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2008 Patient Questions

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Dear Andrea,

Thank you for your email. You have Graves’ disease with some eye problems which occur with Graves’ disease. It is not clear whether you are still hyperthyroid (over active) but you certainly need your T3 and T4 checked carefully. Propanolol can sometimes interfere with the thyroid function test to a small degree. If you are still over active, I would certainly suggest you had a repeat dose of radioiodine as you have had one already. If you are over-active and have radioiodine, the symptoms should resolve. Not all patients are successful with the first dose of radioiodine and it is quite in order to have another one or even a third one. I think you are on the right track with your treatment. It is very important that you do not go underactive from the thyroid point of view (as a possible consequence of radioiodine) as this might affect your eye.

Best of luck.

Yours sincerely,

Professor JH Lazarus

29/09/2007

Hello Dr.

This is the first time I have found your website and have enjoyed the reading. I am 23yr old female, I had a child when I was 20 years old. I was diagnosed with Hashimotos at age 19 after taking Tapazole, Toparol for 8 months I coincidently stopped taking my pills and within 1 mo became pregnant. My child is very healthy and my pregnancy went well, But about 8mo after her birth I went into the hospital for a Thyroid Storm. It started with a few days of vomiting and then preceded with diarrhea, bulging of the eyes, goiter, HR 140, BP 140/100, tremors, etc. and a loss of 35lbs over the course of 2 weeks. I was hospitalized for 4 days and was going to have RAI in the hospital but as i was wheeled down to Nuc Med the nurse asked about any PTU and I had told her about the large amount I was given in the ER. After being released on Propanolol I was supposed to follow up shortly to have the RAI but I started working and within 2 months was back in the hospital for 3 days. Tha t time I recieved the RAI it was Aug 2005. Now after recieving it I remained on Propanolol and lost ins coverage by Feb 06 …by Oct 06 I had a case of iritis in my left eye which all symptoms cleared within 10 days, and obtained new ins. I know that recent thyroid test have revealed a TSH that has remained around 0.001 for the past few tests (over the last year and a half) and currently T3 and T4 within normal range. From memory my Thyroid Antibody levels are very high in proportion to the reference range but I cannot remember the specific numbers. My current Endo has seen me twice one last year and once this year and wants to do more RAI which I understand the reasoning. MY REAL QUESTION is with as much as I feel I am on top of understanding my disease and communicating with my doctors I feel TERRIBLE on a daily basis. Today I went to see him and he said my thyroid has become smaller over the last year upon palpitation, but when I told him my symptoms or I tell doctors I feel that no one takes me seriously or feels they are important. My current symptoms for the past year have included “feeling” of a racey heart, shortness of breath, swelling of my eye lids and feelings of overproductive tear glands, flushing of my cheeks on a daily basis, hot flashes then spurts of cold hands, chills, almost flu like symptoms. Nausea, overactive bowel 4-5 times a day usually in the morning, tiredness, and in appetite that even when I eat well ..will feel like Im starving an hour later. I am very moody and emotional . I cry over everything. Today I was told that it sounds like anxiety. But Iam not buying it. I feel just like when i went in for the thyroid storm except my pulse and BP are in normal ranges. Is it possible that the Propanolol 20mg q6h that i take is masking the symptoms of a toxic thyroid state. I just feel that no one believes my feelings or maybe my recent doctor does not explain enough to me for me to be confident in his answers. Iam going for blood work in a few days and within a month i will have an uptake and scan, and hopefully my 2nd does of 131 but are these symptoms going to last forever? Do patients that have had similiar problems or symptoms every get relief? Am I on the right track with my treatment?

I THANKYOU FOR YOUR TIME , AND GREATLY APPRECIATE YOUR ANSWER .

Sincerly,

Andrea, South Florida.

Dear Ms Guthrie,

Phenobarbital can interfere with the metabolism of thyroxine and may precipitate a problem with the thyroid in some individuals. You should probably have one or two readings before making a decision to go on to thyroxine if “high” indicates that your thyroid is failing.

Yours sincerely,

Professor JH Lazarus

28/09/2007

Dear Dr. Lazarus:

I have been prescribed 64.8MG Tablets of Phenobarbital to be taken by mouth twice daily. I have been faithfully taking this medication to treat “space-outs” or mild secondary epilepsy related to meningioma in 2001. I had successful surgery in June 2001 after a Grand Mal Seizure. However, without the above medication I continue to have “space-outs”.

The “space-outs” usually last less than 2 minutes and I have not had a “space-out” in over two months.

My question: Does Phenobarbital contribute to a high thyroid reading? My medical doctor performed the simple blood test for thyroid and he said I had a “high” thyroid reading I do not believe I have any symptoms of hypothroidism.

Thank you.

