 165.This seems abnormally high. Could this mean I have some other unrelated problem in my body like cancer or an immune problem? –sciple l m

Response

I agree with your doctor that this is hardy anything to worry about. In the first place your antibody level is only mildly elevated. Strongly elevated levels are in de many hundreds or may be thousands. The presence of these antibodies is only a risk factor that at any time in your life you may develop ether hyper- or hypothyroidism. A yearly check of your TSH is there fore mandatory.

Georg Hennemann, MD


THYROXIN TREATMENT AND URTICARIA

Question

I am a patient who has underactive thyroid and have been on medication for a long time. I just develped uticaria out of the blue. Never heard of such a thing. went to the dr. He put me on Prednizone, Zantac and Zyartec which are all antihistamines. Can this be due to my throid changing. All of a sudden. Are there any diets you can go on. I appareciate your answer. My dr. took all blood tests. He thinks it is a virus that hit the immune system. Is that possible.

joankjoank@msn.com

Response

Very rarely patients become allergic to the thyroid medication. Not so much because of the thyroid hormone it contains, but to the other material in the tablet. In such case changing to an other thyroid hormone preparation is usually sufficient. Again this situation is really verry rare. It can certainly not be due to a change in thyroid function. Of course there are many other more frequent causes of urticaria.

Georg Hennemann, MD


THYROXIN DOSAGE AFTER PREGNANCY 26Sep 2006

Question

I have been taking synthroid 50mcg for years. I then became pregnant and my dose was upped to 75 mcg. after having my baby and nursing for 4 months i was feeling extremely awful and all my hypo signs returned. My tsh was tested and came back 14.78. The doctor ordered and additional TSH and it came back 17.48 in one week it went up from 14 to 17. My goiter has also become enlarged. My doctor upped my Synthroid to 150 mcg and ordered additional blood work in 6 weeks. I am afraid she doubled it and that may be too much.Do you think 150 is too much of a jump from the 75?

Response

You may be right. However you are most probably suffering from post partum thyroiditis. This condition may occur in women who have thyroid antibodies (anti-TPO) in the circulation. It usually develops in the first year after delivery. It can cause either hyper- or hypothyroididm. You apparently were already partially hypothyroid before pregnancy. This has now aggravated after delivery. The following process may occur. Either the severity of your present hypothyroidism remains permanent and may become even worse, or resolves to the pre-pregnancy level. The increase in dose, considering your TSH level may certainly be too high for the present time. A jump in dose of 50 would probably have been better. However if your thyroid is going to be damaged even more the dose may have to be again increased further. Note that for appropriate dose finding only the TSH level, and not the T4 and or T3 levels, is important. The TSH should be in the range of 0.4 and 2.0. Can breastfeeding cause the TSH levels to rise so high? No How quickly do you feel side effects from synthroid? If appropriatly dosed there are no side effects. If the dose is too high, side effects, in the sense of hyperthyroidism, may ensue after 1 to 3 weeks. How soon do you feel improvement after taking higher dosage? This may start between a few days and 1 week.

G Hennemann, MD


HASHIMOTO’S THYROIDITIS AND MANY PROBLEMS26 SEP 2006

Question

I am a 34 year old mother of 2. About one year after my first child was bornI was at a health seminar were I had a health screening. Being a Physical Education teacher and avid fitness buff, I thought they had sent me incorrect results from my cholesterol test. It came back high and with a warning to see a Doctor. I ignored the test andthe next year became pregnant with my second child.I had a much more difficult pregnancy with my second. I had severe fatigue, a strange skin condition around my mouth, my eyes and my ears and gestational diabetes (which is not prevelant in my family at all, and my pregnancy weight was totally normal). MyOB chalked it up to being a mother of one and hormones. (I have a wonderful OB).Approximately 6 months after the birth of my second child I experience major weight gain, severe fatige, dry skin, scruffy voice and hives. I was immediately sent to an endocronologist after my TSH levels came back high at my yearly OB visit. Too make a long story short (TOO LATE) I was diagnosed with hashimoto’s. I am taking Synthroid .111. I feel much better then last year, but I still have some conditions that are interfering with day to day activity. First of all the strange dryness around my eyes and ears are gone, but is still around my mouth all the time. Every 2 to 3 weeks I have these episodes where I become completely irritable and unable to control my temper and emotions, my vision gets blury, I become forgetful, bloated and my periods are out of control. My mother who also has thyroid issues (not as severe as mine) often says give the medicine another year. I don’t think I can. I call my endo. regularly, but his nurses seem to blow me off and on the rare occasion I do talk to him I don’t feel like I get any answers.He has sent me for lab work, all of which comes back fine. My question is this. Are there answers out there to get or am I losing my mind. I feel crazy and am beginning to wonder if I am ever going to feel normal again. Just curious if I should pursue a different route or stay the course. I hear wonderful things about my endo. from other people and I certainly don’t want to complain about him, however, I really need to get back on track and even if one person could tell me that I will be back to normal one day soon it would make me feel so much better. I greatly appreciate any response you might have time to give me. I can tell by reading the thyroid disease manager website you are very busy, but I am very impressed with all the responses.

Thank you for your time.

Katie

Response

Dear Katie,

In the first place the question is if you are appropriately treated with thyroid hormone. The only correct way to dose this is on the basis of the TSH value that should be between 0.4 and 2.0. T4 and T3 are unnecessary and even sometimes misleading. Check with your endo if this is really the case. You should know that all! abnormalities and symptoms, caused by Hashimoto, revert to normal after correct treatment, This may sometimes, in long term severe cases, even take a year indeed. However in that year there has to be a continues improvement, So, if complaints remain, one have to think about other causes. As Hashimoto is an auto-immune diseases, one has in the first place to think of other auto-immune conditions that may play a role, For instance dry mouth and eye problems may occur in Sjögren’s disease. Psychological problems can certainly exist in inappropriate thyroid hormone substitution and generally in people who feel awful for any reason. Talk to your doctor!

Georg Hennemann, MD


TREATMENT OF PAPILLARY THYROID CANCER26 SEP 2006

Question

My son is 23 yo who was diagnosed with papillary carcinoma of the thyroid in 1995. He had a total thyroidectomy and a right radical neck dissection. He was treated with 83.2 mCi of I131 post surgical ablation.In 1996 he was again treated with another 29.5 mCi of I131 for an elevated TG of 450. TSH was 51.1. Post therapy scan revealed a single small uptake of iodine in the right upper lung. Six months later 1997, he was treated again with 29.4 mCi of I131 for an elevated TG of 2200. TSH was 144.2. Post therapy scan revealed that the single area of uptake in the right upper lung has resolved. However, there was diffuse uptake seen throughout both lungs, which was interpreted as microscopic metasatic papillary carcinoma. Six months later in 1998, he was treated again with 178.13 mCi of I131 for elevated TG of 1300.TSH was 217.6. Post therapy scan showed no significant change from the prior whole body scan six months ago. Six months later in 1998 he was again treated with 161.77 mCi of I131 for an elevated TG of 1121. TSH was 185.9. Post therapy scan again showed no significant change from the previous. Chest X-Rays were all normal and Chest CT’s showed diffuse lesions mainly in both lower lobes largest being 10x11mm. Most of the lesions are 7x6mm or smaller. CT findings have been relatively the same as well as the I131 whole body scans. A recent PET CT fusion scan revealed the same findings. In 1998 it was theopinion of the attending Nuc Med physician that we stop and watch the disease due to the accumulativeI131 doseof over 500 mCi and my sons age of 15 yo. Since then we have followed the disease by TSH suppression and TG. Results have be shown to have a slight increase from 85 in 1999 to 141 in 2006. Currently, his physician has recommending another I131 therapy treatment utilizing dosemitry for the maximum dosage which is scheduled for Oct 18, 2006. Last year when the question was raisedof therapya Nuc Med physiciansuggested banking bone marrow. This time, on multiple occasions his endocrinologist has been calling him and informing him of the high risks on sterility and complete destruction of his salivary glands. I have been in the Radiology field for 30 years and through all the lititure I can not find anything to support the extent of these risks. I do findthe risks to be classified as “suppressed” rather than complete destruction. Other concerns are leukemia and pulmonary fibrosis. My son is raising questions of quality of life. Few physicians when asked why do therapy if it is stable? Most jump to the guns and say treat with I131 despite knowing he has had 5 therapeutic doses of I131 for a total over 520 mCi.Some after learning the history of my son say that being conservative is also an option. Some have talked about future medical advances which may cure this disease. We again are having mixed feelings about this therapy. Getting a good experienced second opinion is very hard to come by. We are in search for an unbiased good experienced second opinion. I have readsome of your publication and feel you are the most experienced that I have found in the 11 years of searching. Could you please give us your thoughts, suggestions, and recommendations.

George Miladinovich

Response

I have reviewed the facts in your son’s case carefully. Although it is difficult to comment on the decisions made by others in retrospect, it does seem that the administration of radioactive iodine was done with reason and for contemporary indications. Generally your son would be considered to have a good prognosis as he was diagnosed at a young age. Individual progression is difficult to predict but there is some indication that his thyroglobulin is rising despite TSH suppressive therapy. It is likely, given the diffuse nature of the apparent disease in his lungs that surgery is not a viable option. As such his physicians may be balancing the risk of progression of the thyroid cancer versus the down side of additional 131-I treatments which do include the risk of salivary gland damage, and higher risk of secondary malignancy such as leukemia. The comments about transient bone marrow and testicular suppression are valid and indeed some patients have experienced bone marrow failure (risk is likely greatly lessened with dosimetry) and infertility. The banking of sperm has been recommended for those undergoing higher dose 131-I therapy and I would think that bone marrow banking might seem reasonable as a measure to utilize in the case of marrow failure or the development of leukemia. I do not believe that marrow banking is generally recommended in current guidelines. So what to do? If there is evidence of anatomic progression, further treatment with 131-I would seem reasonable if the post (or pre for that matter) treatment scans indicate that the 131-I was taken up into the tissue. If the post-treatment scans show no uptake however, consideration of chemotherapeutic protocols currently under investigation would be reasonable if there is evidence for progression of disease.

James Hennessey, MD


FLUID RETENTION, ? CUSHING’S, ESTROGEN TREATMENT, EXCESS WEIGHT23 Sep 2006

Question

I`ve been to several endocrinologist in the UK over the last 20+ years, who don`t seem to be up to speed.I initially had increased prolatin some 20+ years ago I was prescribed T3 which helped with fluid retention. However after 3 months it stopped working. I found out many years later that after 2 to 3 months T3 causes a rebound reaction..I was then prescribed a narcotic thename evades me at the moment.. It made my blood pressure drop like stone.Then about 10 years ago I had 2X 24 hour urine samples and I appeared to have 11 Hydroxycortisol missing along with one or two other elements.The endocrinologist I saw were I am very much afraid out of their depth…They were only concerned I might have Cushings.They did not want toentertain I might have adrenal hypoplasia.I did get some dexamethose for a private GP and natural path which seem to help.and some saline solution.But since then I got myself off the dexamethsone.I`ve been borderline diabetic for many years, but the endocrinologist did not want to know..I`ve gone into early menopause at about 37.. I was found on a private test some 3 or so years later myoestrogen level had dropped below so called normal menopausal levels.I think it was 8%..I`ve been on oestrogen of various kinds for the last 8 years or so.So I still have periods… But my weight keeps increasing.. I am about 20 stone and don`t eat much.Is there any help you could suggest? Like experts in the UK who know what their doing.

Carol J.R. Rae

Response

If you do not have Cushing’s disease or thyroid malfunction, the increase in bodyweight can only be due to an imbalance between energy intake (food) and energy expenditure (exercise etc). The only solution is to decrease the first and increase the second.Regards.

Georg Hennemann MD


HYPOTHYROIDISM AFTER OPERATION23 Sep 2006

Question

I’m a 51 year old regularly menstruating female.Irecently had a total thyroidectomy for possible Hurthle cell ca found on biopsy of one dominant nodule (multinodular goiter with previously normal free T4 and TSH). The final path report was thankfully negative, and I began my exogenous hormone replacement at 75mcg four days postop, not feeling particularly fatigued. At 4 weeks (9/8), my Free T4 was 1 and my TSH was 24.5, and the fatigue has set inI’m now on a 150mcg dose daily, but feeling significantly more fatiguedeach day. This increasing fatigue made me suspect that my “homemade” supply has been exhausted and I’m now solely relying on my RxMy questions are– (1) How long does the body “hold on” to its T4 and T3 post total thyroidectomy, and how long does it take for the Rx to “take hold?” If a “total” thyroidectomy is really total, usually a minimal remnant stays, thyroid hormone levels disappear from the blood in about 6 weeks. (2)How often do you recommend TSH monitoring before a euthyroid state is achieved?

Thank you for your expertise and your time!

Response

Erica B That depends on the time periods that the dose is increased until the desired amount. I suggest that after each increase in dose, the TSH should be checked about 4 weeks later. Note that for optimal dose finding and maintenance the best test is that of the TSH. In patients on thyroid hormone treatment it should be between 0.4 an 2.0. The values of FT4 and T3 are irrelevant in this respect.

George Hennemann, MD


MANAGING A THYROID CYST23 Sep 2006

Question

I read on your site that cystic growths may not be visible on MRI. If draining of the cyst is a treatment option, then (a) How do you ascertain the location of the cyst (and where to drain it from) (b) Is draining sufficient for a total cure (if it is fully liquid)?

Thank you.

ggopal@mba04.rsm.nl

Response

Cyst are best visualized by ultrasound. Draining is done under ultrasound control by needle puncture. The best results, about 30% complete and in 60% partial disappearance, are obtained, when after draining the cyst is rinsed with ethanol.

George Hennemann, MD


HASHIMOTO’S THYROIDITIS AND MANY SYMPTOMS5 Sep 2006

Question

I am a 39-year old white female who was diagnosed as having Hashimoto’s thyroiditis 7 years ago. At the time I was hyperthyroid and received medication to treat that for 1 month, but have since then be euthyroid. My latest TSH levels were 1.7 in January and 1.3 in June. My thyroid is enlarged and has been since prior to diagnosis. I have had a series of thyroid sonograms that do show several small insignificant nodules that are not changing in size. I have also had an uptake scan done which is normal. My problem is the body aches and fatigue that have accompanied the initial thyroid symptoms have not dissipated. I have had an endocrinologist and an ear nose and throat specialist tell me that “you have an autoimmune disease–deal with it”. My general practitioner frequently runs all types of blood work and has no answers. Because I am currently euthyroid, I am told that I do not require treatment, but I am very frustrated with the fatigue and body aches. The endocrinologist that I was seeing has since retired and there is at least a 6 month wait in my area to get an appointment with one. I am currently being treated for high blood pressure, endometroisis, anxiety and TMJ.

Any suggestions?

lscrawley@verizon.net

Response

In Hashimoto’s thyroiditis, we usually use thyroxine tablets when patients have decreased thyroid function, and we call this is the replacement therapy. Sometimes drug is used to suppress TSH in order to decrease the thyroid size or to inhibit the growth of thyroid nodules. In latter case, some patients complain heart palpitation, hand tremor etc., just like you, due to slightly increased serum thyroid hormones. Initially you might have this condition. It seems unlikely that there is functional difference among different brand tablets. Hashimoto’s thyroiditis gradually develops into hypothyroid condition and your current treatment with 0.1mg of Levoxyl is appropriate since your TSH 1.47. Anti-thyroid peroxidase antibodies (TPO -Ab) keep their high titers for life long and are not disappear and just show continuation of thyroid autoimmunity. However, TPO-Abs have no biological activities. Liver function tests are influenced by abnormal thyroid function but slightly increased ALT in your case may not be related to thyroid problem since your thyroid function seems to be normal due to suitable replacement therapy. Your feeling of fatigability may not relate to thyroid problem since your thyroid function is normal.

N Amino, MD


THYROXINE DOSAGE FOR CONGENITAL HYPOTHYROIDISM1 Sep 2006

Question

My daughter, who is nine months old, was born with congenital hypothyroidism. It was caught because of the heel prick test and she began taking Synthroid in her second week. She has been on a dose of 25mcg pills of which she takes 1.5 pills per day. We have been to several dr appointments and her med levels have not changed. She went to another appointment this week and they want to adjust her to 1.5 pills one day and 1 pill the next, alternating. Her TSH level was 1.65 and her T4 level was 0.05. The doctor said the the T4 level was a bit low but the TSH level was good and that she wanted to decrease the dosage just a bit. I have seen the normal levels on your site but wonder are these levels the same for infants. She is developing normally and the doctor says there are no problems. She did ask me if she was restless sleeper. What would this mean and how do I know what restless is. She has been sleeping through the night since she was 1 month old and very rarely wakes up. Is restlessness an indicator of something? Also what sort of signs should I look for that may indicate that there is a problem with the dosage of medication. She only goes to the dr every three months currently.