C. C. Guthrie (60 year old female)

Dear Ms Provoost,

In general most women who become pregnant on thyroxine should have an increase in dose. I agree that this is not 100% of women, but your values suggest that if your TSH has risen in early pregnancy you should have a modest increase in dose. The study of Larsen et al, some years ago from Boston, indicated that a mean increase of around 30 mcgs was appropriate. My suggestion to women is to increase by 50 and then get another TSH level some three or four weeks later. We are not specifically doing research in that area and I don’t know who is at the moment. I can inform you that there is no particular risk of increasing the dose of thyroxine for a period of time providing the values are checked. Hope this helps.

Yours sincerely,

Professor JH Lazarus

Corinne Provoost

27/09/2007

Dear Sir, I have been reading with great interest about your research on thyroid treatment during pregnancy on the Internet and I see that a research is being planned on this. It is great that there is actually scientific research being done again on this subject, as there seem to be a lot of assumptions, but no real facts and figures. I would be very interested to participate in this research if I can, but I have no idea how this can be done, so I thought I’d give it a go with this email I found. As a thyroid patient myself, I have no active thyroid gland since birth (did not sink enough, pre-mature baby) and I am taking Levothyroxine on a daily basis. This has been working fine. At the moment I find myself questioning research and results a lot because I have just become pregnant (with difficulties) and I am doubting if I should increase my dose of thyroxin and I find that different parties have different takes on this. I am reading everywhere about the relationship of the brain development of the foetus and the thyroid function and I am of course worried about my own situation with artificial intake. I did a test at 4 weeks pregnancy and my TSH levels have gone up significantly (from 1.68 to 3.11), while T4 has remained stable (22). My GP thinks because I am within the official limits, this is not to worry about. I am worried because I have never had such a known high TSH (always between 1.68-2.4) and I wonder how quickly this is rising now. Plus some researchers suggest that my TSH should be 0.4-2 in early pregnancy stages. Temptation to just take a bit more is high, but the scare of not knowing what can happen then is preventing me for now. Anyway, that is my personal experience, having difficulty finding and trusting information and not knowing what’s best for the development inside of me, and I would like to participate as a patient perhaps to get the information there.

Kind regards,

Corinne Provoost

Dear Mr Krishnan,

Eltroxin can be taken any time. There are some things that interfere with it’s absorption, namely soya, iron and some indigestion tablets. Calcium and other vitamin tablets can really be taken at any time.

Yours sincerely,

Professor JH Lazarus

27/09/2007

SIR,

SHOULD ELTROXIN BE TAKEN IN EMPTY STOMACH EARLY MORNING OR IS IT OK TO TAKE IT 30 MINUTES BEFORE FOOD ? CAN CALCIUM & OTHER VITAMIN TABLETS BE TAKEN AFTER FOOD ?

Dear Ms Stoppard,

You indicate that your TSH was 6, which is slightly higher than normal, but not probably a level which requires treatment with thyroxine. You do not say what your serum thyroxine level was, or whether you have thyroid antibodies. If you have thyroid antibodies your thyroid function should be monitored every six months or so. Unfortunately some people who do stop smoking do put on weight and have symptoms, I think the kind of doctor you see initially is a General Internist.

Yours sincerely,

Professor JH Lazarus

27/09/2007

I am a 50 yr old female who had been quite happy and healthy until seven years ago when after 20 years of smoking, I quit. Within 4 months I had gained 35 pounds, started having periods that lasted 3 weeks with heavy bleeding and clotting, (all new symptoms) my gums bled when brushing my teeth, I was very tired, depressed (needed to cry for 15 minutes in the shower every morning for no reason before going to work). I was very very tired, with very low energy. My thinking, memory and alertness had deteriorated an alarming degree. I was always hot and sweated profusely. The heavy bleeding was checked by a gynecologist I had no fibroids or cancer and without treatment it eventually stopped being so irregular. It was found out that my TSH was 6. I was put on the lowest Sythroid .50 and was checked periodically. The TSH levels were sometimes 2 and sometimes 8 even though I took the pill every night before bed. I had these symptoms for over 2 1/2 years and decided that since all this happened when I quit smoking “cold turkey” maybe it would correct itself if I went back to smoking. Stupid but deperate reasoning and unbelievably it helped by about 60%. I quit taking the Synthroid and there was no difference noted. My only complaint now is how tired I get and my lack of energy.

My question is: What type of doctor should I see (I hope you don’t say psychiatrist) and do you have any idea as to what my problem is?

Thank you.

Dear Ms Crownover,

It is possible to be allergic to throxine. It is certainly usual. One option would be to change the tablet maker. There are other pharmaceutical companies in America that make thyroxine. It may not so much the actual thyroxine but the one or more of the components used in the manufacture. An alternative is to take tri-iodothyronine. This is less satisfactory, but in the circumstances it may be the only option. Sometimes the symptoms of an allergic reaction can be confused with hypothyroid (under-active thyroid symptoms) although a rash is not usual with those.

Yours sincerely,

PROFESSOR JH LAZARUS

21/09/2007

Dr. Lazarus:

My daughter had a complete thyroidectomy a few weeks ago, one nodule on each gland which were cancerous. She was started on thyroxin (levoxthryoin) and seems to be allergic to the medication (this according to the allergic reaction stated on the patient information sheet given by the pharmacist). SHe spoke to the pharmacist who informed her that she did seem to have the allergic reaction as listed. The sheet said to see her Dr immediately if she had certain symptoms (rash, muscle pain, etc). Her Dr says no one can be allergic to thyroxin and he won’t see her until her return scheduled appointment but she is getting more sick daily. Dr also told her to quit reading the infomation sheet as they mean nothing. Please address the issue of allergic reaction to thyroxin and what should be done and how quickly should she be seen and the medication adjusted?

A quick response will be much appreciated.

Karen

21/09/07

Dear Ms Colwell,

You are correct that there are some medications (certianly not all) where grapefruit juice is not advisable to drink. This is not true with Synthryoid. I believe you are quite safe to drink grapefruit juice with this medication.

Yours sincerely,

Professor JH Lazarus

20/09/2007

Hello –

we have all heard that Grapefruit juice is not advisable to drink when taking medications. Is this true with the medication “Synthroid”? Would like to drink it but I do not want to negate the benefits of the medication.

Thanks for your help

Susan Colwell

Dear Ms Hunter,

Clearly your hypothyroidism has been helped with synthroid. Firstly you need to be sure that 100 mcgs of Synthroid is the proper dose for you and this should be checked with a blood level of TSH and also T4. Although your ANA is positive at 1:80, this is not a very high titre, but does raise the possibility of other connective tissue disease, although sometimes ANA can be positive in patients with Hashimoto’s thyroiditis which is probably what you have. I do not believe your urinary frequency and chloride levels are related to your thyroid. You require a work up for connective tissue disease and a work up for all aspects of renal function.

Yours sincerely,

Professor JH Lazarus

18/09/2007

Dr. John,

I was diagnosed with hypothyroid after going a year feeling terrible. I thought after I was diagnosed that finally I would get better yet I seem to be getting worse. My TSH was 5.75 not too high but it certainly showed that I was hypo. I started treatment in March of this year. My symptoms included: sore throat, problems swallowing, high cholesterol, weight gain, I was so tired I began sleeping 12-14hrs a day and urinary frequency. I also develop a metallic taste in my mouth (kind of halitosis). I was also very constipated. I was treated with 50mcg of synthroid and after a few months moved up to 100mcgs. The constipation, cholesterol are better and the weight gain has halted yet all the other symptoms are worse. The urinary frequency is so bad I go to the bathroom all the time, my internist thinks my kidneys are being strained. I had blood work done and my ANA was positive at 1:80. My CO2 levels were low and my chloride levels were high. Do you think my thyroid is the problem? I am 27, healthy, 137 (I was 125 before my thyroid became a problem). I eat well, I don’t smoke and I don’t drink. Any help you could provide would be appreciated.

Dear Ms Boyer,

Your original TSH level of 3 was within the normal range, therefore it is liable to fluctuation and is now a little less than that. You possibly have thyroid antibodies and that’s why your endocrinologist thought your thyroid might be failing. You also need to see what the serum level of thyroxine is. Tests should probably be done in three to four months.

Yours sincerely, Professor JH Lazarus

18/09/2007

I have been feeling miserable.I saw an endo for thyroid and said that my tsh level was 3 and that my thyroid was in the process of failing. retested in 6 weeks and now thyroid is normal. can you tell me why this could have happened? any help would be greatly appreciated.

thanks

kay

Dear Mr Hughes, The stabilisation of your thyroxine administration is normally done by checking the TSH and T4 while on a specific does of thyroxine. It may be necessary to increase the dose, but only within the confines of the numbers generated by the tests. The dose may vary from time to time as absorption of thyroxine could vary depending if any other substances are taken to affect this. It is very unlikely that your condition of hypothyroidism will be reversed.

Yours sincerely,

Professor JH Lazarus

17/09/2007

Good evening

I hope you don’t mind me contacting you, but I have been diagnosed with hypothyroidemia for almost 3 years. During that time I’ve seen my GP and an endocrinological consultant at Morriston Hospital. I have been prescribed Thyroxin with doses that have been regularly increasing and occassioanlly decreasing, but there still seems to be a problem in trying to stabilise the condition I was discharged from Morriston Hospital yet after some weeks the symptoms returned. I’m having great service and support from my GP.