Thank you for your help.

Janice McKinstry

Response

A dosage of 37.5 mcg (i.e., 1 ½ 25 mcg tabs) is a common dosage for babies with congenital hypothyroidism. Visits every 3 months are OK. One of the signs of thyroid hormone overdosage is difficulty sleeping which your baby definitely does not have if she sleeps through the night.Are you sure that it is not the free T4 that is 1.65 ng/dL and the TSH 0.05 mcU/mL? If so, then decreasing the dosage would be reasonable.

Sincerely,

Rosalind Brown MD


RAI TREATMENT IN A 14 YR OLD WITH MINIMAL CANCER(25 AUG 06)

Question

My name is Sheila( from UK)and my 14 year old daughter underwent hemithyroidectomy in April 06 to remove 3.5cm tumour, which was found to be microinvasive follicular carcinoma.She subsequently had the second half of her thyroid removed in July 06, and this was found to contain a tumour <1cm in size. Now her surgeon is considering RAI ablation, but says he is not keen on this type of treatment, and that my daughter and I have to decide whether or not she should have it.My questions are- what are the risks of radioactive iodine for a girl this age, and could measuring her thyroglobulin levels indicatewhether or not the cancer may have spread?

Sheila

Response

Although the prognosis in this situation is very favorable, the usual response would be to ablate the residual thyroid tissue with RAI. There is probably no detectable risk with this treatment. Alternative but less satisfactory approaches would be to 1) follow thesituation with imaging and blood tests, or 2) delay RAI until age 18. But I doubt that either is quite as satisfactory as to treat now.

L De Groot, MD


TREATMENT OF RAI INDUCED HYPOTHYROIDISM25 Aug 06

Question

I had been diognised with
Hyperthyroidism — Graves Diseasefor years with Tapozle. Then my endocrinologist suggest me to take RAI. After RAI, I still hyper, so continue to take Tapozle. After 1 year of RAI, right now I am
Hypothyroidism — after RAI treatment. AndI am on Synthroid 0.088mg for 3 months, then my doc change to Eltroxin 0.05mg now.I am searching for the better treatment for myself because I don’t think these chemical medicine is good for the body. I regret that I took RAI without knowing the serious side effect for my rest of my life. From what I had experienced I will NOT sugguest people to take RAI !! I suffer lots of symtoms after got Hypo. after RAI. Not sleep well, no energy, hair loss, dry skin, feel cold..and I am only 23 years old! I feel helpless…but I believe the natural herbal may be can help me..I found a site
http://www.greenlife-herbal.com/and want you comments. What do you think I should do?? What do think about the western medicine and tradiational herbal treatment?

Waiting for you answer. Thank you a lot!!

Kelly

Response

RAI treatment is the best treatment for Graves’ disease. Appropriate treatment with thyroid hormone is easy and people feel 100%.For dose finding the only important thing is to check serum TSH that should be between 0.4 and 2.0. Both Eltroxin and Synthroid are perfect medications for hypothyroidism. Alternative treatments do not work and life is not possible without the availability of thyroid hormone!!

Georg Hennemann MD


STAPLES IN THE NECK AFTER THYROID SURGERY24 AUG 06

Question

At least ten years ago, I had a goiter removed, surgery went well, no complications. About five years after that, I had to have xrays taken on my neck, and found out by the technicianthat I have staples where my goiter surgery was, actually it is more to the left up the side of my throat! Is this common, or did the Doctor just want to do a “quick” job to get done, or did he forget to remove these? I have since relocated from the area that this surgery was performed, but many times this has been an unanswered question in my head. Can you enlighten me on this matter?

Thank you

Lynn

Response

It is normal to have staples present in the area of prior thyroid surgery, and harmless.

L De Groot,MD


HYPOTHYROIDISM AFTER REMOVAL OF HALF THE THYROID24 AUG 06

Question

I am a 40 year old female. My doctor discovered a tumor on my right thyroid lobe in 2002. I immediately underwent surgery due to results of the ultrasound, uptake and scan. When the surgeon removed the gland tests indicated the tumor was benign, so he left the left lobe in tact.Since this time I have been taking 100 mcg of synthroid daily. I’m not sure how I feel. I have not felt like myself since prior to the surgery. I do know that I feel better when I take the Synthroid than when I’m not because I stopped taking the meds before.I began seeing a new doctor 3 weeks ago. I had not taken the synthroid for approximately 3 weeks so she ordered blood work at that time. I went back today and she told me that my blood work confused her because my TSH was 7.4 and my T4 was 5. and the T3 was 2.4. She wants to repeat my blood work again in two weeks 24 hours after I have taken my synthroid.I don’t understand any of this and I have never asked about my blood work results in the past. I just let them draw the blood and took the meds the Doctor prescribed. I do know that I feel fatigued and catch every virus and cold that I’m around. I also believe that something is affecting my mental health. Can thyroid disease effect all of this and do you have any answers based on the small amount of information I can provide?

Sandia

Response

If one lobe has been removed by surgery, the other lobe usually compensates for the whole thyroid function. In other words, there is usually no additional thyroid hormone substitution needed. It may be that, because you used thyroid hormone that you recently stopped, your thyroid is resuming function that was suppressed by the thyroid medication. I therefore think that is too early to conclude that you need permanent thyroid hormone medication because your TSH is elevated at the moment. I would suggest to wait at least another 8 to 12 weeks before taking a decision about treatment with thyroid hormone for permanent thyroid failure.

Georg Hennemann MD


QUESTIONING THE DIAGNOSIS OF GRAVES’ DISEASE24 AUG 2006

Question

I am a 40 year-old female who has been diagnosed with Grave’s disease, but I am questioning this diagnosis for the following reasons. I have been hypothyroid for 10 years and taking thyroid medication. When I switched to this Dr. she had my blood tested for antibodies, which came back positive. These were my results in 12/04. FT4 was normal at 1.0, TSH was abnormal at 11.584, anti-thyroglobulin AB was 125 (<40 IU/ML) and antithyroid peroxidase was 553 (<35 IU/ML). She put me on thyroid replacement (Synthroid) at that time and told me that I had Grave’s disease because I tested positive for antibodies. I came home and read all that I could find on Grave’s disease, but could not find anything that supported treating GD with thyroid hormone replacement. The next test I had she only tested me for TSH, which was 9.473 in 7/05. Then just recently, she only tested for TSH again, which was 8.023. She has increased the dosage of my medication. Can you please tell me if this is a correct diagnosis? Most of what I have read would point me towards Hashimoto’s Thyroiditis as opposed to Grave’s disease. However, as far as I can tell I do not have a goiter. Is it possible to have autoimmune thyroid disease without having Hash. or Grave’s, or is that for sure what the antibodies are predicting? I would appreciate it so much if you could help me with this. Each time I told my Dr. that I couldn’t find any literature to help back up what she has diagnosed me with, according to my labwork, she tells me that I had hyperthyroidism at one time, but that my thyroid burned out and doesn’t work any more and that is why I am taking thyroid replacement. Is this possible? I have always been very cold, low temp, suffer from bouts of depression, and very tired. I’m just questioning this diagnosis. Thank you for any help you can give.

Anita

Response

You do not have Graves’disease , but auto-immune hypothyroidism. The misunderstanding however is that Graves’ disease and auto-immune hypothyroidism are from the basic causal point of view not very different. Graves’ disease is caused by thyroid auto-antibodies that stimulate the thyroid to hyper function. These antibodies are called Thyroid Stimulating Immunoglobulins ( TSI ). However in Graves’ disease, also thyroid damaging auto-antibodies are being produced, i.e. anti- TPO and anti- Tg . It depends on the ratio of the present stimulating and damaging anti bodies what the clinical picture will be, hyper- or hypothyroidism. If stimulating antibodies prevail hyperthyroidism will ensue, but at the long run the thyroid will be damaged by the concomitantly present damaging antibodies, resulting ultimately in auto-immune hypothyroididsm . If the damaging anti-bodies are initially dominantly present the primary picture is that of auto-immune hypothyroidism. Thus both diseases are caused by the same basic process, but differ in clinical picture.Your doctor has to increase the thyroid medication on the basis of the TSH level that should be between 0.4 and 2.0.


HYPERTHYROIDISM AND WEIGHT GAIN19 AUG 06

Question

I have gained 10 pounds in the last year and haven’t felt myself. Went to Dr. and they tested my thyroid – much to my surprise-they are telling me I am hyperthyroid even though I have a lot of hypothyroid symptoms – My bloodwork and RAI uptake test all came back – over an 8 month period, my TSH has continually been 0.01 and now my Free T3 is high – my endo is recommending that I have a treatment of Iodine Therapy and then take PTU 48 hours after the treatment. Is this the correct approach? I am very nervous. I don’t know what to do.

Tracy

Response

It is exceptionally rare to have weight gain during hyperthyroidism, but it happens indeed! Only if your thyroid is not or only slightly enlarged it is worthwhile trying to treat you for at least one year with an anti-thyroid drug. However relapse occurs in the majority op patients. More and more the first line of treatment is administration of radio-active iodine. It is harmless except for the thyroid that is intentionally being damaged. Hypothyroidism will ensue in due time, frequently already in the first year. But treatment with thyroid hormone is easy. In fact even after (successful) treatment with ant-thyroid drugs, hypothyroidism develops ultimately in many patients, but over a longer period of time.

Georg Hennemann MD


THYROGLOSSAL CYST(16 AUG 2006)

Question

Hi, my name is Dianna and my son has a thryo glossal cyst. He is only 2 years old and I was told that it needs to be removed along with the hyoid bone. Will this cause him any danger getting the hyoid bone removed? Will he still be able to talk normal and be a normal 2 year old. Please help me because he is due to have the surgery soon. Thank you fortaking time to read this.

Thank you,

Dianna

Response

The suggested operation is thecorrect procedurefor this boy. There should be no significant difficulties with swallowing or speech after surgery. The central part (Sistrunk) of the hyoid is removed. If it is not removed, recurrence can occur. If the patient does not have surgery, there is the possibility of a recurrence.

If I can be of further assistance, please let me know.

Edwin Kaplan, MD


HYPOTHYROIDISM AND HIVES

Question

I am scratching myself crazy. I am getting hives several times a day and it’s pushing me over the edge. The hives are coming more often and spreads to a larger area with a burning and crawling sensation. At the end of last year my doctor put me on SynthroidI started out at 100 and elevated to 150 mcg. I stopped taking it @ January after only being on it a cpl of months due to a lost of insurance. In the past several months the hives are back Big Time, I have went from 180 to 255 in 6 months ( I barely eat and my fiancee and daughter are constantly on me to eat—-but I’m getting scared to because of the incredible weight gain;I am 6′ tall so 165-180 is my normal weight – I am 43 yrs old), I am losing hair like there is no tomorrow, my blood pressure is extremely low always, I have absolutely no energy, my periods are extremely irregular and very heavy ( I go through 2-3 boxes of tampons & 2 bottles of Pamprin Max each period- passing ALOT of clots), my face is puffy and at times it is a bit sore, and as weird as it may sound when the hives come my tongue gets fat and it seems with each episode it stays fatter, headaches are constant at this point and it seems to effect my vision alot, and unless I take something – I am constant constipated…am I going crazy? Menopause from hell? or is my thyroid wacked out? My mother died @ 25 years ago, however, I know she had major issues w/her thyroid and even at one point had goiter surgery. My daughter has borderline TSH levels and I have several nieces w/thyroid issues and are on constant medication. Can this be dangerous or just extremely annoying and uncomfortable….I do not have insurance and know retesting and meds are extremely high. My doctor moved to FL at the time I ran out of meds and insurance so I would have to find a new one…..Guess I just want to make sure this isn’t dangerous, as well as, is there anything I can do that isn’t going to put me into financial hell.

Donna Gillstrap

Response

Your complaints and symptoms sound very serious and are quite compatible with severe hypothyroidism! I am compelled to say that going on like this may be life threatening! You may even be in a situation that immediate full replacement with Synthroid may be dangerous too and that substitution has to be done carefully in a graded manner, for instance every for week an increase in dose of only 25 microgram and starting with this dose as well. Appropriate treatment should aim at a TSH level between 0.4 and 2.0. T4 and T3 levels are absolutely unnecessary and cost only money. It is only the TSH that matters.I am really sorry about your financial situation but this is life priority!I can’t exactly explain your hives problem but there may be a connection with your present state of hypothyroidism.

Georg Hennemann, MD


HYPOTHYROIDISM AND HIVES20 JUL 2006

Question

I am a 37 year old female who is experiencing urticaria x 3-4 years. My hives have been progressively getting worse. I recently went to an allergist to be tested, hopefully to receive immunology injections to alleviate this problem. He ordered a series of blood work to determine if my thyroid was normal. My lab results came back with my TSH High at 5.37, my Anti-thyroid ABS–TPO AB is High at 1335,Antithyroglobulin AB High at 77. My IGE, total and Immunoglobs A/G/M QN were all in the normal range. After researching hypothyroidism I have almost every symptom there is–low body temperature, dry/breaking hair/dry eyes/fatigue/weight gain/low bp/irregular periods/increased snoring and unexplained anemia, etc. My other concern is my mother to my knowledge has not had any thyroid problems but she had multiple sclerosis which is another autoimmune disease. Could this autoimmune disease be related to MS?

Thanks,

Pam

Response

Although rare, thyoid auto-immunity (positive for TPO- and Tg antibodies) maybe related to hives. Your thyroid is starting to fail and that will certainly worsen looking at the high level of your TPO antibodies. There is no doubt in my mind that you should start with thyroid hormone (levothyroxine) treatment.

Georg Hennemann, MD


CONCEPTION AND HYPOTHYROIDISM20 JUL 2006

Question

I had missed two cycles on menses, was advised a TSH which turned out to be high. Have got T3 and T4 done. My question is does this affect the chances of me getting pregnant ?how much time would the drugs to get TSH normal and me to start ovulating ? Thanks Fatema Bangalore

Response

It may take several months before you start ovulating again, at least if this symptom is not due to anything else other than your thyroid problem. Patients on thyroid hormone substitution should have a TSH that varies between 0.4 and 2. T4 and T3 levels are not important for dose finding! When you have conceived be aware that you may need about 30% more thyroid hormone during your pregnancy. This is very important for optimal development of your child, in particular the nNervous system. I would advise to start immediately with this increased dose after conception and adjust the dose after 4 weeks to the required TSH interval I indicated. Regular check of your TSH during pregnancy is advised. A TSH during pregnancy no higher than 1.0 is even better. After pregnancy you can reduce the dose to the pre-pregnancy amount.

Georg Hennemann, MD


POSITIVE THYROGLOBULIN ANTIBODIES AND NORMAL TSH

Question

Hi,

I’m so glad I found your site! I’m 41 and feel like I’ve been struggling with fatique for a very long time. I’m a medical technologist so have the ability to run most routine blood work at will. Nothing came to light. Then 2 years ago I learned of estrogen dominance and determined that was part of my problem so I started using natural progesterone cream with great relief(P:E ratio improved too). Now, however, the fatigue has returned somewhat but the bigger battle is with constipation! My TSH has pretty muchrun above 2.5 for the last six years with the exception of one 2.33 value in 2/2005. My highest reading to date was in May at 3.47. I stumbled across something that said kelp could help decrease fibrocystic breasts (it hasn’t!) so about 4 weeks ago I added 225 mcg to my supplements. I ran my TSH last week and it was lower than usual at 2.42…which I attibuted to the kelp. I finally sent my thyroid antibodies off and low and behold my TPO is negative but my Thyroglobulin antibody is high at 91 (lab ref range <20). Is this a common findiing? From what I’ve read it’s usually the opposite. So, could there be a chance that the kelp is causing the high anti-thyroglobulin antibody? If so, please explain b/c I can’t put reason to that. I’ve since stopped the kelp b/c I didn’t realize there is 1mg in my multi-vitamin. I guess there’s always the theory that the 1mg of kelp in my multi-vitamin has been keeping my TSH lower all this time. I feel I’m hypothyroid based on my symptoms and TSH tending to run above 2.5 plus the antibody. My mother is also hypothryoid but not sure if she’s ever had antibodies tested. I’d be curious to hear your thoughts before I head off to an endocrinologist to tell me I’m nuts! I’m a very healthy, active, health conscious person who used to be an energizer bunny. I know age slows one down but geez! Thanks for all you do!