A few personal facts I am male, 59 years of age, currently taking 150mg thyroxin per day (the highest I have taken) and before this condition was dignosed, I had never been to see my GP about any other ailment (only my name and address was on record at that time), and otherwise consider myself to be quite physically fit and active Are you able to suggest anything that I may be able to do to stabilise (or even reverse) this condition.

Many thanks in anticipation

Les Hughes

Dear Ms Joshi,

I think your doctor was right to advise you for further thyroid tests and if the TSH is at that level or higher, you should take thyroxine. Your current tests do not indicate definite hypothyroidism, so I would not be too concerned. At this stage of pregnancy the baby is making it’s own thyroxine, although it does still need some from the mother.

Yours sincerely,

Professor JH Lazarus

11/09/2007

Hi Doctor,

I am 28 weeks pregnant and 26 yrs old. In my recent blood report TSH level has been found high at 4.46 .Free T4 is at 0.9 and Antibody Screen is Negative. Doctor has advised me for further Thyroid tests.I have read on internet that problems related to thyroid can lead to low IQ child.This is my first child.Pls advice.

Thanks Aditi

Dear Mr Barakat,

You should certainly have your serum TSH and serum thyroxine (T4) checked on the dose of 125. If you are on slightly too much thyroxine the sugar levels could be altered, so it is a question of establishing exactly what dose of thyroxine you need to be on. If you do not have papillary cancer, you do not need to have a very low TSH. On the other hand if the nodules had turned out to have cancer then you need to be sure that the TSH is low or suppressed.

Yours sincerely,

Professor JH Lazarus

11/09/2007

I had my thyroid glands completely removed back in May to suspicious nodules for papillary cancer. I have been on replacement hormones. Since the surgery I have noticed a drastic change in my blood sugar levels. My BS used to be in the mid 80s in the morning but now is in the high 90s and low 100s. Also, before the surgery, I was the type who perspired very little even after a hard work out in the summer. But now I’d sweat profusely and with minimum physical work. I started with 150 mg but now I am on 125. I have headaches and muscle aches most of the time.

pls advise.

Dear Ms Ashe-Wallace,

I am not sure exactly which measurement you are talking about and what the normal range is because assays vary across the world. It sounds as if it was T4. I think actually you said it was 1.85 and now is 2.15. If this is TSH then it is still normal.

Regards,

Professor JH Lazarus

Carbimazole

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 10mg daily. I am feeling very well and able to live a full and active life. La st test results l.4 TSH : 11 T4: 4.4 T3. I have tried coming off twice b ut symptoms return and will continually try to reduce or come of this drug if blood test results allow. If this is not possible what are the lo ng term consequences of staying on cambimizole compared to the multitude of cases I have heard of and read about that have had disastrous results for RAI treatment and the resulting hypothyroidism. I understand the risk of a sore throat and the need to have a immediate test but would like to kn ow what other risks are involved in long term use of this drug. Does diet and stress reduction play any part if reducing symptoms?

Many thanks

Jane Sinclair

Dear Ms

Sinclair,

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

Dr. John Lazarus,

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. 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)
  • ANA Negative
  • Antithyroglobulin Ab < 20 (0-40)

Okay, so after this long story, here is my question. I’m going to see an Endo in Columbus Ohio at the Ohio State University. Her name is Dr. Elizabeth Diakoff. I’m confused as to how I can have Hashimoto’s Disease with no antibodies present in my body? Also, my primary care doctor has not started me on any thyroid medication because he said my thyroid is working just fine and he is not going to give me anything until it isn’t. The surgeon explained that I needed to be on thyroid medicine so that the left side of my thyroid did not work too hard and become enlarged. I’m confused as to why this was not started as soon as I was out of surgery. I am not feeling better at all. My neck is still swelling and I am still getting the tender throat and the sore throat, so I know the thyroiditis is still there. Plus the SED Rate being elevated tells me that as well. I still feel exactly the same as I did before the surgery. Actually, I didn’t expect to feel any different. But to know that I’m not nuts and to actually have a “diagnosis” is very comforting. It was just a shame that it took cutting open my throat to get that diagnosis. I wish more doctors would “listen” to how we feel and not go by the numbers. I’m not real familiar with this disease. My Primary Care Doctor is treating it like it is Viral Thyroiditis because of no antibodies in my blood. But I’ve read that you can still have Hashimoto’s with no antibodies. I’m just going by what the pathology report said. And when I research lymphocytic thyroiditis, it takes me to Hashimoto’s. My tonsils are very large and trap a bit of bacteria. I do get sore throats frequently. My dr. believes that I am getting Strep which is traveling down to my thyroid which is causing the thyroiditis. He put me on a month supply of antibiotic, but this has not helped. Any suggestions? What should I ask when I go to my appointment? Should I demand to be put on some medicine even though my labs are normal? What will be my options? Should I just have the other side removed?? 20 I’m so tired of feeling sick. It’s been five very long years.

Thank you so so much for taking the time.

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

Graves’ Disease

Hello,

I was diagnosed with Graves’ disease two years ago (September 2005) (can’t remember the numbers, but my pulse was over 120 resting, I was jittery and uncontrollably emotional/irritable, lid lag, the whole nine yards of symptoms shown to the nth degree). My T4, at that time was over 8, T3 was about 6x normal range and TSH was unmeasureable, with thyroid uptake scan showing about 88%). I was treated with I-131 to ablate my thyroid in December 2005. The pre-ablation ultrasound used to determine an approximate dosage showed a normally-sized thyroid, so they calculated 6 microCuries and that’s what I received. The radiologist said I could still have hyperthyroidism, it could be low or I could be euthyroid after the treatment. It’s now two years later; my TSH is still fluctuating between 0.05 and 0.1, but my T3 and T4 are absolutely normal and I feel great–I mean I feel 100% of myself. My endocrinologist is now starting to suggest that because the therapy was failed that I need to have a repeat ablation therapy to stave off another course of Graves’ disease…and another thyroid storm. I will do it if I absolutely have to, but since I was not diagnosed with cancer, I feel GREAT (for 53 years old…active with horses and dogs and dog shows and horse training), I am utterly post-menopausal and am not on hormone replacement therapy, and my lab results have been VERY stable (I am a MT..to me the TSH fluctuation could very well be due to hormonal or analyzer fluctuation) since about 5 months after the ablation therapy, I am really resistant to the idea. I have not had to take ANY thyroid medication of any kind. I am on simvastatin (low dose) and HCTZ, 25mg PRN…I have been taking it daily on the advice of my endocrinologist (cholesterol high at 235, normal at 208 for me, and never low in the past 20 years….it’s familial through my Dad’s line). I’ve done a lot of research on the internet, but I have not found anything that conflicts with my desire to NOT repeat the ablation therapy. I really don’t care that the therapy failed according to the medical definition of ‘failure’ in this case; I know I feel great, I have great, but not inappropriate, energy, and my lab results are normal with the exception of the decreased TSH…..I want to, and WILL say, “no”, unless I find VERY convincing evidence that I am endangering my health by not repeating the RAI. Do you have any evidence (and how strong is it) that says I NEED to repeat the ablation? I do NOT want to kill off all my thyroid altogether right now if I don’t HAVE to. All the documentation I have found says that it’ll eventually probably decrease to zero over the next 8-10 years, but that data was published in 2000. Can’t I just worry about it when it happens? What is the risk that my horrible symptoms will come back?

Thanks for answering this Hoosier.

Dear Ms

Thank you for your email.

You have had radioiodine and your T3 and T4 are absolutely normal. Therefore I would not be concerned with your TSH levels. They can remain low in Graves’ disease for quite some time. They do usually return to a normal level after two years or so. Nevertheless I do not believe there is any specific indication for a repeat radioiodine and I would agree with you that if you feel well I do not believe there is any indication for a further therapy. There is a concern that people with low TSH levels may be at risk of cardiac arrhythmia and bone loss. What I would suggest is that you check your TSH every six months or so and arrange a bone dexa scan in a year if it is still on the low side. At that time it may be worthwhile having a 24 hour holter monitor tape to check for average heart rate, but once again I would certainly not administer radioiodine at this time.

Yours sincerely,

Professor JH Lazarus

Goitre

18/10/2007

Dear Sir/ Madam,

I have a Retrosternal goitre, diagnosed approximately 6 yrs ago, and asymptomatic of this. A Fine needle biopsy showed a benign multinodular goitre with a tracheal deviation to the left. All TFT’s were within normal range, and was advised to monitor the growth regularly, and check TFT’s. 14 months ago I suddenly began to experience pain bilaterally in the Achilles tendon area. This would start first thing in the morning after being in bed overnight. I had to adopt this shuffling gait until I.’Warmed up’ approximately 2 – 3 hrs, now the stiffness never actually never leaves me. I now find that if I sit for a period of time ( 15 – mins. ), I am as bad as I am first thing in the mornings. ( My husband affectionately calls me the ‘Penguin’ in the mornings.) Plus, my gait pattern, even at the end of the day is ..a conscious effort to walk as normal as the people I am passing by. I have NO history of Back Pain or any other soft tissue trauma.’ Overall, It’s getting worse, ( which is why I am writing to this website) I am now experiencing a type of Laryngeal Stridor ,this occurs if I tuck my chin down into my chest.to apply jwellrey, style hair etc. etc and if I do any moderate physical activity…such as going for a brisk walk or climbing stairs…surely not too much to expect from an otherwise healthy, 175 cm tall / 69kg 50 yr old !! The size of the goitre appears not have grown to much, but the Achilles Tendon / shuffling gait / stiffening up after only a short period of sitting has me totally confused. My GP perceives it as an ‘Injury’ that I do not remember doing.but bilaterally ??? plus I have not done any moderate or extreme exercise to cause this type of injury,(I walk our dog, but not on uneven surfaces or the beach, and tentatively, trying to present a ‘Normal gait Pattern’ to the public at the same time…) however, my GP did admit that to injure the Achilles Tendon’s bilaterally did not quite fit the picture. Incidentally, a recent TFT was abnormal.raised I believe, but only slightly.. Some other symptoms may include..anxiety, weight gain..or am I going mad ??