Tracey

Response

Your TSH has always been in the normal range. The variation in values is also quiet normal. It is mostly that when thyroid antibodies are present, it is the TPO that is elevated and not the TG antibody. Having anti TPO increases the risk of future development of hypothyroidism. Your value of 3.47 tends into that direction but not quite. It has been shown that iodide may induce hypothyroidism indeed in susceptible subjects. As your mother had hypothyroidism, and most probably also thyroid antibodies, you probably have that susceptibility , What is your FT4? If that is not lowered, there is no reason to start with thyroid hormone, considering your values. Do not take kelp anymore and test your TSH and FT4 every half year.

Georg Hennemann, MD


NORMAL TSH IN AN INFANT2 Jul 2006

Question

Is the normal reference range of TSH in an infant the same as that for an adult? If not, what is the normal range? Background:- 5 month old girl TSH .473 and I’m getting conflicting information on whether that’s normal but a little low, or something to be concerned about. (And in case you wonder why I don’t ask my doctor: he thought low TSH meant hyPOthyroidism.)

Ariel Shkedi

Response

The normal TSH value is higher particularly in the first few days of life ; <25 mcU/mL on the first day; <20 mcU/mL 2nd day, <10 mcU/mL after the first week. After the first week a value up to 9.1 mcU/mL is normal up to 20 weeks according to the Quest normative data. As you know, it is hard to get one’s hands on good norms. Quest reports the normal TSH from 21 wks to 20 yrs as being 0.7- 6.4 mcU/mL. Another reference gives a range of 0.8-6.3 mcU/mL in the first year of life (progressively lower thereafter), so, at least for a 5 month old, I think that there appears to be good agreement. More information can be found in Chapter 15 of Thyroid Manager.

Rosalind Brown MD


POST-PARTUM HYPERTHYROIDISM

Question

I am a 40 year old female, who gave birth to my third child in January of 2006. Following my pregnancy, I have developed a thyroid problem. Slowly of time, it continues to get slightly worse…my T3 is now 277 and my TSH is <0.01. I was referred to an endocrinologist, who put me on 5mg of Tapazole, but I developed bad hives from it. So, I have since stopped the medication. I also have a “lump” on the right side of my thryoid, that seems to move when I swallow. My doctor seems to have the lets wait and see mode…I have also lost a bit a weight. He says if I loose four more pounds to call him. Am I wrong to tell him that I want an ultrasound to be on the safe side?

Cheryl

Response

It is unfortunately not uncommon, that women develop thyroid problems within one year after delivery. This condition is called “post partum thyroiditis”. It is caused by antibodies that circulate in your blood that are directed against your thyroid. They can cause both hyperthyroidism (increased thyroid function), but also hypofunction of the thyroid (hypothyroidism) or alternatively both conditions. In your case apparently hyperthyroidism. This condition may disappear spontaneously in weeks or months. If you are allergic to tapazole, your doctor has the following options for treatment. Treat with PTU, that also inhibits thyroid function but in 50% of cases that are allergic to Tapazole also induce allergic symptoms. You can try it and if it also is allergic to you, propranol is the best alternative. It does not affect thyroid function but suppresses the symptoms of hyper function. If your hyperthyroidism does not subside over a few months, I would advise treatment with radio-active iodine. If your hyperthyroidism does resolve spontaneously then regular thyroid function tests, throughout your whole life, are obligatory as you have a risk of ultimately developing hypothyroidism any time in your life. If spontaneous resolution occurs, the risk of developing hyper- or hypothyroidism during or after a next pregnancy is increased and regular thyroid testing should be performed during that time. Ultra sound of your thyroid will be of little help in this problem. However a lump may point to a hyperactive nodule. If this is the case than your hyperthyroidism is caused by this node and this condition is not related to your pregnancy. It may have developed coincidentally. To investigate this, a radio-active scan would appropriate to establish the diagnosis. In that case it should be treated by operation, ethanol injection or laser therapy. Treatment with drugs is useless.I hope this answer is of some help to you.

Regards,

Georg Hennemann, MD


THYROID MEDICATION AND HAIR LOSS

Question

I am trying to understand my current condition of HYPOTHYROID. My biggest concern is excessively falling hair. The situation is quite bad. I have tried everything from homeopathy to chinese medicine but no success.I list below my blood test of date 1. What is your blood test result most recently?















































Feb 24-06 June 06-06
FT3 3.7 2.9
FT4 18.6 14.0
TSH 0.11 1.10
Anti Thyroglobulin Abs 3.7 2.6
Anti Thyroperoxidase Abs 61.4 424.4
Iron 7umol/L 15
Folic Acid 51.5
Red Cell Folic Acid 885

Between Feb-06 to June-06 my dosage has changed. Till Feb-06 I was taking 125mcg per day. From June and now, I take Mon, Wednesday, Friday, Sunday take 100mcg. On Tuesday, Thursday and Saturday I take 150 mcg. My Iron was low, so I take natural snowdonia water to help get over my iron deficiency. I have just started to take KELP as you will notice that my AntiTHyroperoxidase Abs is very high which means I am seriously Iodine deficient. I also take Multivitamin with minerals, Vit A 7mg and Betacarotene -1 a day. andVIT D + Calcium 1250mg – each tablet – taking 2 tablets a day.If there is anything you can suggest to improve myhair falling problem woudl appreciate it. Ihave: no fatigue, no constipation (never did), good sleep, good energy. Sometimes less concentration, falling hair – handfuls , cold hands and feet,swelling on top of my eye lids in the morning and swelling under my eyes – more on the right hand side.I am going to a homeopath also but it has not helped at all.Pleaselet me know if there is anything that can help me reducemy hair loss.

Kind regards,

Gohar

Response

You were overdosed indeed with 125 ug, but on 100 ug T4 you are OK. I can see this from the TSH values. My advise is that your TSH should be kept between 0,4 and 2. If your falling hair were to be due to variations in T4 dosing then it will surely recover if your present TSH stays between the range that I indicate here. This may take some time even a few months. If it does not normalize then there must be another reason, for instance varying iron levels sometimes dropping below 10. What is the reason for this low iron level. Do you suffer from heavy menstrual blood loss? If not, you may discuss this with your doctor. The thyroid antibodies will not hurt you and there is no reason to take extra iodine. You are now taking thyroid hormone and you are not anymore dependent on iodine. I can hardly believe that iodine deficiency would still occur in the US. Extra iodine may however affect your thyroid if there is still some functioning left. It may aggravate the hypothyroidism but also induce hyperthyroidism.A last advise. Why don’t you use iron tablets? It is probably cheaper and contains a constant amount of iron.

Georg Hennemann, MD


Thyroglossal cyst

Question

Thyroglossal cyst When I was a child I had a thyroglossal cyst removed from under the neck, it returned and a second surgery removing the hyoid bone and soft tissue around the neck and throat were removed because of the cyst’s “track.” I am 32 years old now and when I get a cold it immediately turns into pain and mucous in the throat. I have trouble removing the mucous, and swallowing during this time, and my neck glands become sore and swollen. My doctor’s say by looking in the throat they see nothing. Is this a normal occurrence for people who have had a cyst removed?

Dana Clary

Response

Removal of a thyroglossal cyst and twice operated for, is such a rare event, that I think that nobody has any experience such to tell you if your complaints are ‘common’ for this surgery. It seems to me that your complaints are directly caused by the cold, for which they are certainly ‘normal’, rather then anything else. However your second operation was certainly relatively extensive and may aggravate these symptoms.

Georg Hennemann, MD


THYROID ANTIBODIES AND QUESTIONABLE HYPOTHYROIDISM6 June 2006

Question

Hi, I am a 50 year old woman. Since age 12, I’ve experienced repeated bouts of over activity followed by under activity, the duration and recovery of each bout has also increased over the years. I’ve been unable to return to work since 1993. I heard about Hashimoto’s and requested tests in March 1996, TSH 2.3 and T4 80 (previously 1.1 and 94 respectively in Jan 94).

April 96

October 1996

Antithyroglobulin

Neg

1:100

Antimicrosomal

1:400

1:25600

I started on 25 mcg Thyroxin, increasing over 15 months to 100mcg, but could not find a dose that returned me to ‘normal’, my TSH also fluctuated – 1.4/0.2/1.5/0.2/1.2. I was concerned about taking replacement T4 when antibodies can also increase T4, but both my GP and Endo said not to worry. I settled on 75mcg for the next 3 years, even though I still experienced fluctuating symptoms I felt overall much better with a clearer mind and sleep down to 8-10 hrs. I was still not able to work but was able to start an OU physics degree course.

T4

TSH

T4

TSH

Dose

T4

TSH

T3

20-1-99

1.8

22-5-02

31.6

0.1

75mcg

9-5-03

18.6

<0.1

2.1

29-3-99

22.1

0.3

30-8-02

22.3

<0.1

50mcg

2-6-03

17.4

<0.1

1.8

6-4-00

30.7

0.1

9-12-02

24.9

<0.1

25mcg

23-9-03

1.0

24-8-00

1.9

18-3-03

24.4

0.1

0mcg

23-1-04

1.2

9-3-01

28.5

10-8-04

1.22

By May ‘02 I felt so hyper that I started to decrease my dose of Thyroxine and have had none since March ‘03. In May 2003 Anti-TPO was 1212 u/ml. I believe the low TSH was due to the antibodies but GP thinks it was over-replacement – What is your opinion? I have continually deteriorated since and now am unable to concentrate on my coursework and sleep 12-16 hrs a day (as well as other symptoms). GP won’t put me back on replacement but has referred me to Endo. I’ve been reading about T4/T3 combo for people who continue to have symptoms on replacement T4 only. What is your opinion and what tests should I expect the Endo to do? My latest TSH was 2.65 in Dec ‘05. I am not sure if you reply by e-mail or only on your site. It would therefore be appreciated if you would e-mail me as to whether you are able to respond to my questions or not.

Thank you in anticipation.

AJ McGowan

Response

It strikes me, if correctly understood, that you started on thyroxin while you were not hypothyroid? I agree that you have high titers of thyroid antibodies, but that does not automatically imply underactivity of the thyroid! Or did you have an elevated TSH at that time? At any rate, your present situation shows that your thyroid is normally functioning without medication! Consequently meaning, that the antibodies have not damaged your thyroid to the extent that it can not function normally. A point of note is the fact that even a low dose of thyroxin. i.e. 25 microgram suppresses your TSH which does not occur in subjects without thyroid affection. In normal subjects the TSH stays in the normal range with this dose. In your case this is probably explained by the fact that you have also an other thyroid antibody circulating named TSI which stands for Thyroid Stimulating Immunoglobulin. This antibody contrary to the other ones does not damage, but stimulates the thyroid and can not be suppressed by thyroxin. Hence the lowering effect on your TSH. My suggestion is that you keep discontinuing thyroxin usage, but keep a close watch on your TSH. My guess is that ultimately you really will develop Hashimoto and then it is time to start with thyroxin. Be aware, and not all doctors realize this, is that when on thyroxin, you have to keep your TSH between 0.4 and 2. The values of T4 and T3 are not important in the dosing of thyroxin in those situations.

Georg Hennemann, MD


RAI TREATMENT, FERTILITY, AND EYE PROBLEMS3 May 2006

Question

I am a patient I have been fighting Graves disease for almost 4 years I have almost gone into remission 2 times using tapazole. This last time I came closer then ever and was put on synthroid because my thyroid level was low. They took me off the synthroid for6 weeks and when my thyroid levels didn’t normalize they did an ultrasound and uptake and discovered the graves had come back and now my doctor wants to do RAI and I am very worried about the side effects Namely thyroid eye disease and difficulty getting pregnant as well as the possibility for the disease coming back. I have detached retinas in both eyes that have been operated on and I am legally blind I am worried if I do the RAI my eyes will get worse. I have also had Cerebral palsy since birth and I am worried how these conditions may be effected. My doctor says RAI doesn’t effect fertility is this true. How will my other conditions be effected by the RAI and can it come back after the RAI? I want to go back on the tapazole because RAI terrifies me? Please respond if you can do so thanks.

Eidwriter@aol.com

Response

I think that I understand your problem fully. 1.RAJ does not affect fertility 2.There is no side effect of RAJ treatment established so far in the many million patients treated as such, despite scrutinized follow up over more than 50 years, but for one exception and that concerns you in particular. That is that in a minority of patients eye problems may be induced. In essence these signs involve an increase in volume of the tissue behind the eyeball causing bulging of the eye outwards. This process may consequently lead to increased intra-occular pressure that probably may increase the risk for a 3 retinal ablation. It is possible to prevent this complication by administration of prednisone before treatment and for several weeks thereafter. However this scenario seems to be equally risky for you as prednisone may raise intra-occular pressure as well. My conclusion is that there are 2 remaining options for you. 1.Start again with tapazole. However this treatment does not always prevent eye problems, especially if it is not performed with a full inhibiting dose of tapazole on thyroid function in combination with a dose of thyroid hormone that keeps the TSH in the low-normal range. Even then eye signs, though rarely, can not always be prevented 2.So my final advice to you is to have your thyroid (near) totally removed by a very experienced surgeon. The less thyroid tissue remains, the lower risk of developing eye problems in the future. I suggest that this operation should be done by a thyroid surgeon experienced in operating patients with thyroid cancer as they are used to perform total thyroidectomies.

Georg Henneman, MD


THYROID TUMOR WITH NEGATIVE IMAGING AND POSITIVE TG18 MAY 06

Question

I’m a 30 year old male who has PTC and has had: A partial thyroidectomy (right side tumor ~10cm and attached to all surrounding structures, with lymph node metastis which were removed), Surgery to remove the remainder of the thyroid (no tumor, but left lymph node metastis which were removed), I-131 treatment on two occassions with 150 mCu on each occassion, Numerous I-131 WBS with negative results, Numerous US with negative results, Numerous chest and neck CT’s with negative results, One whole body PET scan with negative results. However, my Tg is significantly elevated (not sure of the exact level). My questions are: Given that no tumor can be found through imaging, what are my options for next steps? Where could the residual tissue be located? Will further I-131 treatments are required? Would a neck dissection be required?Thanks.Any help would be appreciated as this has been a two year ordeal and I see no end in sight.

B Woodford

Response

Your problem is, unfortunately, not rare, and causes both the patient and physician a great deal of distress. There is no perfect answer. To begin, I assume that your antibody test is negative, so that the TG assay is meaningful. If so, to some extent the answer depends on how high the TG is with TSH suppressed, and with TSH stimulation, and whether the TG level is rising, stable, or even falling,over time. Another question is whether the post therapy scan with that 150mCi treatment was negative, or not? So long as there is no identifiable tumor lesion on any modality, and in view of your prior therapy, there is probably little to do except for continued follow-up with TG, US, and sometimes 131-I scan and PET scan. More specific answers to your questions should come via discussion with your own MD, who knows you, your exam, and your treatment history. L De Groot, MD.

THYROXIN THERAPY IS FOREVER?16 MAY 2006

Question

I am wanting to know if once you are diagnosed Thyroid problems does it ever go away.Meaning once you are on Synthyroid do you ever stop meds or does it mean you have this problem for life or does it get betteras the doctors here are telling methat you can get better with time.??? As I had always been on meds for a while then moved to the UK-military doctors took me off when I got here said i was in the normal range…but I have all my symptoms that it is not better. I am suppose to see internal meds this month and they are going to look into futher but when i was in the states when to Endo doctor and with my low pulse and all the other symptoms was put on Synthyroid it helped lots. But now i have stuggled since Jan 04 with doctors here as they say i am in the normal range isnt everyone normal range different from one person to the next? And sometimes some of the doctors would not even do any more than a TSH test no T3 or T4. I am waiting to get those test back now. Please if you can possibly answer any or some of my questions it would be greatly appreciated. I am so in need of help and for someone to let me know if I am in the right direction.

Thanks so very much,

Beth Wray, Military Wife

Response

Presumably you are on synthroid because of an underactive thyroid. This almost certainly will not go away and you will need to stay on thyroid replacement therapy for ever. There are a few people in whom it does go away and this can cause a lot of confusion.If the blood tests suggest a very overactive thyroid while on synthroid it would be advisable to stop it for at least 1 month and then be retested. Please note this is a rare event Normally you should have a TSH and a T4 measurement done for routine evaluation of Synthroid therapy. The TSH level in your case should ideally be in the lower range of normal but if it is a bit lower than that it probably doesn’t matter. I hope these comments are helpful.

John Lazarus, MD


CHANGING SOURCE OF THYROXIN14 MAY 2006

Question

I have been on thyroxine for 9 years and take 200mg daily for an under active thyroid. My question is that I have recently shifted from New Zealand to Australia and have changed the medication to oroxine and would like to know if there is any difference in the composition in the making of the tablets. I have developed un explained headaches – all the usual reasons have been eliminated by scans etc. I am trying to eliminate all possible causes and was hoping that you would be able to answer my question. Many thanks.