Dear Ms

I do not think that your bilateral achilles tendon pain is related to anything to do with your thyroid. It sounds like a rheumatological problem or clearly connective tissue disorder. As far as your thyroid is concerned, it sounds as if your retrosternal goitre has indeed enlarged a bit and, most importantly, because of your abnormal thyroid function you are mildly thyrotoxic. Because of the enlargement and because of the overactivity, it would seem to me that you need to have surgery to this goitre. You should not have surgery if your thyroid tests are high. You should start on antithyroid drugs until the tests are normal and then have the surgery.

Yours sincerely,

Professor JH Lazarus

Thyroidectomy

15/10/2007

Dear Dr. Lazarus,

Hope you are doing well. I have a thyroid related question for you. In Aug 2006 I had a partial thyroidectomy. I had this procedure because after I had my second child I developed a goiter and my endocrinologist attempted to shrink or stop its growth by having me take synthroid. That never worked, so after a year of that I decided on surgery. At that time and now my blood tests for thryoid levels have always come back NORMAL. However, I have been taking 50mcg of Synthroid ever since my surgery. My questions for you are: 1) My doctor says I will need to take synthroid forever. Is this true? (I don’t have thyroid disease, but she thinks I should continue synthroid to prevent another goiter). 2) Would having another child affect my thyroid? Would it make me get thyroid disease or possibly another goiter where I might have to have a total thyroidectomy? 3) What are the long term effects of taking synthroid at the dosage I’m taking? Do those who have had a partial thyroidectomy eventually develop thyroid disease?

Thanks so much for your time. I appreciate your feedback.

Dear Ms

After your partial thyroidectomy you have been taking Synthroid without affect. It is not clear what the diagnosis is and what the histology of the thyroid was when it was removed. The answers to your questions are: (1) Synthroid is probably not necessary to take for ever, it does not always prevent the recurrence of goitre, but your thyroid levels should be checked regularly. (2) Having a child can affect the thyroid but it is not clear whether it would affect yours. If you have thyroid antibodies then there is a possibility that it could be affected but it would be unlikely that you would require a further operation on the neck. (3) The long term effects of taking Synthroid at the dosage you are taking are nil or minimal. It is unlikely that you would develop further thyroid disease having had a thyroidectomy for what is called a non-toxic goitre. However one cannot absolutely guarantee that recurrence of a goitre would not occur even when one is on Synthroid.

Yours sincerely,

Professor JH Lazarus

Dear Mr Stinson,

You say that you had a recent diagnosis of hyperthyroidism, but that six years ago you were diagnosed with hypothyroidism. However, you do not cite any evidence of hyperthyrodism. Your FT4 was only just above the normal range and your T3 and TSH were also normal, indicating very probably euthyroidism (normal thyroid function). It is true that some patients with hypothyroidism can develop hyperthyroidism at a later stage of their illness. This is an autoimmune situation. You do not say whether you have thyroid antibodies as a cause for your initial hypothyroidism. It now appears that your hypothyroidism has resolved, which is unusual but not unknown. Clearly you should have regular thyroid function tests including antibodies to check that all is well. The other factor is that you have had high blood pressure and been on therapy for that and this may have affected some of your symptoms. In relation to your specific questions: (1) When you obtain thyroid function tests having been off Synthroid for at least six weeks the doctor will be able to be in a position to indicate whether there is any specific abnormality. If, for example your thyroid hormones are above the normal reference range and you have a measurable TSH, then indeed some of these rare conditions you cite should be checked. However, from the information you give, I think that these are unlikely. (2) The TSH is a sensitive test for hyperthyroidism and if it was not low or suppressed at the time of measurement then you are very unlikely to have been hyperthyroid. (3) As far as I know there is no specific interaction between 5 or 4 ASA and thyroid hormone.

Yours sincerely,

Professor JH Lazarus

15/10/2007

Dear Dr. Lazarus,

I have a question regarding my recent diagnosis with hyperthyroidism. I will give you a bit of background on my situation first. Approximately 6 years ago I was diagnosed with Hypothyroidism (my first year in University) and put on Levothyroxine Sodium. My dosage was adjusted until my TSH was normal. The high reading was approximately 19 mIU/l (not sure on the units). I remember feeling very tired and depressed and snapped out of it when being put on the medication. My TSH was checked once every 3 or 4 months that year and after that only once per year.

Approximately one year after being put on the Synthroid I was put on medication for hypertension that was discovered before going in for surgery (a hernia from a previous bowel resection). My high blood pressure seemed to fluctuate a lot but it was consistently high enough to be put on medication in my doctors opinion (ranging from 130/80 to 165/85). It seemed to be fairly consistently systolically high which in my understanding could indicate hyperthyroidism, but my TSH was normal.

Since I started working full time after University I have been having increasingly worse anxiety which had developed into a severe depression. I finally realized something was wrong at the end of June this year when nothing I was doing was helping. I was put on antidepressants without being checked out medically first (Effexor 37.5 mg) and one pill kept me awake for 48 hrs. I could feel the effects probably 15 minutes after taking it which were not pleasant. My Dr. thought this could be an indication that I was Bipolar and wanted to put me on a heavy medication for that (I cannot remember which one). I told him that I wanted to be medically evaluated first before any more medication.

My tests came back indicating that my free T4 was approximately 25 pmol/l (not sure on the units) my T3 was normal and my TSH was also normal (under 1 but still in the normal range). He told me to stop the medication cold turkey which I did. My dosage was 75 mcg/day. I could feel the effects the afternoon of the day I stopped which were not unpleasant. I felt better than I had been feeling. I had been nauseated in the mornings for at least 2 months prior to the visit to the Dr. with extreme anxiety and depression as well. Prior to this episode of extreme anxiety and nausea I had also been taking 3 grams of Pentasa (5-ASA) for Crohn’s disease, which I discontinued in February 2007 (the nausea started around the end of march) on the advice of my gastroenterologist. I had also been taking 20 mg/day of Vasotec (Enalapril Maleate) and a multivitamin daily, both of which I continued.

After being taken off the Synthroid cold turkey I started to have extreme emotions that I couldn’t seem to control. I had uncontrollable crying for multiple days and went to see another Dr. who put me back on a lower dose of Synthroid which seemed to help a lot. it has been approximately 3 months since that initial dosage stop of Synthroid with a period of approximately 1 month on 18.75 mcg/day (1/4 of my 75 mcg pill). Through this time I began to feel light headed and was on a vacation with no contact with my doctor so I cut my vasotec dosage in half (after checking my blood pressure which was now consistantly around 115/60). After returning home I totally quit my synthroid and blood pressure medication (on my doctors advice) and have been off them since then with my thyroid function normal and blood pressure consistanty 120-130/70-80. I will add that when I stopped the vasotec (both cutting down and completely stopping it) it felt like a huge weight had been lifted from my chest. I could run without becoming out of breath and could no longer feel my heart pounding on small exertions.

After that background information I have a few of specific questions:

1) Is it possible that I could have some sort of disorder of the pituitary gland (either selective tissue resistance of the pituitary to thyroid hormone or a TSH secreting pituitary adenoma) considering my TSH has been consistantly normal for the past 6 years (since my original dosage adjustment of Synthroid) and my free T4 has recently been discovered to be elevated? I will add that I think I may have always been slightly hyperthyroid. I think it has presented itself now after I started full time employment and no longer have the time to recover both mentally and physically from it. My whole perception has changed since stopping the synthroid and I don’t really have a normal reference point to judge how I feel anymore.

2) Since no tests other than TSH were done until July of this year, is it possible that I have been slighlty Hyperthyroid for that time? If that is the case could I have developed some heart problems or other problems as a result? I didn’t realize a lot of symptoms that I was having until they went away. I used to consume huge quantities of food (and juice, I used to drink approximately 2.5 litres of pure grape juice a night) and not gain any weight with little no exercise.

3) I have a specific question regarding 5-ASA since my symptoms seemed to worsen after I stopped the medication. Is it possible that there is an interaction between Synthroid and Pentasa (5-ASA) that disappeared when I stopped taking the Pentasa and as a result caused me to be essentially overdosing on synthroid daily? I know that there is a documented interaction between some salicylates and synthroid but I was wondering if 5-ASA falls into that category. I know there are documented cases of 4-ASA causing Hypothyroidism. Is it possible that the isomer 5-ASA (which I was taking) either has a similar effect (no cases that I can find) or the manufacturing process of the Pentasa produces some 4-ASA with it and this is what had originally caused me to become Hypothyroid in the first place?

I realize that some of these questions may seem fairly far fetched but my experiences in the past year have been not pleasant and I really want to figure out what is going on with me.