Maree Wright

Response

There may be some difference between these medications, predominantly by differences in absorption from the gut. This is however easy to solve. Take just that dose of oroxine that keeps your TSH between 0.4 and 2.0uU/ML. It may take some time to find the proper dose. Do not change dose sooner than once a month. The values of T4 and T3 do not matter for dose finding.

Georg Hennemann, MD


RAI TREATMENT AND PREGNANCY10 MAY 2006

Question

My husband who is 30 years now was diagnosed with Papillary carcinoma of thyroid two years back(2004).In Sep 2004 a total thyoidactomy was done and he was adivsed to have 300mcg of Eltroxin. In Nov 2004 he had RAI.While this iodine treatment was going on i was 20 weeks pregnent and 4 weeks later i had to go in for an MTP due to the child having TOF(Tetrollogy of Fallots). Since the doctor advised us to wait for one year after the radiation for another child, i didn’t conceive for one year. In Aug 2005, he started getting giddiness and the doctor found that Eltroxin intake was high and reduced the dose to 200mcg. After two months in October 2005 again he had RAI and found that no spread of cancer in the body.The Eltroxin tablet was increased to 250mcg subsequently. The doctor again advised us to wait for one year after the second radiation to conceive.

My questions are the following:

1. Can i conceive after one year (by September 2006).Is it safe?

2. If i conceive will the child have any defects since he had two RAI?

3. Will there be any infertility problem for my husband ? or do we need to go in for a sperm test before conceiving to check the whether radiation is still present in the body.

4. I am assuming that my first child had ToF because when my husband had RAI i had accompanied him to hospital and also during the time of his surgery (Sep 2004) i was with him in the hospital inmy 8th week of pregnency for a week after the surgery.

5. If i conceive and in case ny husband has to undergo another RAI what steps do i need to take.

6.Do i need to check my husbands T3,T4 and TSH levels before conceiving.

Thanks,

Elizabeth

Response

1. Yes. Generally it is advised for males to wait 6 months after RAI before starting a pregnancy, but there is no hard datato supportthis suggested time period.

2. There is a 4 percent chance of a fetal abnormality is all pregnancies. The added risk related to prior 131-I treatment is very low, and is usually ignored. However the occurrence of a previous abnormality raises a concern that you should discuss with your Obstetrician. I do not think the occurrence of the Tetrology could be related to your husband’s treatment when you were in the 20th week of pregnancy.

3. Fertility could be reduced. There can be no RAI left at this point. I do not think there is any practical test that can be done to answer the question you raise.

4. See above.

5. You must discuss this carefully with the therapist. Mainly you need to avoid close contact for about a week. 6. The dose of medication that he is on probably makes him mildly hyperthyroid. While not dangerous, it might be reduced toward a more normal level.

L De Groot, MD


T3 FOR WEIGHT LOSS

Question

For years I have tried to loose weight. I have a small goider but nothing serious with no changes. My T3.T4. TSH, Free T3, etc. always come back within normal range. My hair is falling out, I am always cold, plus other symptoms that point to thryoid issues. I am close to putting myself on a trial of a T3 thyroid medication. What are your thoughts?

Thank you for your time and attention,

TPerk1211@aol.com

Response

Using T3 to loose weight is dangerous. It mainly decreases your body protein meaning that your organs like muscle, heart, liver etc are being damaged, while your body fat is hardly affected.

G Hennemann, MD


EYE PROBLEMS, ON STEROIDS

Question

I have been on prednisone for over 4 months. I was put on it for my eye lidswelling and bulging with severe pain. A CT showed the muscle in the back of the eye and right side of the eye not working correctly.Every time we try to get off the prednisone, it swells again. I had T3,T4, and TSH done and all came back normal.I went to a new Dr and he did thyroid antibodies and it came back none. I had another CT done today. Can you give me any clue has to what this can be?

Kathy

Response

Usually eye signs are decreasing spontaneously over time, what may take years. Mild and moderate eye signs are at present not routinely irradiated by X ray. However if eye signs are more severe irradiation should be considered seriously. Also when eye muscles are not functioning well in the sense that they do not move precisely simultaneously, they may be infiltrated by fibrous tissue, which stays there more or less permanently. This may lead to squinting. In this situation I advise orbital irradiation under supervision of an experiencedendocrinologist and radiologist. Good luck!

Georg Hennemann, MD


CONCERNS ABOUT THYROID DAMAGE3 Apr 2006

Responses by G Hennemann, MD

Do you know of any medications that can cause your Thyroid to be over active? Iodine in susceptible people Also do you know if a person has had surgery in that area C 5 C 6 Fusion. Could there be signs of scar tissue that could shoot off the Thyroid hormones into the Blood stream?

Highly improbable

If so could this cause the T3 T4 levels to change?

See above

Why would you need an Biopsy of the area with aspiration of small needle of the gland?

Because a small needle is much simpler and less damaging than a thru cut biopsy

Can this also cause voice problems?

Not if properly done.

Thanks,

Carolgammon1@aol.com


THYROID CYSTS AND THYROXIN TREATMENT13 March 2006

Question

Good day to you Doctor. I’m Juvy C. Garcia here in Guam, USA, 42 years old. Two years ago (March 09, 2004 to be exact), I underwent a Thyroid Ultrasound Test. The findings was “There are two focal lesions. In the superior pole of the right lobe, there is an entirely anechoic lesion measuring 7 x 4 x 5mm. There is quite hypoechoic sharply demarcated 4 x 2 x 3 mm lesion in the extreme interior aspect of the right lower pole. The background thyroid stromal echotexture is normal. There are no other focal hepatic abnormalities. There are no areas of abnormal stromal echotexture.IMPRESSION: THIS IS A NEAR NORMAL EXAMINATION. THE TWO LESIONS IN THE RIGHT LOBE OF THE THYROID GLAND HAVE EXTREMELY BENIGN CHARACTERISTICS. My questions are as follows: 1. When I had vacation in the Philippines, I had it biopsied and Thank GOD, it turned out to be negative for malignant cells. Doctor my question is, if it was diagnosed non-malignant the first time, will it turned out to be malignant after two years? 2. Sometimes, I feel pain but not too much? It’s like feel that it has grown or it’s just in my mind. What is this Doctor? 3. My Doctor prescribed me Eltroxin? Is this a good medicine? And what are the side effects of this medicine? 4. Will it be good to just continue taking it because I stopped it for awhile.

Thank you so much.

Juvy

Response

I get the impression that the focal lesions are cysts. A cyst is defined as an entirely an- or hypoechoic lesion with a sharp demarcation all around. You do not mention anything about the demarcation of the lesion in the upper part of the right lobe. But as this lesion is anechoic I presume that this is a cyst as well. Thus probably you have 2 cysts in your thyroid. Cysts are by definition non-malignant, because they have no cellular lining on the inside and if there are no cells, then there is obviously no malignancy present. There is usually little effect of thyroid hormone treatment on cysts. Cysts usually do not cause pain, so it may be in your mind. If they cause pressure feelings in the neck and or are disfiguring the first line of treatment is aspiration of the fluid and subsequent rinsing of the cyst with alcohol. This procedure can be repeated say 3 times in a period of 3 months. They may disappear completely or partially that may be often considered as sufficient. If there is no effect at all, operation is the only remaining option. There is little chance that thyroid hormone treatment will have a sufficient effect, but there is noting against it to try this. To do this optimally the dosage of thyroid hormone should be chosen such that your TSH comes down just above the lower normal level oh the assay. If after half a year there is no effect. You may discontinue thyroid hormone gradually in a 2 week period. However if there is an effect you should not be surprised if the cysts relapse.

Georg Hennemann, MD


MAXIMUM DOSE OF THYROXIN10 MARCH 2006

Question

My query is what is the maximum dose per day of l- thyroxin in adults?

khanhasinkhan@hotmail.com

Response

There is no specific ‘maximum dose’. You have reached the proper maximum dose when the TSH of the patient stabilizes between 0.4 and maximally 2.0 uU/ml.

Georg Hennemann, MD


THYROXIN DOSE AFTER PREGNANCY8 MARCH 2006

Question

Not a physician but in need of assistance. I was diagnosed as having Graves disease in ’97. I chose radio active iodine as my solution. I went off to college and had a horrible 1st year not being able to get back in touch with my Endo who did not inform me and my parents of the need for continued meds. In early 2005 I finally got pregnant. I had been going steady on 88mg for about 2 yrs and got increased from 125mg to 112mg during the pregnancy. I gave birth in Oct. and my dose was decreased to 100mg in December. in mid Jan my TSH was @ .43. Now in early March my TSH is .088 and my T4-Free is 1.98. My Dr. advises to decrease back to 88mg. My question is will this be a sufficient decrease? Can this affect my child in any way in regards to affecting the quality and amount of breast milk? I originally thought the dose needed to be increased as I seem to be having the same symptoms as when I did the radioactive iodine e.g.. significant hair loss, weight gain despite working out three days a week(I have always been skinny), lethargic, depressed etc. I read an earlier response also about cold medicines not affecting properly managed individuals. I have found that I get palpitations and shortness of breath when taking them. I’ve just settled for OJ and water as my cures. Any other suggestions?

Coleen Jackson

Response

Probably you will need to go back to the same dose you took before pregnancy, if your weight is about back to normal. The tiny excess hormone (if present) certainly will have no adverse effect on your infant. Mild hyperthyroidism could relate to palpitations, but I hesitate to relate it to your other symptoms.

L De Groot,MD


HAIR LOSS AND NORMAL THYROID TESTS21 Feb 2006

Question

What do you know about Wilson’s Thyroid Syndrome and T3 & T4 treatments? In July, 2005, I had my thyroid levels tested. Everything was considered “in range”, except Antithyroid Peroxidase which was 46 when range should be <35 Iu/ml. As a result, I was diagnosed as Hypothyroid and began the Wilson’s Thyroid Syndrome regiment (T3/T4 compounds) in July, 2005 (for about 7 months now) where I take my temperature every morning, evening. Starting with 7.5 mg, If my temperature is below 98.6, I would escalate up another 7.5 mg etc. up to 37.5 mg. My temperature is steadily around 97.9 – 98.1. I have felt an increase in my energy level and able to sleep much better at night, plus my night sweats were eliminated. However, I am experiencing an abnormally severe hair loss. I am 50 years old, and have always had issues with hair breakage—but they were short pieces, spurts of growth and then slight breakage (due dry hair and possibly peri-menopause). Now I am losing full, long strands with white bulbs on the tips to a point of bald patches in the back and sides of my head. Additionally, I am experiencing severe thinning in the top —you can see clear through my hair to see my scalp. I do not have a perm or use chemicals on my hair. I do use hair coloring, but brands with no peroxide. It’s winter where I live, but my skin is dry and is very itchy and stings. I am frantically scratching—but there is no rash. I have not lost any weight as I was expecting. My metabolism seems to still be slow. In August, 2005, a sonogram indicated a large mixed nodule on the left side w/ no abnormality—2.0cm x 2.7cm in diameter. A biopsy showed it was not malignant. I am not experiencing any pain—so I have not made a decision to have removed at this time. What do you recommend my next steps should be? I have made the decision to stop the T3/T4 regiment as I only experienced this drastic hair loss since being on the medication. My dermatologist is baffled. My thyroid surgeon recommended I see a Doctor of Internal Medicine—I’m confused. Do I need to see an Endocrinologist or Hormone specialist? Is there something else I should be taking for my hypothyroidism, or to generate hair growth? I want so much to solve my hair loss problem and am not sure what’s causing the loss. Will it grow back? Can you give me some general direction where to begin? T3, Total – in range at 1.2 Reference 0.6 – 1.8 ng/ml T3 Uptake – in range 29.53 Reference 24.4 – 39.1% TriiodoThyronine Free 2.6 Reference 2.3-4.2 pg/ml T4, Total – in range 7.2 Reference 6.5-10.5 mcg/dl Free Thyroxine Index 7.1 Reference 6.0-11.4 Free Thyroxine (FT4) 1.0 Reference 0.8 – 1.8 ng/dl TSH (3 Generation) 1.620 Reference 0.35-5.50 mciu/ml Anti-thyroglobulin AB <20 Reference <40 iu/ml Thyroglobulin 23.7 Reference <=55.0 ng/ml AntiThyroid Peroxidase Out of Range 46 Reference <35 iu/ml Even though I was primarily “in range”, my symptoms were low energy, low sex drive, wintery skin, restless nights, irritability, inability to lose weight, night sweats, stiffness, hot/cold intolerance. My doctor felt it was better to treat the symptoms. There has been some improvement as noted below. But no weight loss (not 1 lb), low sex drive, wintery skin, hot/cold intolerance is still a factor

Diane Peoples

Response

You had a thorough set of thyroid tests, and they are all normal. Thus it is not possible to attribute your symptoms to a lack of thyroid hormone, no matter what your arm-pit temperature is.The predicament you have is similar to that bothering many middle aged women.There are many causes for hair loss, so you need a careful medical evaluation, which unfortunately often ends up “negative”. Hair loss is certainly associated with alterations in thyroid hormone levels, especially when changing from hyper- to hypo- and back again. Hair loss is common with aging, serious illness, psychological stress, excess androgens, and can be due to autoimmunity. You apparently have low levels of anti-thyroid antibodies, so to some extent, Hashimoto’s thyroiditis. This could possibly be related to hair loss, but in view of normal thyroid function, does not offer an approach for treatment. So probably the best advice is to have a thorough medical exam to rule out other illness, consult your dermatologist about possible treatments, but notexpect miracles to recover the hair.

L De Groot, MD


PAINFUL HASHIMOTO’S THYROIDITIS10 FEB 2006

Question

I am not a doctor, but am in need of advice. If you cannot reply, I understand. I am a 40 year old female that was diagnosed with hypothyroidism six years ago. I was placed on levothyroxine and up until one year ago, was doing fine. In January of 2005, I started losing weight. Then in June of 2005, my thyroid became enlarged, with significant pain. My doctor sent me to an endocrinologist, who diagnosed subacute painful thyroiditis. At this time, my TSH was low, and FT4 was high and my T3 number was so high that it did not register. I had all of the symptoms of hyperthyroidism. I was placed on a beta blocker and was taken off of my levothyroxine. The enlarged thyroid and pain persisted, and in July I was placed on 40 mg of prednisone per day. At this time, I also went back on the levothyroxine, at 125 mcg. After a month of prednisone, they tapered my dosage, but as soon as I got down to 10 mg, the inflammation and pain would come back. I was then sent to the University of Michigan Health Center, where they diagnosed me with Hashimoto’s thyroiditis. After one month, I was to again told to taper my dosage of prednisone and again when I got down to 10 mg, the inflammation and pain would come back. We tried to taper the dosage eight times, with no success. I went back to the University of Michigan in January 2006. The ultrasound confirmed the Hashimoto’s and the thyroid is still enlarged. At this time, I was taking 5 mg of prednisone per day and I was instructed to stop taking the prednisone on 1/27/06. Two days off of the prednisone, I had severe prednisone withdrawal symptoms along with a very enlarged thyroid, and extreme pain. I am back on 5 mg of prednisone. They have also placed me back on a beta blocker, as I have episodes of heart pounding and tremors. I am currently having weekly flare ups and the thyroid is still quite enlarged. There are days that you can see it from across the room and it has been extremely tender. During these flare ups, I have difficulty swallowing, and the pain radiates up into the ears. U of M told me that I have two options. One is to stay on the prednisone for another 6 months to a year or the other is to have a thyroidectomy. The side effects from the prednisone have been horrible. I have a history of ulcers, and take Prevacid daily. My bones are becoming brittle. I broke a rib from coughing. I have bad leg cramps and weakness. I am told that because of the enlarged thyroid, and because it has been enlarged for so long, surgery risks are increased. Is this true? My question is, are these my only two options, or should I get another opinion? I am afraid about the risks of surgery, but am desperate to get my quality of living back to what it should be. Any insight that you can provide would be greatly appreciated.

Julie Lofgren

Response

Assuming everything you say is “as is”, and that the diagnosis is really painful Hashimoto’s thyroiditis (and not subacute thyroiditis), thyroidectomy sounds like a conservative answer to your struggle. We have reported this problem, treated with surgery, and sometimes RAI in addition.(Go to PUBMED on your browser and search for “degroot lj AND painful thyroiditis”)

L De Groot,MD


FLUORIDE AND THYROID FUNCTION6 Feb 06

Does fluoride indeed affect the thyroid levels? I have Hypothyroidism and take Levothyroxine.137 1x daily. I am a Dental Hygienist and I would like to know for myself and for my patients. I use a fluoride toothpaste and I recommend it to my patients. I also give every patient a fluoride treatment after a cleaning. So any information would be very helpful.

Thank You.

Robin Carney RDH

Response

I have never heard that the concentrations used in toothpaste en the tablets given to children affect the thyroid in any way.Below you find a report of a study in workers contaminated with fluoride because of their work that do not affect thyroid hormone blood levels. I do not know what amount you use after teeth cleaning. Is that really necessary when you use fluoride also in toothpaste? You may know that fluoride in toxic doses may cause bone abnormalities.

See also abstract below.

Georg Hennemann, MD

Epidemiologic assessment of worker serum perfluorooctanesulfonate (PFOS) and perfluorooctanoate (PFOA) concentrations and medical surveillance examinations.

Olsen GW
,

Burris JM
,

Burlew MM
,

Mandel JH
.
J Occup Environ Med.2003 Mar;45(3):260-70. Perfluorooctanesulfonyl fluoride (POSF, C8F17SO2F) is used to create applications for surfactants and paper, packaging, and surface (e.g., carpets, textiles) protectants. Such POSF-based products or their residuals may degrade or metabolize to PFOS (C8F17SO3-). PFOS concentrates in liver and serum and results in hypolipidemia as an early effect of cumulative dosages. Male and female employees of two perfluorooctanyl-manufacturing locations (Antwerp, Belgium and Decatur, Alabama) participated in a periodic medical surveillance program that included hematology, clinical chemistry, thyroid hormone, and urinalysis testing. Serum concentrations of PFOS and perfluorooctanoate (PFOA, C7F15CO2-, used as a fluoropolymer emulsifier) were measured via mass spectrometry methods. The mean serum PFOS and PFOA concentrations for 263 Decatur employees were 1.32 parts per million (ppm; geometric mean 0.91, range 0.06-10.06 ppm) and 1.78 ppm (geometric mean 1.13, range 0.04-12.70 ppm), respectively. Mean concentrations were approximately 50% lower among 255 Antwerp workers. Adjusting for potential confounding factors, there were no substantial changes in hematological, lipid, hepatic, thyroid, or urinary parameters consistent with the known toxicological effects of PFOS or PFOA in cross-sectional or longitudinal analyses of the workers’ measured serum fluorochemical concentrations.


HYPOTHYROID AFTER TREATMENT FOR TOXIC MULTINODULAR GOITER

Question

I am writing you for help. I have been a thyroid patient in some form for the last 8 years. The reason I am stating in some form is that I have had several thyroid related issues in the last 8 years. My first abnormal TSH test came back in August of 1998 with a level of 0.32. After a couple of other blood work ups I was sent for an uptake and scan. At that time my scan showed a large hot nodule and an increased uptake. My PCP at that time thought I had subclinical thyroiditis. They placed me on a high dose of prednisone to be tapered off with in four weeks. After two weeks I went in for a follow up and my doc decided to taper me off quickly as I had gained 12 pounds in that two weeks and my symptoms showed no change. At that time I began having more symptoms of hyperthyroidism with the rapid heart rate, hot flashes, insomnia, and inability to concentrate. Unlike most hyperthyroid patients I had an increased weight. It took me until April of 1999 to began being taken seriously for my symptoms as my doctor noticed that the right lobe which had the hot nodule was becoming larger. At that point I had an ultrasound done and another uptake and scan. The ultrasound showed a cold nodule with no blood flow. The uptake and scan again showed increased uptake and a hot nodule that was slightly larger than the original scan. I do not know the exact levels of the uptake. I then was referred to a general surgeon as my symptoms had increased. I had neck pain, difficulty swallowing, rapid heart rate, hot flashes, insomnia,mood swings,muscle weakness, and severe fatigue. At that time my surgeon diagnosed me with Plummer’s Disease (Toxic Nodular Goiter). I was scheduled for surgery two weeks later. Surgery took longer than expected due to the size of the nodule once the surgery was under way. My doctor told me it was golf ball size so that I would be able to understand opposed to millimeters. I began to notice a remarkable difference almost immediately. I lost all of the 40 pounds I gained in total and felt great.

About a year and a half later I began to feel bad again. I had problems again with weight gain, muscle weakness, mood swings, heart palpitations. I had them run my labs and the only abnormal result was my T3 which at that time came back as 291. Since I had already had the right lobe of my thyroid removed they thought that maybe I was beginning thyroid decline which I had been warned might happen. At that time they put me on .25 synthroid. My symptoms worsened, I began sleeping all the time and had no energy. They changed it to 25 of cytomel to see if maybe there was a conversion issue. I felt better and had a little more energy. I stayed this way for close to another year. As I continued to gain weight and feel worse, I just thought it was me and this is how I was supposed to feel. I went to the doctor in May of 2003 and had labs drawn. Again my TSH and T4 were normal. My T3 again was 246 still way above normal. My doc at the time refused to do anything stating they weren’t abnormal enough to worry about even with my history. I began to see another doctor who was a little more progressive. He suggested a new uptake and scan. The scan showed increased uptake on the left side that remained and some residual growth on the right side. At that time my TSH was back into the hyperthyroid stage again. I was sent to a endocrinologist who did a physical examination, and review of labs and the uptake and scan, as well as new blood work. My TSH at that point measured 0.17. I was diagnosed at that time with Grave’s Disease and due to increased risk due to scar tissue it was suggested that I have RAI. I went in two days later for the RAI of 17 microcurions (sp?). Within 2 days I began to have symptoms of radiation thyroiditis. My endocrinologist considered it the worst case he had ever seen and that I was lucky at that point to only have half of my thyroid as it was severly swollen. Within 6 weeks I had a TSH of 79. I began levoxyl at that time. I began at 127 then moved down to 112 back up to 127 then 137 to 150 and finally to 175. At that time I was asked to come back in 6 months. I did not have insurance 6 months later and my doctor would not refill my levoxyl without new labs. I ran out of levoxyl and was off of it fora month. I ended up in the emergency room where my TSH was over 300 the point where the lab stopped measuring. They gave me a prescription for 150 levoxyl. I was able to get insurance and see a doctor in August. She ran new labs at which time my TSH was still high I believe it was close to12 and she wanted to see if it came down in a month due to my being off of it for so long. When I ran new labs my TSH was up to17 but my T4 and T3 were normal. She thougth this was indicative of possible pituitary problems so she had the office endocrinologist see me the following week. He said he did not think that there was an issue with my pituitary and ran a full panel of pituitary tests. Again they raised my levoxyl this time to 150 one day and 175 the next alternating. Well I went in a couple of weeks ago and had my TSH and T4 drawn again. My T4 came back at 1.10 which is mid-range. My TSH however went up again to 20.9.

After going through all of this for so many years I have gotten to a point where I do some of my own research. I know most docs don’t like this, but you can only feel bad for so long before you start to look for answers. Right now I have a variety of symptoms besided feeling awful. I am have gained 30 pounds again. I am have severe dry skin, fatigue, headaches, difficulty concentrating, muscle weakness, and visual problems (I have had since grave’s diagnosis). My question is am I losing my mind? I have no thyroid function and I thought that as long as my T4 and T3 were normal my TSH should be too. The only thing I can find that fits what my labs are showing and I am feeling is a TSH Secreting Pituitary Adenoma. My doctor doesn’t want to run an MRI or CT. Is it within my rights to demand one? Do my symptoms truly match those of someone with a TSH pituitary adenoma? I am looking for help, any advice is appreciatedand words are never a diagnosis I am aware. So any thing you can offer me is appreciated.

Stephanie L. Jackson

Response

On the basis of the supposition that your story is exactly how all happened (I have not heard the standpoint from your doctors), the least that I can say is that I am not impressed by some aspects of the medical expertise that you were confronted with. I feel no urge to go into detail about this comment. I just like to say that you are now (most probably) permanently hypothyroid. It is far from true that the TSH value is not important as long as the T4 and T3 is normal. In contrast, the reverse is true, i.e. as long as the TSH is in the range that is the best when treated with thyroid hormone, which is between 0.4 and maximally 2.0, the value of T4 and T3 are of little importance. The TSH is by far the most sensitive measure to monitor optimal thyroid hormone substitution. I am almost convinced that if you guard your own lab results and fulfill this criterion, no matter what your doctors say, you will ultimately (this may take some time) feel normal again. I agree that that is no reason for a MRI or CT of your pituitary, because your thyroid hormone values are ‘normal’ for a person who is still under substituted with thyroid hormone.

Georg Hennemann, MD


HYPOTHYROIDISM TREATMENT, SOY, AND PREGNANCY12 JAN 2006

Question

I have been looking at your site and hope that one of the experts has time to consider the below and provide some answers. I was diagnosed with hashimoto’s earlier this year (July) following a positive test for antibodies and an ultrasound of my neck (which showed a number of small nodule). I have had a noticeable goiter (about twice the normal size)for about 15 years (it was first noticed when I had glandular fever as a child)and my TSH level has been regularly checked (and always been within the ‘normal’ range), this year I was tested for antibodies for the first time. Since diagnosis I have been on ‘oroxine’ (600mcg / week). My TSH levels have dropped (from 3.3 in July to 0.68 in November),my FT4 has increased slightly (16 to 19) and my FT3 is pretty stable (4.7 to 4.6). Following my diagnosis my Mother has also been diagnosed with hashimotos (she has no symptoms) and I know that my Grandfather (on the other side of my family) had thyroid problems and had his thyroid removed in the early 1940s. Two months before the hashimotos diagnosis I had a miscarriage at ten weeks (the baby was only 6w2d – my TSH levels were ‘normal’ during pregnancy). We have been trying to conceive again since August (last time we got pregnant on the first cycle). Since I started on the ‘oroxine’ my periods have been getting longer (from having always been 27-8 days now up to 32 days last cycle) and I am worried that the hashimotos or the oroxine is interfering with ovulation. Is my lengthening cycle just coincidence or could it be a result of the hashimotos or oroxine and if so, what does that mean in terms of trying to conceive?

What levels should my TSH, FT3 and FT4 be to allow conception and maintain pregnancy? When we do conceive, other than regular TSH tests, are there any tests or treatments that I should request? I’ve never had any thyroid symptoms (other than the goiter and indigestion problems) but have read that I should be avoiding salt and soy products (I am intolerant to lactose and fat so I have a lot of soy products), is this true?

I have recently moved countries and feel very much in the dark as I don’t have a specialist or Doctor here yetto consult with and would really appreciateany advice you might have on managing hashimotos, particularly in relation to conception.

Thank you for your consideration.

Kind Regards,

Gemma.

Response

The “normal” levels of TSH of people using thyroxine, is different from that in the normal population, in that it is between 02-04 and maximally 2. The FT4 under these circumstances is in the high normal range. In fact as long as the TSH is OK, the values of FT4 and T3 are not important. Under these conditions there is no influence on the ovulation, cycle, or conception

There is no specific reason to avoid salt. Soy however is an other story. Soy interferes with absorption of thyroxine from the gut. To avoid this you should take your thyroxine on an empty stomac. It is not known how long you should wait before taking soy to avoid this problem. I would guess at least 3 hours, if complete avoidance is possible at all!

In almost all women the dose of thyroxine has to be increased during pregnancy. This is very important for optimal brain development for the child. As soon as you have conceived you have to increase the dose you are using at that moment, by 30%. Then have your TSH checked every month during pregnancy to keep it around 1. After delivery you may go back to the original dose.

Georg Hennemann, MD


CONFLICTING OPINIONS ON A NODULAR GOITER12 JAN 2006

Question

Glad to come across your ad so I’d be learning more about my thyroid condition.I’m Ryanna,female,34, from the Philippines.I’ve been under medication for nodular goiter for 2 years.I started with eltroxin 100mg for about three months but when I went to a new a new doc, my medication was changed to euthyrox. T3 =1.62 nmol/1, T4= 92.90 nmol/1, TSH= .75uIU/mL as of June 2004 result. My first ultrasound was done 6-1-04: Right thyroid gland enlargement with a cystic nodule.R thyroid gland is enlarged measuring 4.9×2.5×3.0cm with a cystic structure measuring 1.8×1.0x1.8cm with a volume of 3.8cm. Euthyrox dosage started from started from .25mg and gradually raised to .50, .75 and now to 100mg. Ultrasound as of 6-14-05 shows Right Thyromegaly stable in size with progression of the cystic nodules. A new cystic stucture was noted inferior to the previously noted nodule. FNAB as of June 2005 = Negative for Malignant Cells. My ultrasound as of 10/24/05 shows a .56x.42x.23cm(LWH) with a volume of .03ml hypoechoic solid mass in the superior aspect of the isthmus, solid mass with cystic changes in the right lobe of the thyroid gland measuring 4.19×2.7×2.42cm(LWH) with a volume of 14.21ml. The cystic structures measures 1.82×1.5×1.19cm(LWH) with a volume of 1.7ml and 1.27×1.03x.51cm(LWH) with a volume of .35ml.I was then advised for an operation.I sought for a second opinion then,.The new doc asked for another FNAB and the result shows cells suspiscious for malignancy, of papillary origin, and was also advised for an ops.I was then alarmed so I thought of taking another opinion.TSH result = less than 0.05 uUI/ml as of January 2006. I’m still watiting for the ultra sound result as of this moment.My concern here is that if I could get well through medication and not undergo an operation,then the better…Do you think it’sok that I change doc for the third time?Aftyer all, it’s a patient’sprerrogative , right? I’d be very glad to hear from youso I could better decide whether i should really submit myself to the operationas the doctors here suggested.

Have a great day(*?*)

Ryanna

Response

This is not an easy problem! If I understand the situation correctly then you have partly solid and partly cystic lesions in the right lobe and the isthmus. They are progressive despite treatment with thyroid hormone. You have one FNA negative and one positive for malignancy. If the pathologist is experienced then I think operation should follow. If he is not that experienced in FNA’s, I suggest to have both FNA’s evaluated by a third pathologist with a nationwide experience in FNA’s. I am sure that my good friend Dr Mazzefari, who is a world known specialist in thyroid carcinoma, can help you further. I send him a copy of this e-mail.He will certainly advise you too what to do and if his advise goes against mine, do follow his!

Regards,

Georg Hennemann


ANTITHYROID DRUGS VS RAI OR SURGERY6 Jan 06

Question

Dear Sir/Madam-

I’m not a physician, only a 28 year-oldlady aspiring tostudy graduate medicine.I was previously a consultant in audit risk management. In October 2004, I was diagnosed with Graves’ Disease: T3 >12.0 (1.57- 2.59 NMOL/L);T4 >90 (9.6- 19.1 PMOL/L);TSH <0.006(0.36- 3.24 MU/L); andTSH Receptor Antibody >40.0 (0.0- 1.5 IU/L). Iwas given Lugol’s iodine mix fora weekand started on antithyroid drug of 20mg. Currently, my dailyCabimazoledosageof 10mg hascontrolledmy T4 at 12.42 (10.00- 20.00 pmol/L).TSH is 0.014 Low(0.290- 3.770 mU/L). I still have a goiter which occassionally becomes painful in the evening.The problemarose6 months after medication, when my doctor recommended me for RAI. My parents felt that it wasn’tthe best option for me and we switched physician, hoping to find a dedicated doctor who cares for patients more than the number readings. Nevertheless, my current doctor also seems to be gettingimpatient on me and hasbeen pursuading me into RAI, otherwise surgery, for the past 3 months (or 1 year since the onset of Graves’ disease).Although my T4 of 12.42’s within the lower normal range, I’m already experiencing the hypothyriod symptoms such as muscle aches in my body, retardedness,decreased concentration and weight gain. Comparing the hyper and hypo stages, I definitely function better in a slightly hyperthyriodone. No way wouldI trade my body for a life-time hypo plus hormone replacement.My doctor claimed that “it would be much easier to taking only1 pill after RAI” butI could foresee the difficulty of adjusting to the right amount of thyroid hormoneafter the body enters the permanenthypostage.The body will be fighting against the hypo symptomsat onepoint or another as the thyroxinehormonecan never be accurately prescribed.It will not be me when I cannot push myself to perform to my full potentialand concentrate in my studies, muscle pains, lethargyand weight gain. The outwardphysical ills are secondary, the body has to cope withlife-long hypo symptoms which decrease the quality and momentum of life.For an olderwoman entering menopause, the body would not adjust as well with fluctuating hormonal changes and slower metabolism.How many patients actually thank their doctors after gulping down mouthful of RAI? Why wasn’t proper informed consent presented to the younger patients about the after-years effects of RAI? Why are doctors rushing patients into irrevocable options when 1- 2 years of antithyroid drug trials are not up? Wouldn’t a patient on medication be given a higher chance of remission of illness? This can be easily achieved bydoctors without having to adjustthe standing antithyroid dosage much.

If my physician bugs me in March again, I am prepared to sack him for another doctor. Is this the practise at your side too and for what reason, or is this only happening in Singapore? I am thankful that antithyroid medication at leastgives me hope for a miraculous recovery–to be free ofmedication one day. This would not be possible with RAI. The option of surgery, on the other hand,has its shared amount of risk.What do you reckon is the best option in the patient’s interest?

Yours Sincerely,

Celeste Yeo

Response

The vast majority of patients seem to do well after RAI therapy, or surgery, but of course some have problems. Often it is difficult for the physician to know whether the problems are due to the thyroxin replacement, or another situation in the patient’s life. Life is complicated, and everything interacts with how a person “feels”. You can continue to take antithyroid drugs for years, and unless you have a reaction there is no absolute reason to stop. MDs typically suggest RAI or surgery after one or two years of pills, if there has been no sign of remission. This is because usually life is simpler on replacement therapy than on antithyroid meds, and because, as I note, most patients feel well and normal on the pills. I suspect that if you discuss this with your MD, he/she will agree to follow you on the pills until you remit, or grow tired of the process.

L De Groot, MD


THYROID AND WEIGHT GAIN, REDUX!

Question

hi my name is louise i have had under active thyroid for about 13 yrs now i feel ok most of the time but sometimes i feel i cannot eat anything because i gain weight so fast and very easy.I cannot eat fruit or veg or i would is there anything i can eat that won’t give me a bloated stomach every other day

thanx

Louise

Response

You have to be treated with thyroid hormone, if this is not already the case. Your doctor has to see, in order that you get the appropriate amount of thyroid hormone, that your TSH blood level is between 0.4 and 2.00If the latter is the case, any weight gain is not caused by your thyroid problem.

Regards,

Georg Hennemann, MD


BULIMIA AND EXCESS THYROXIN

Question

I am sorry to bother you with this question, but I have researched my question on the internet and cannot seem to find an answer. I am bulimic, and in addition to purging and laxatives I take 10 x 100mcg Oroxine tablets a day. I know that this is a bad habit, and I am working out my problems with a therapist, but I would just like to know the exact repercussions that I may face if I continue taking this kind of dose. At the moment I am continually restless, my legs ache and I get some pretty bad pains in my chest… Can you tell me exactly what might be happening?

Kind Regard,

Jean

Response

Oroxine is the Australian brand of thyroxin, and if you actually absorb all of 10 X 100ug of thyroxin each day, you will become dangerously hyperthyroid. (“thyrotoxic “). That is 6 to 10 times the usual dose, and could cause heart failure and death. I hope I have been clear about the danger.

L De Groot, MD


SPONTANEOUS VARIATION IN TSH LEVELS

Question

I am not a physician. I am 45 and started suffering from severe menstrual irregularities about 4 years ago. After an abalation, I switched to another GYN closer to me who happened to be a reproductive endocrinologist. She couldn’t understand why tissue taken during the ablation was from both before and after ovulation and apparently neither could the pathologist. That and the fact that my sister has Grave’s and my mother has Addison’s and a hypoactive thyroid prompted her to do a TSH. My TSH history is below.Ablation May2003 Jan05 TSH=3.087 July05 TSH=0.67 July05 TSH=0.61, t4=9 Aug05 TSH=4.255, 1.198 Dec05 TSH=2.77 Lab normals for TSH =0.3-5.5 Any ideas on the reasons for the TSH fluctuations? In addition to periodic sweating and palpitations and a dizzy spell or two, which are resolved now, my menstrual cycles are all over the place (20-54 days) and the GYN says this is not due to perimenopause based on other tests she’s done. My GYN said to come back in another couple of months for a repeat TSH.

Thanks much!

Michelle

Response

Certainly your genetic heritage suggests you are prone to multiple endocrine autoimmune diseases. I would guess that, assuming the TSH levels are accurate, you have Hashimoto’s thyroiditis, and that your thyroid produces variable amounts of hormone from time to time. Another explanation might be related to adrenal autoimmunity (much less common), which could affect the thyroid. I suggest that you MD check anti-thyroid antibodies, and adrenal function. On the other hand, all of the TSH levels , save one, are in the normal range, so there does not seem to be any acute problem.

Leslie J De Groot, MD


TSH REMAINS ELEVATED20 Dec 2005

Question

Hi,

I have been experiencing elevated TSH levels on my last 2 checkups, even though I never miss a dose of the Synthroid. I had been having normal levels but 6 months ago my first TSH was 22.0. I attributed this to having taken the medication approximately 2 hours before having the labs drawn. A follow up was much lower. A few weeks ago, the first level was 12.0 and it was 9.0 when re-done. I am not having considerable fatigue. My doctor does not want to adjust the dose as of yet but I am just wondering what would cause this elevation regardless of the fact I’m taking the meds correctly.

Wrosebush@wmconnect.com

Response

There could be many reasons. Have you gained weight? Are you pregnant? Do you have Hashimoto’s thyroiditis? Did you change brands of thyroxin? Are you on another medication, iron, or other material that might alter your dosage? Maybe you just do not have quite a big enough dose. If none of these factors are present, and your TSH remains elevated, you most likely need more hormone.

L De Groot, MD


THYROID HORMONE DOSE AND WEIGHT GAIN11 Oct 2005

Question

I HAVE BEEN DIAGNOSED WITH THE ABOVE ABOUT 2 YEARS AGO. I HAVE A QUESTION ABOUT TRIGGER FOODS. ARE THERE FOODS THAT TRIGGER THE MY PROBLEM TO MAKE THE WEIGHT GAIN COME ON? WHEN I AM FUNCTIONING FINE I CAN TAKE THE WEIGHT OFF PRETTY EASY. I HAVE HAD A CONTINUALLY FLARE UP SINCE THE SECOND WEEK OF AUGUST. ALL THE WEIGHT I TOOK OFF HAS CAME BACK.. IT IS A UNUSUAL FEELING OF EXTRA WEIGHT. (SQUISHY FAT AND IT IS ALL IN THE MIDDLE) IT IS VERY HARD TO EXPLAIN. ONE OF THE THINGS THAT MADE ME MAKE MY DOCTOR PERSUE THIS WAS I WENT FROM A 7/8 SIZE TO A 12/14 IN THREE TO FOUR MONTHS.

PLEASE HELP.

PAHARRIS@MANDTBANK.COM

Response

As long as you are being treated with the proper thyroid hormone dose and consequently your TSH is normal (not higher than 2.0) the thyroid hormone dose can not cause increase your bodyweight. There is one exception and that is that if you still have a partially functioning thyroid, excess iodine can further suppress its function. However if you are on a full dose of thyroid hormone iodine can not hurt you either.Discuss this with your doctor.

Georg Hennemann, MD


PROPER DOSE OF THYROXIN23 Sep 2005

Question

I am a 34 year old female. In late May this year, the doctors discoverered my T4 level to be low. I was placed on 25 mg of Synthroid. In July, the dosage was raised to 50 mg, because the T4 level was still low. I have recently startted to gain weight rapidly-12 pounds in 2 months and I am very active. I am wondering when or if this will stop. I want to stop taking the Synthroid, but it is working for my other symptoms. What shall I look for?

Dawn

Response

The only way to check if substitution with thyroid hormone is OK is to measure blood TSH. This should have a value no higher than 2.0, preferably 1.5. The level of FT4 is of secondary value.

Georg Hennemann, MD


VERY ELEVATED TSH LEVEL24 Sep 2005

Question

March my TSH level was checked and was in the approx 780. My doctor wanted to recheck before putting me on medicine..so in April my level was 895. The doctor, before putting me on medication, wanted to have the ultrasound and subsequent radioactive iodine scan. Which came back normal. So I started Synthroid at .25mcg with the doctor noting that the medicine would most definitely need to be increased, but wanted to wait a few months to see the effects. So I just did my bloodwork and the doctors office called that the TSH level is 1200. I know this is way out of range and will be going in to see the doctor, but am very curious at why with medicine my TSH has increased. To note, my symptoms that persisted prior to medication are gone (constant menstruation, inability to tolerate cold, etc….) The only symptom I seem to have developed recently are dizzy spells and muscle cramps. Any help would be greatly appreciated.

Thank you

Sherri

Response

Your TSH results are almost certainly an artifact in that these values are most probably caused by circulating anti-bodies against TSH in your blood, interfering with the test.This can be easily sorted out by the laboratory chemist. He should perform so called “dilution curves” of your blood TSH and of the standard TSH of the test and compare parallelism of these curves. This phenomenon has no health consequences for you. There is no reason to continue using thyroid hormone. This assumption is based on the presence of a normal FT4. If this value is also elevated then it is theoretically possible that your pituitary produces too much TSH. To investigate this, a MRI of the pituitary can give the answer.

Georg Hennemann, MD, PhD, FRCP


REACTION TO ANTITHYROID DRUG

Question

I hope that you will find a time to answer my question although
I am not a physician. I am a pharmacistand recently I have been diagnosed with hyperthyroidism, precisely with Grave’s disease. I live on a small tropical island and I would have asked my physician what to do but the problem is he is out of the island and there is nobody else available. I started taking Methimasole 20 mg 2 times a day on 25 of May 2005, and I started feeling much better (my hair stopped falling, my pulse became normal, excessive sweating and shaking has been decreased) but yesterday when I got my blood results I noticed that liver enzymes have increased which left me in doubt
what should I do next-decrease the dosage of the medicine or discontinue it because of possible hepatotoxicity?
Grave’s disease was diagnosed based on the following results: 20 may 2005FreeT4…….4,12 ng /dl (0,9-1,9),TSH………..0,007microUI/ml (0,18-3,4) TRAK (antibodies for tsh receptor)……4,4 (n<1,5 IU/L) Dimensions of the gland were normal and without any nodules, ultrasound results pointed possibility of Hashimotos.I had almost all the symptoms except that instead of losing I gained weight and there was no goiter. My eyes are notbulging, but sometimes I feel discomfort and redness.
After one month of therapy with Methimasole 20 mg two times a day, I got the following results:Free T4…..2,3 ng/dl,Free T3…..5,0 ng/ml (1,40-4,40), TSH………..0,005microUI/ml
GOT(AST)………42 U/L (0-40), GPT(ALT)………89 U/L (0-38)Alkaline Pho……80 U/L (37-137) Bilirubin –di…….0,0 mg/dl (0-0.8) Bilirubin-to………0,4 mg/dl (0,2-1,6) GGT………………..29 U/L (0-60) Bilirubin ind……..0,40ml/dl (0,10-1,0) CBC with film was normal except LYM%……50,8% (13-50) I would very much appreciate your advice, because there is nobody else that I can ask at the moment, I am 29 years old and haven’t had any major health problems in the past, in my family there are 2 cases of hypothyroidism as I know, and I have to mention that I had some major stressful events in the past years (including death in the family).

Vesna Nastovska, Pharmacist

Response

Methimazole can certainly cause liver function abnormalities on the basis of allergy and/or of toxicity. These abnormalities are very rarely serious and then especially of the cholestatic type. In your case only ALAT is mildly elevated. Apart from allergy or toxicity these abnormalities may also be due to the hyperthyroidism itself. The high normal count of lymphocytes is due to the Graves’ disease per se. A toxic reaction is likely less probable because the cumulative dose used is so far very low. Most probably the abnormal tests are due to the hyperthyroidism itself. As your hyperthyroidism has been successfully (partially) blocked by methimazole, I would suggest to decrease the dose to 20 mg daily. Check your liver function tests for the time being twice a week and stop the methimazole if they do not normalize in a few weeks and if they increase stop immediately. If you have to stop, I would not advice to try propylthiouracil as there is considerable overlap in side effects, but start with propranolol, 40 mg 3 or 4 times per day and have yourself treated with radio-active iodine eventually abroad. You can even use prednisone in addition if necessary.

Kind regards,

Georg Hennemann


HYPOTHYROIDISM AND JOINT ACHES

Question

Is there a relationship between inflammation of muscles/ligaments and thyroid problems.

I had total thyroidectomy1 year ago (actually 2 partials) for follicular cancer. Lately I have had pain in the achillies tendon which passed. This week it is in my knee, I do exercise but I have done nothing for a few days and suddenly this afternoon pain in my knee. I can harldly lift my leg but there is no radiating pain of visible inflammation. I took 600mg of Motrin which has given me some relief. Someone told me that ligamament inflammation can be related to the thyroid. Is this true?

kfrebo@comcast.net

Response

If you are properly treated with thyroid hormone to suppress your TSH, your complaints are most probably not related to your thyroid condition.

G Hennemann, MD


ESTROGEN AND HIGH T3 LEVEL24 MAY 05

Question

I have now been taking Diane35 (estrogen) for 6 months following the doctor’s advice for treatment of PCO (poliquistic ovaries). Now I have the results of a recent blood analysis showing high levels of T3, while T4 and TSH remain normal. Values are as follows: Triyodotironina (T3): 3.58 (ref. values 0.90-2.79) Tiroxina (T4): 150.3 (ref. values 24.5-171.6) Tirotropina (TSH): 1.94 (ref. values 0.35-5.50) I am wondering if the high T3 levels are caused by the estrogen pills, and what effect this might have. I am supposed to stop taking those pills in September to control PCO.

Thanks!

Victaria Mengual

Response

Estrogen raises TBG, which raises bound hormone, but not active free hormone. This appears to be the situation since your TSH is normal. The test should normalize when the estrogen is stopped, but it is not a problem anyway.

L De Groot, MD


HYPERTHYROIDISM AND PREGNANCY27 Apr 2005

Question

Hi I am in my 29th week of pregnancy. I have my thyroid levels checked once a month and am on PTU’s I currently am taking 150mg a day. My question is this every time have my thyroid levels checked my TSH is less than .001 and my t4 is highly elevated. I think around mid 20’s. My question is this. What affect will these levels have on my unborn child and what affect will the meds that I am taking have on my son. I have had one ultrasound at 14 weeks and they said it was a boy and everything looked good, and he is growing like he should but I am not sure if anything could be happening to him because of how long my hormones have been so messed up while I am pregnant and the doctors dont seem to have an answer. I really would like to know if there are complications or possible birth defects that I could expect so that I can prepare myself for these.

Michelle Rhodes

Response

Your thyroid overactivity should be controlled to the normal range as soon as possible. Hyperthyroidism can definitely cause difficulties in maintaining a normal pregnancy. PTU is the usual treatment, and is not anticipated to cause trouble with the fetus unless relatively high does are required. It is best that you discuss all of these issues with your MD.

Regards,

L De Groot,MD


ARMOUR DESSICATED THYROID AND SYMPTOMS24 Apr 05

Question

Does Armour thyroid medicine, or the condition of hypothyroidism cause a fast heart rate? I have been diagnosed with hypothyroidism about 3 months ago and am now on 90 mg of Armour. I check my heart rate during the day and after resting for 15 minutes my heart rate is usually around 90-100 but sometimes it is higher. My doctor seems to think it is NOT from the medicine but it sounds like the logical explanation to me.

Thank you,

Alica Rutherford

Response

Dear Madam,

I have personally no experience with Armour but can tell you that as long as your TSH blood level is within normal range you are not using an overdose. In overdose situations TSH is below normal or even totally suppressed.

Regards,

Georg Hennemann


THYROTOXICOSIS AND PREGNANCY21 APR 2005

Question

Hi. My husband who is 27 was diagnosed with ‘grave’s disease’ in February of 2004. He is currently on PTU and Propranolol, and his endocrinologist has recommended he has the iodine therapy done, as the medication is not working successfully. Weare trying to fall pregnant,and I am concerned about the affect (of any) of the iodine on a males sperm and reproductive system. Should my husband consider freezing some sperm before he has this done? Also, There seems to be lots of information regarding women’s fertility but not mens! Does having an overactive thyroid cause infertility? If so, why? If infertility happens when your thyroid is overactive, when the levels settle down, will fertility ‘come back?’ We would really appreciate any advice you can give us.

Thank you for your time.

Response

Thyrotoxicosis can reduce fertility, and it should return to normal after treatment. RAI can damage sperm formation. Freezing sperm is possible. Often males are advised to wait several months after RAI treatment before planning pregnancy.

L De Groot,MD


HYPOTHYROIDISM AND PCO

Question

I am 28 years old hypothyroid patient, married 4 years back. We are trying to conceive from the last 3 years and 2 years back we found that I am hypothyroid and have polycystic ovary also. From the last 2 years I am having 100mgm Thyroxine sodium ( Electroxin from Glaxo) and ovary ruptured ( one year back) by laparoscopy as per infertility specialist direction to reduce PCO. But I am not yet conceived and the doctor says my LH level remains too high during the initial period of my cycle and hence the eggs are not growing or producing. Recently I tested my blood, blood sample collected on 3 day of my period, the LH value was 19,( Reference range is 1.1-11.6) and the FSH is within the reference range. Doctor please advise me on the following:

A. Is there any relation between Hypothyroid and Poly Cystic Ovary?

B. Is there any relation between Hypothyroid and LH surge on the initial days of period?

C. What are the probable cause of LH surge, other than hypothyroidism, and treatments for a successful conceive?

Thanking you.

Rachel

Response

As far as I know, there is no relationship between polycystic ovaries and thyroid diseases including hypothyroidism. Neither, certainly when substituted adequately with thyroid hormone, between hypothyroidism and the LH surge, as you indicate. The elevated LH levels in polycystic ovaries are a characteristic feature of this syndrome but not fully explained. Other causes of elevated LH are the post-menopause state and a benign tumor of the pituitary gland.

Georg Hennemann, MD


FACTORS ALTERING THYROID BLOOD TESTS4/2/05

Perhaps you could have the following questions answered in “the patient asks” section of
www.thyroidmanager.org.

  1. For a patient who’s hypothyroid because of autoimmune thyroiditis and taking thyroid meds, what effect could transdermal estradiol have on total T3, free T3, and TSH?.
  2. What effect might SHBG below normal (e.g. .5 (range 1-3)…hyperandrogenism) have on metabolism of thyroid meds and thyroid blood tests?
  3. Is atrophic autoimmune thyroiditis (nongoitrous) resulting in hypothyroidism a distinct entity compared to goitrous Hashimoto’s disease?
  4. What effect could the presence of anti-TG antibodies in the absence of anti-TPO antibodies have on thyroid blood tests for someone who’s hypothyroid?

Thank you.

Idlle Port

Response

  1. It will probably cause some increase in total T3 and temporary decrease in free T3, but in time the latter should return to the pre treatment level.
  2. Should not influence it.
  3. There must be some difference in the pathogenesis (immunology) of the conditions, but at the practical level treatment is the same.
  4. Unless the TG antibodies included the rare anti T4 antibodies, it should not make any difference.

L De Groot,MD


CONTINUED HYPERTHYROIDISM AFTER SURGERY

Question

I don’t know if it’s proper for me to show my case here, but I’m in argent need 4 help. My name is Salar Hesen Omer Berwari, I’m 28 years 28 years, male, single & I work as a constructions engineer. I live in Duhok- northern Iraq, in my city we don’t have expert in thyroid diseases so I was going 2 another city 2 have treatment, but under the bad situation of security in that city I couldn’t meet physician any more, & it seems that I’ll not be able 2 go there till a long time. I got Hyperthyroidism in 1997 & used 2 have carbimazole in deferent doses starting from 12 tablets of 5mg/ day. But the size of the gland still increased & the excretion of T3 & T4 was on, there I did a surgery in Oct. 2002 & removed the great % of the gland (270 g). & all features of Hyperthyroidism disappeared, & tests didn’t show any kind of cancer in the removed gland. I was going on taking carbimazole after the surgery for about a month, & after 3 months features of Hypothyroidism appeared, but I didn’t take anything against that, after about 5-6 months features of Hyperthyroidism appeared again 7 the test of T3 & T4 show that there was a great increasing. I started taking carbimazole again, 12tab.s for about 2 months, 9 tabs for 45 days, 6tabs for a month & then 4 tabs till now, that with inderal & Predizolon according 2 the physicians recommendations. But after that the size of the gland started increasing under unknown reasons ( I was taking 4 tabs that time) & after that features of Hyperthyroidism started again (pulse increasing, high temp.) & now I don’t know what 2 do. Can u plz help me & show me what can I do till I meet my physician again?? Why I was back 2 Hyperthyroidism after the surgery?? & why going on taking carbimazole can’t stop increasing the gland & the hormones?? For information I don’t have any family history of thyroid disease and/or diabetes.

Thank u so much.

Salar Barwari

Response

From what I understand is that you have relapsing hyperthyroidism despite thyroid surgery and continuation of carbimazole . You also had an increase in thyroid size for unknown reason. My general impression is that the dose of carbimazole that you are using are higher than usually necessary. We know that high doses can lead to goiter formation. However if at the same time or soon after an increase in goiter size during carbimazole hyperthyroidism relapses, the increased volume is probably related to the persistence of the hyperthyroidism. I think that it is very important to establish if you still have hyperthyroidism. If that is the case the best treatment is administration of radioactive iodine. Would that be possible in your circumstances? If that is not the case you have to continue with carbimazole in a dose that normalizes your thyroid function properly until you can get permanent treatment. I would strongly advise you not have a second operation as in that case complications causing paralysis of your vocal cord(s) and or inadvertent removal of your parathyroid glands are possible. If you can have your TSH and T4 being measured periodically, I am quite happy to advise about the dose of carbimazole that you have to take until you can consult your doctor again. I am not very happy about the fact that you use prednisolone . Inderal is OK for the time being.

Georg Hennemann, MD


Question

I have had a multinodular goiter for at least 5 years, although I suspect its been more like 10 years.. I am 30ish female with multiple symptoms on NO meds, cause my doctor likes voodoo medicine. The body canheal itself, etc…..I have ultrasound once a year. Fine needle biopsy ,have lost up to sixty pounds in a two month peroid, massive hair loss, periods have dissapeared,6 months no period. dizzyness…singular pvcs,tremors.heat intolarance cold intolerance,memory loss with personality changes, TSH is .48…t4,9.8 my question is my dr says labs are fine perfect do you think I need meds?

JL Shearer

Response

Voodoo medicine is potentially dangerous for any patient. My advice to patients is to turn away from doctors who practice this kind of quackery.

The complaints that you have are typical for someone who’s thyroid functions too rapid. It may be so that your lab results are (just) within the normal range. However this does not mean that they are normal for any subject, as the normal ranges of TSH and T4 are rather wide.

Your doctor apparently has not determined your blood T3 concentration. T3 is another thyroid hormone that is much more active than T4 and I would not be surprised, considering your symptoms, if this would be elevated. But even if this is not the case than I still think that your thyroid is (borderline?) overactive. This expectation is on the basis of the combination (1) of your typical complaints, (2) the fact that you have a longstanding multinodular goiter that very often develops into hyperfunction and (3) the combination of a low normal TSH and high normal T4.

Even if hyperfunction is borderline it can produce substantial symptoms on the long run, which is possibly the case with you.

My advice is to consult an endocrinologist who practices regular medicine.

Kind regards,

Georg Hennemann


ELEVATED T3 LEVEL AND ESTROGEN

Question

I am not a doctor but I have a medical question (I am going to a doctor. soon) I had a thyroid profile II because i was having problems with anxiety (the doctor checked for graves because my sister has it) my test results were the following: TSH 1.217, T4 12.9, T3 uptake 21,Free Thyroxine Index 2.7, T3 241. My doctor is concerned about the T3 results and told me to go see my regular Dr (the first Dr is a Dr at my school) I did some research and found that a high Estrogen level can cause an elevated T3 level (I have been telling my doctors for years that I thought I was producing to much estrogen) my question is can High Estrogen cause an elevated T3 level or am I in early stages of Graves and if it is the estrogen how do i get my doctor to test for that I have been trying for years to get my hormone levels tested and not just by one doctor.

Erika

Response

The normal TSH gives a strong indication that you do not have thyroid hormone excess. Estrogen does increase the TOTAL levels of T3 and T4, but estimates of the free level are normal when there is no thyroid disorder. You do not give the units or reference ranges for T3 and T4, but the T3 concentration, if high, will correct to normal when the low T3 uptake is taken into account. If you are taking an OCP it would explain these tests. Hope this is helpful.

Jim Stockigt, MD


THYROXIN DOSE AFTER THYROID CANCER SURGERY QUESTION

Hi I am a 46year old female being treated for papillary carcinoma. In 1997 I had a partial thyroidectomy and was told that my biopsy revealed follicular neoplasm. I was told everything was okay. InApril 2003 I was not feeling to well and visited my doctor. I have an existing B12 deficiency and thought that might be my problem but I also stopped sweating(I usually sweat alot) and was just not feeling to well. My T4 was checked and my levels were to low according to my doctor. I went from 75mcg to 100mcg and started feeling better. But in August I started noticing changes in my voice and a lump in my neck. My voice started to sound shaky and the lump was preventing me from swallowing properly.. I went to my doctor and he ordered a ultrasound of the thyroid. There appeared to be a mass in the left side of the thyroid. The right having been removed in 1997. I went for a FNA to biopsy the mass. The biopsy revealed changes of either a follicular variant of a papillary neoplasm or a follicular neoplasm. I had surgery in February of 2004. The report reads as follows. The specimen was sectioned in its entirety. The sections show multiple nodules of varying sizes and the nodules contain follicles of varying sizes some of which are very large. Some small nodules are composeds of very small follicules. The largest nodule, witha nearby long black suture, is also mainly composed of follicles but show a fairly large component of papillae fomations.These papillae are arborizing in areas and have a fibrous and fibrocascular stalk. The lining epithelium is composed of columnar cells which are medium to large in height. A few show nuclear grooving and a rare cell shows internuclear vacuolization and some cells show clearing the nuclei. The findings are those of a papillar carcinoma. This focus occupies approximately .7cmin the center of this nodule which is approximately 1.5cmindimension. This case represents papillary carcinoma.. I was told 6 weeks later of this finding. I was also told by the surgeon not to worry it was no problem because it was all removed. On seeing my endocrinologist he informed that I would be needing treatment and this was not to be taken lightly.. I was put on a low iodine diet and taken off my levothyroxine. I was without my thyroid meds. for 11 weeks and was treated with I-131 and then given a body scan 2 weeks later. My body scan showed 3 foci’s. Two in the area of the jaw and one in the lower left region of my clavicle. Four months later my TSH levels and other blood work was done. My TSH levels were to high and I was put on 150 mcg of levothyroxine as the Endocrinologist informed me that cancer could come back. I wanted to know if the 3 foci’s were of concern and my doctor just shrugged his shoulders and told me he would be keeping an eye on it. Now it has been 5 weeks since my dosage was increased. I am experiencing blurred vision, heart palpitations I am urinating about every 1/2 hour I also feel agitated, numbness in the hands and feet and excessive sweating. I also feel like my mind is racing and I am more irritable than normal. I am 5’1″ and weigh 114 lbs. I do not know if the amount of levothyroxine is to much for someone of my size. I do not see the endocrinologist until Feb 2005. Should I be concerned with the amount of levothyroxine I am taking?

Lilliane Dubois

Response

In brief, yes. You need enough thyroxin to keep TSH near 0.1 when you are on the med, but for you that dose is probably near 125ug . The exact amount can only be determined by trial. Get a blood test now.

L De Groot,MD


HIGH TSH AND THYROXIN TREATMENT QUESTION

Question

After years of vague symptoms attributed to menopause (I am F 52yr.), my G.P. did yet another TSH (previous thyroid panels were all negative) and it was 187. Because it was so high, should I be concerned about the pituitary gland having a problem? And, is it OK to treat hypothyroidism by just monitoring TSH levels? Should Free T4 and T3 also be drawn? I have been on Synthroid 75 for 7 months now, and my TSH is down to 4.3.

Cindy

Response

  1. Meaning of high TSH at diagnosis: A very high TSH value indicates marked hypothyroidism. The value reflects a combination of the severity of the hypothyroidism, its duration and some individual factors. As long as the level has been falling with T4 therapy, there is no need to be concerned about the pituitary gland.
  2. Laboratory follow-up for treating hypothyroidism In most patients with hypothyroidism, it is not necessary to check T4, T3, free T4 or free T3 levels during treatment. As these values can vary widely within the population and the pituitary gland is very sensitive to changes in thyroid hormone levels, monitoring just the TSH is usually sufficient. I would recommend though that you dose be increased to maintain the TSH within a range of 0.4 to 2.5.

David H. Sarne, MD FACP


History of controlled hypothyroidism: now with hives

Question

I have had hypothyroidism for ~ 18 years now. I also have a history of ebstein-barr virus in 1988 which manifested itself with (L) sided weakness and burning- neurlogical symptoms that still remain. I have been on Synthroid 150 mcg po qd and my T3, T4 in Feb 04 was normal. I am 41 years of age. I had a child in October 03. For the last 5 months I have had to deal with hives. Initially, they were on my most dense on my abdomen & back, and some on my legs, arms, lips. My family Dr suggested Benadryl. No help. After they worsened, I went to see a Dermatologist who put me on Zyrtec 10 mg po qd. That did help for about 3 1/2 months. I would have intermittant hives but they were tolerable. For the last 3 weeks, they have been horrible again. Raised, red, itching and burning relentlessly. They are most dense on my legs this time, but also appear on arms, lips, hands, back and abdomen. Dermatologist doubled my zyrtec to 20 mg daily with no improvement. I saw him and he gave me 60 mg of kenalog IM and added allegra 180 mg qd as well. He did bloodwork as follows:

T4 – free, direct tryroxine 1.14 nl(.61-1.76) TSH 1.778 (.350-5.5) T4-thyroxine 8.7 (4.5-12.0) T3 128 (85-205) Thyroid Peroxidase 65 high nl 0-34 Thyroid antithyroglobulin Ab <20 nl 0-40

I have to wait a week to see my family Dr. I am not established with an endocrinologist as I had been stable. Please help me understand what is going on and what the next steps should be.

Thank you,

Dee

Response

I understand how difficult your problem is. It appears that you have been appropriately treated. Generally a search is made for any possible environmental factor that might cause an allergy, for certain genetic traits, for other diseases associated with hives, and for “collagen-vascular” disease, but this is often fruitless. You do have autoimmune thyroid disease , and that is definitely associated with the hives that you have. However to my knowledge that does not offer any recognized different approach to treatment. Typically over time the process subsides, often to recur to some extent at a later time.

Sorry I cant be of more help,

L De Groot,MD


HYPER AND HYPOTHYROIDISM AT THE SAME TIME

Question

Is there a disease related to thyroid hormone that causes one to have symptoms of hypothyroidism and hyperthyroidism simultaneoulsy?

Samantha S Schilling

Response

To my knowledge there is no specific disease that can cause such a condition. Nevertheless it is very easy for anybody to have some symptoms of hyperthyroidism, and some symptoms of hypothyroidism, at the same time, since the symptoms are so common in many other conditions, and so non-specific.

L De Groot,MD


THYROID NODULES AND ACUPUNCTURE11 May 2004

R ecently I was accidentally Dx through an MRI, and later Nuclear med test…with having cold nodules on my thyroid. The left lobe nodule is 2.5 cm x 1.0 cm x 1.5 cm. the right side nodule is only 3 mm. I have had two USGFNB os these noduleswhich are not palpable.Both attempts at USGFNB biopsy came back as inconclusive. My ENT Dr.suggested that I have a partial thyroidectomy done or take a high dose of synthroid for 3 months in an attempt to reduce and possiblymake the nodules disappear. Thosearemy two options from him. My question is, Do you know of any successful treatment studies done on these types of nodules that have been treated through acupuncture and Chinese medicine? And or what are the consequences of not choosing to have these nodules treated, or not treated successfully minus the surgery? Do they ever go away by themselves? I am a 37 y/o/f. My only C/C prior to my MRI has been left ear radiating pressure that increases after singing, talking a lot,eating and my voice becomes hoarse after singing only several songs or I have been talking a lot.

Thanks for any advice youcan give me.

C. Bauchert

Response

The nodule is fairly large and your symptoms could be related to it. Unless you have a good negative result of an FNA, usual practice would be to remove it , and with both sides abnormal, a near -total thyroidectomy by a specialized surgeon would be the approach. Although thyroid hormone therapy might help suppress growth of a benign nodule, the typical natural history of such nodules is slow growth. Obviously if it is in fact a malignancy, it is possibly much more of a problem. You sound too intelligent to waste your time and money and health on acupuncture and Chinese herbal medicines.

L De Groot,MD


SYNCOPE DURING THYROID NEEDLE BIOPSY

Question

Hello,

I found your website while doing some research on thyroid nodules.I recently underwent a thyroid biopsy for a nodule that is a 1.5 cm dominant nodule among several smaller nodules. During the biopsy, I passed out, at which point the doctor discontinued the biopsy. Needless to say – he did not obtain a sample. The doctor is sending me to a cardiologist to rule out a heart condition, but I think will eventually want to rebiopsy. I do not think I have a heart condition (I am in good health and run 3-4X weekly) but I do have a history of passing out during medical procedures (I have to lay down for blood tests). As a result of this episode, I have extreme anxiety about repeating the procedure. Have you had to deal with patients like myself? Do you make special accommodations to prevent this type of reaction?

EB

Response

It is not amazing that you get weak when someone wants to stick a needle in your throat! Actually, in the hundreds of patients I have biopsied, no one has ever passed out. In our clinic we do the procedure with the patient lying flat, rather than sitting up, as some MDs do. But quite a few had to keep flat for a few minutes to recover from the same sort of hypotension that you experienced. I suppose a small dose of Valium prior to the event could be useful. We do that frequently for patients who can not stand being in the closed space of the MRI machine, for example.

Good luck.

L De Groot,MD


WHAT IS THE PROPER DOSE OF THYROXINE?

Hello,

I know you are mainly for professionals but I really need some advice. I am sure your comments would not take long on this if you could please just take a few moments to read this. I am a 34 yr old male with auto immune thyroid (Hypothyroidism). My blood tests (04.12.2003): Glucose, Lactate, Leucocyte count, Erythrocyte count, Hemoglobin, Hematocrit, Mean Corpuscular Volume, Mean Corpuscular Hemoglobin, Mean Corpuscular Hemoglobin Concentration, Trombocyte count, Potassium, Creatinine, Sodium, Alanine Aminotransferase, Amylase, Aspartate Aminotransferase, Calcium, Billirubin, Billirubin conjugate were normal; but TSH was 51.80 mU/l (norm here is 0.6-4.2). Two weeks later my blood test was (19.12.2003): FT4 – 7.2 pmol/l (norm here is 9-20), TyglAb – negative, TymsAb – 6400 (norm here is <400), TSH – 61.50 mU/l. My blood pressure based on averaged measurements made per hour one week was: (a) after waking up, but before standing up: systolic – 99.4+-2.3, diastolic54.9+-2.4, pulse, (b) during the day: systolic – 114+-5.5, diastolic – 67.7+-4.2, pulse – 56.9+-4.3. I have not any symptoms of hypothyroidism. But I have headaches (often). My questions: (1) What is the optimal dosage of thyroxine therapy for me, considering my blood tests and the absence of symptoms. My weight is 63-64 kg (stable over 20 years)? (2) Should I take it all my life, or I can stop when the blood tests will normalized? (3) What is the mechanism for decreasing antithyroid antibodies by thyroxine therapy?

Thank you for your time,

Alexander Fingelkurts

Response

The common dose needed is around 1 microgram /pound of lean body mass, but your MD must determine the exact dose by trial until TSH is in the proper range. Usually you need to take the med all your life. The antibodies commonly stay positive for years or forever even on treatment.

L De Groot,MD


CANCER IN THYROGLOSSAL DUCT

My 40 year old son has recently had a Thyroglossal Ductal Cyst removed and the pathology report was Thyroid Papillary Carcinoma. He was told that it is very rare to find cancer in these Cysts. His head MRI and Chest CAT scan show no evidence of any caner remaining. He will see a radiologist and endocranologist next week to determine what if any followup he needs.Are there other test that should be taken to determine if the cancer has spread to the Thyroid or other tisue? Would you recommend I 131 or followup surgery to remove the Thyroid? I can’t seem to find any information about this type of caner within a Cyst. Could you provide some information?

Thank you in advance,

Daryl McRoberts

Response

Whether to remove the thyroid and look for nodes, or not, is a matter of debate. There is some chance that the tumor involves the thyroid. If the physical exam is negative, the thyroid ultrasound is absolutely negative, and the serum TG is normal, I believed it would be safe to wait and follow with periodic exams, ultrasounds and TGs. If these tests are abnormal, it probably would be best to operate and do a near-total resection of the thyroid.

Leslie J De Groot,MD


Can I take antithyroid meds for Graves Disease for a long time?

Question

Good Afternoon. I have Graves Disease diagnosed in 1996. In 1998 try to leave the antithyroid tablets but my thyroid became over active again. I started the tablets again. Since then I have been taking methimazole tablets 5mg daily and every second. day 10mg (5mg in the morning and 5mg in the evening). I am now normal/stabilized for nearly 4 years, but want to know why I cannot continue with the tablets for life? Thank you.

Kind Regards,

Charlotte Dreyer

Response

There is no specific prohibition to taking antithyroid drugs over a long period, but there is always the small possibility of an allergic reaction. Generally patients and their MDs give up after a year or two or three, because of the inconvenience, and resort to RAI or surgery.

L De Groot,MD


TWIN PREGNANCY AND RAISED TSH LEVEL

Question

I have had my thyroid levels tested twice now with my TSH raising both times. We have found out we are expecting twins. I am 8 1/2 weeks pregnant. My levels were: TSH is 8.66, T3 is 150, T4 is 7.7. I am going to see a thyroid doctor next Thursday. We lost a child last year at 12 weeks. Are a little nervous and wondering if this is a problem we should be worried about. My Ob said not to worry because my T3 and T4 are normal but it is the TSH that is high.

Response

No matter that your T3 and T4 are normal. When your TSH is raised it means that you, and especially your BABIES!!, need thyroid hormone. You have to be treated with L-Thyroxine such that your TSH drops to below 2,0 mU/L.

Good luck

Georg Hennemann, MD


PAXIL AND ELEVATED TSH

Question

I have been taking Paxil or Paxil CR for nearly 3 years now. I have been slowly gaining weight and increasingly feeling tired/unmotivated. I started working out, then ordered some Royal Jelly (Bee product) for energy – then decided before I start self medicating I really should have a physical. My results included TSH at 2X normal levels (per Internist) and an enlarged multinodular goiter per ultrasound of Thyroid. So… I just read a science article from the U of Georgia where they state that they believe fluoxitine inhibits thyroid and so they’ll be looking at that in an upcoming toxicology study re: wastewater and wildlife. I guess the body’s internal pathway of using and recycling hormones is complex and the SSRI’s may inhibit ‘something’ in that pathway. I know only 1 in 1000 of Paxil takers can get hypothyroidism from Paxil. So it’s ‘possible’ that MY Paxil created my Thyroid problem. (I prefer not to be diagnosed and treated based on ‘probabilities’ if specifics can be found!!!) I guess the REAL question clinically is – how would you differentiate what caused my hypothyroidism? Did those ‘rare’ ones who lost their thyroid function from taking Paxil have returned function after ceasing taking Paxil? Is it reversible – do we KNOW? If you believe you can get to the real ‘root’ of this issue better than I’ve tried to parse it here, please feel free to answer as you see best.

Thank you for your time!

Cheryl

Response

Paxil activates enzymes in the liver that metabolise thyroid hormone, thus increasing the requirement. In people who are”normal” this presents no problem. However in, people with a diseased thyroid, it may produce hypothyroidism, and the same in people who take their hormone from a bottle. If you stop the Paxil you may not need hormone, but at this point if you continue the Paxil you need to take thyroid hormone supplementation. I will wager that if your MD does tests for anti-thyroid antibodies, the test will be positive, and that you actuallya have Hashimoto’s Thyroiditis.

Best regards,

L De Groot,MD


HASHIMOTO’S ANTIBODIES

Question

Does Hashimotos thyroiditis reduce or in anyway influence iodine uptake by thyroid gland? I have extremely high levels of TPOAb and I am wondering that since TPO is very essential for iodination of thyroglobulin, wont TPOAb reduce levels available for the iodination? Are there statistics on how Hashimotos patients with DTC respond to RAI ablation compared to DTC patients without Hashimotos? Thanks, Anita

Response

Dear Madam,

TPOAb does not enter intact thyroid cells, hence can not inhibit TPO-activty. TPOAb however kills thyroid cells and thereby reduces the iodine uptake of the whole thyroid gland. A goiter that has developed because of Hashimoto’s disease is hardly that big that reduction is necessary and if so RAI does don’t work because cells are not viable anymore and do not or only minimally take up RAI. I do not know of such statistics that you ask for.

Georg Hennemann, MD, PhD, FRCP, FRCP(E)


HASHIMOTO’S THYROIDITIS WITH VARIABLE THYROID FUNCTION

Question

I have a question about Hashimoto’s? I was diagnosed a year ago. My TSH was JUST above normal, and then I was tested for antibodies which were high. So I have hashimoto’s (my mother has it as well and has been on Synthroid for years). I also have a couple of small nodules. I must have had Hashimotos for about 2 years, which explained the weight gain (about 15 pounds), aches and pains, dizziness, muscle cramps. At the next test, a few months later, my TSH and all the hormones were normal, so my endo ‘monitored’ me and I was tested again in six months. I know that for some people, small fluctuations in the hormones can cause a lot of changes in how you feel. At my last test, while the antibodies were still present (this was in may) my hormones were at normal levels and my endo said my thyroid shows normal function. SO I am not on meds. And I seem to have lost weight and don’t feel as bad as I did a couple of years ago. Does this happen a lot, that you have antibodies but normal function? Can things turn around like that? I have no idea what caused the change. And can you be treated with synthroid or whatever in a case like this, if you have high antibodies but normal hormone levels?

Marlene, Journalist

Response

Thyroid function can fluctuate between normal and high or low in some individuals with Hashimoto’s thyroiditis. Generally if the hormone supply is normal, treatment is not given. However sometimes thyroxine is given in an attempt to decrease the size of the thyroid, and treatment may reduce the antibody levels. Except for their action on the thyroid, the antibodies in Hashimoto’s are thought usually to cause no trouble.

Leslie J De Groot,MD


Thyroid and Hair Loss

Question

I recently stared taking synthroid. I am experiencing fairly severe hair loss. I have been on it for almost 3 months. It has helped me tremendously! I have lost 25 pounds, have more energy, much more interested in sex and basically feel better than I have in 2 years. I am afraid to stop taking it because I feel so much better. What can I do about the hair loss and will it grow back? It has gotten very thin.

Thank you!

C B

Response

Hair loss is common in people who are either hypothyroid or hyperthyroid. Hair loss is also common when one changes the metabolic state. Presumably you were hypothyroid, and hopefully you now are “normal”, and not over-treated. If this is the situation, there generally will be a return to normal hair density over months. However remember that there are many other causes of hair loss, including many serious illnesses, excess androgens, autoimmune problems, and the aging process. Hopefully your problem will straighten out spontaneously in time.

L De Groot,MD


Painful Hashimoto’s ThyroiditisJune 10, 2003

Question

I know you are only for Doctors but I really need some advice i am sure your comments would not take long on this if you could please just take a few moments to read this. I am a 23 yr old women with auto immune thyroid,Hypothyroism & A Goiter. My last blood work done was–TSH – 6.54, Free t3 – 123, Free t4 – 1.4, and antibodies at 135. I have been suffering from Goiter pain and have told my Endo this several times. It was the whole reason I had been referred to him. anyway I called him today to ask for a recommendation on what I could take other then Aleve for the pain as it was not helping and his reply was that it wasn’t my thyroid he thinks I have a sore throat. ok I think after having this problem for 15 years I know the difference but that is what he insists on he told me to go to my reg DR to have it looked at and I plan to go tomorrow just to be sure But I am not sure what to do if my GP says there is nothing wrong with my throat.I mean should this DR,giving my thyroid problems,have blown me off so easily without even looking at things?Should I see about getting a different Endo?or do my test tell him that things are fine and that is how he knows it isn’t my thyroid? as he never even seen me it was a phone conversation in which he told me to take Aspirin that I am allergic to and he knows that I am.I am currently taking Synthroid .175 for the past 3 weeks up’d from .150.

Thank you for any response you can give,

Kyra

Response

You seem to have Hashimoto’s thyroiditis, and according to the TSH you were a bit under-replaced with hormone at the time the test was taken. Pain in the thyroid is unusual in Hashimoto’s, but does occur, and sometimes people even have to have the thyroid removed surgically to get rid of the pain. Your MD might check out an article published in the last issue of Journal of Clinical Endocrinology and Metabolism, entitled “Painful Hashimoto’s thyroiditis”.

Good luck.

L De Groot,MD


MEDICATIONS WHILE HYPOTHYROID10 Jun 2003

Question

I have been searching for cold medicines that are okay for patients with hypothyroidism. Everything I’ve seen over the counter to date includes a notation that one should check with a doctor if one has thyroid disease. I’ve talked with three doctors, and none have any suggestions. Do you know of anything that will dry sinuses or suppress coughs without containing pseudophedrine products? Or suggestions on who to contact next?

Laurie

Response

After your hypothyroidism is treated and your tests are normal, those restrictions on medications no longer apply to you. You are effectively normal, at least in regard to the thyroid.

L De Groot,MD


1/21/03

Question

Hello,

I just found your website and I am hoping you can provide some insight on my situation. I am a 36 years old female and began to notice hair loss in May 2002. The hair loss is diffuse thinning – more in some areas than others – not alopecia areata. I have seen two dermatologists. The dermatologists do not believe that the problem is male/female pattern baldness. They were unable to state the cause.I realize that hair loss can be caused by many things. My question is related to my TSH levels. Here is a history of my TSH: 10/97 = 0.73 (0.3 – 5.1 uIU/mL) 4/99 = 0.99 (0.3 – 5.1 uIU/mL) 8/01 = 2.35 (0.49 – 4.67 uIU/mL) T4 = 13.9 (4.5 – 12.0 ug/dL) 2/02 = 2.53 (0.49 – 4.67 uIU/mL) free T4 = 1.55 (0.6 – 1.85 ng/dL) 4/02 = 3.69 – (noticed hair loss late April early May) (0.4 – 5.5 uIU/mL) 7/02 = 4.09 ((0.4 – 5.5 uIU/mL) 12/02 = 1.90 (0.50 – 5.00 uIU/mL) I showed these results to the dermatologists but they did not mention the changes in my TSH. Are these changes significant enough to cause hair loss? What could cause these levels to change like this? I was on Serzone (350 mg/day) since August 2001 and began tapering off 25 mg/week in March 2002. Could this affect my TSH directly or indirectly? I am completely off of the Serzone.If the hair loss is related to my thyroid, will the hair grow back? How long (approximately) will it take?Any insight would be much appreciated.

Thank you,

Valarie

Response

My answer is “maybe”. The drugs such as Prozac and Paxil, and Serzone, cause increased metabolism of thyroid hormone, which fits with your increase and then decrease in TSH. However the TSH never got out of the normal range. I am unsure that this is enough of a variation to cause hair loss, but it might be. If so, the hair should regrow when you are now back on the regular dose and your TSH is back close to its former level.

L De Groot,MD


13 Jan 03

Question

Two years ago when I found I had Hashimoto’s, My dr. also told me I had autoimmune hepatitis, due to elevated liver enzymes and the ANA was positive. Is it possible that these two disorders could be closely related, i. e. the thyroid has “caused” the liver autoimmune response?

Thanks for your answer!

Carol

Response

Other autoimmune diseases are sometimes associated with Hashimoto’s, and both the ANA and liver disease could be connected in that way. However it is generally believed that these are independent diseases, and not that Hashimoto’s “causes” the other problem. The cause is probably one step farther back for both, some dysfunction in the immune system.

L De Groot,MD


11 Jan 03

Question

Hi,I found your names in the internet and decided to try asking you a couple of questions regarding my wife’s thyroid disease. She is scheduled to take the “radio-active iodine” pill next week and we are a little concern about the effects of it. We have two girls and we lost a baby last year. We would like to have another baby, but we were told that after taking the pill, we have to wait at least 6 months. My wife is 31 and we are a little scared about “this pill”. She needs to be away from the children and from me for 3 days, she can not use any metalic silverware, her clothes and the sheets she will sleep in during the first three days after taking the pill need to be laundered separately from the rest of the clothes, etc. etc.. So here are my questions:

  1. Is taking the pill the best option we have today? The radio-active pill is indeed by far the best option. The measures that have to be taken such as you mention are precautions not to contaminate others with radio-activity. However I can assure you, that they are more taken for psychological reasons than anything else as even if contamination would occur this is fully harmless because of the low total dose radio-activity your wife is going to have. Even so the 6 month’s period is mostly for psychological reasons and in fact irrational as it is meant to avoid any irradiation of the ovum (egg) after fertilization and for this a maximum of 6 weeks is sufficient.
  2. Is it true she will still be taking a pill the rest of her life? I mean we are very young yet for this to happen? Is there any other alternative we were not told?

Thanks in advanced for your help and input.

Claudio Martin

Response

The consequence of the treatment with radio-active iodine is indeed that the risk is high that your wife has to take tablets containing thyroid hormone for the rest of her life, because the treatment very often results in permanent thyroid failure and its function has to be replaced by using these tablets. However this also occurs frequently after operation, while long term treatment with tablets to suppress hyperthyroidism is usually inadequate as relapses frequently occur. Furthermore, if your wife has Graves’ disease, then the natural course of the disease is often that after many years thyroid failure will develop anyway. Last but not least, although it is unpleasant to have to take tablets every day, treatment with thyroid hormone to substitute for thyroid failure is easy and does not affect health in any way. The only important thing to remember is that during pregnancy about 50% of women have to take more thyroid hormone for adequate supply to the unborn child. This has to be checked during pregnancy.

Georg Hennemann, MD.