Thank you for your time and I hope you are able to take a look at my concerns.

Jon

Dear Ms

Nagula,

If you are definitely suffering from hypothyroidism then you require a full replacement dose of thyroid hormone. The amount to take depends on the blood test and how you are feeling. If you take the correct dose the symptoms you are complaining of should disappear. Sometimes it takes more than two months. I also do not have an explanation for the pain in throat and hands, and it may be that after you have taken treatment for three months or so you should have another examination if there are still things wrong. There may be another condition from which you are suffering.

Yours sincerely,

Professor JH Lazarus

Thyroid replacement therapy

Dr. Lazarus:

Thyroid is a very confusing issue and I, after taking thyroid meds for almost ten years am still confused. I have a doctor that only uses tsh to calculate. Six months ago I had a tsh at of .27 and doc was concerned that I was too low. Cut my Armour back to 45mg. Six months later my tsh is 3.57 and I have been suffering from headaches, neckaches, heartburn, some insomnia and slight depression, all of which I don’t know relate to the thyroid at all. I don’t know what to do. Should I go back to taking the whole grain or should I take 3 and 1/2 –15mg tablets?? This is an extremely confusing situation. My numbers have never ever remained steady and I don’t know if my body is suffering because of the constant change of doses. Do you have any suggestions for me?

Thank you.

Dee Ohio

Answer

Dear Ms

Although Armour may suit a few people it is generally accepted that thyroxine alone (ie T4) is the optimal replacement therapy for underactive thyroid (hypothyroidism). Armour has T3 in it Which is actually made from T4 and this makes it a bit more difficult to assess in the long term. TSH is certainly useful to assess but the T4 and even the T3 level can also be useful on occasions. I do not think a TSH of .27 is significantly low, and if you feel better on the original dose I would make a case for going back to it. You should also be aware that some substances eg soya, iron and some indigestion remedies can affect the absorption of thyroid hormone into the body which or course may alter the levels of TSH.

Yours sincerely

John Lazarus

Hypothyroidism and pregnancy

My husband and I are trying to conceive and I have Hypothyroidism-I was diagnosed shortly after birth (at 29 weeks) and have been on a regimine of eltroxin ever since (ranging from 0.1 to 0.137 at present-Synthroid didn’t agree with me and made me retain more water). There have been several changes with my dose in the past 5 years because I’ve been complaining of increased fatigue, unexplained weight gain, shortness of breath after walking short distances, etc. Despite several requests for a referral to an endocrine clinic, I’ve resolved to regular blood tests. I’ve wanted to make sure everything was “in order” before we started trying…I was told by my new GP that my condition shouldn’t be a problem so we went ahead. Recently, I’ve been reading up (which can be both a good and bad thing) and the information has been more disturbing than promising regarding my ability to conceive and have a healthy pregnancy… FYI, my most recent results during the past six months have floated around 1 and 0.887 for my TSH and free T4… Do you have any suggestions?

Answer

Your current thyroid test results seem reasonable. There is certainly no contraindication to getting pregnant while on thyroxine therapy. Most (but not necessarily all) women need an increase in thyroxine dose during pregnancy. The best thing to do is to increase by 50 micrograms once you know you are pregnant, then wait for a month and then have a thyroid test. (NB If you test before a mont the results are misleading). The dose of thyroxine can then be adjusted as necessary to keep the TSH value around 1. Thyroid function needs to be tested at least once in every trimester. After delivery you should immediately go back to your usual dose. There is no probem in breast feeding when on thyroxine. I think this is probably all you need to know at present.

If there is anything else please mail.

Cancer and radioiodine therapy

I underwent a tt last week for what was found to be stage 1 papillary follicular variant carcinoma. Right lobe 1 lesion 9x5x3mm. Left lobe 2 lesions 1mm and 4mm. Negative nodes.Cleardissection/margins.7year history of Hashimotos multinodular which was monitored annual by US. Endo discovered right lobecarcinoma on routine US followed by FNAB. I’m 41yrs old. No family history of thyroid disease or any autoimmune disorder. No history of irradiation. No other health problems, excellent physical health/condition.

I would like to have your opinion on whether RAI ablation would be more beneficial than harmful to me and, if so, what dose you would recommend. My surgeon said she would do it, even if it had been unifocal. My endo said he would not, even though it is multifocal,and would monitor by US/TSH. I am in Wash DC and my doctors are assoc’d w/Georgetown, George Washington and Washington Hospital Centers. My endo indicated that if I were at Mayo or Sloan, they would probably advise against RAI. Washington Hospital Center would be pro RAI. He said the trend for Stage 1’ers is moving away from routine RAI. Possible radiation-related consequences outweigh benefits of ablation. If I am convinced I want it, he suggested a smaller dose. Is 30mci sufficient for ablation? I had a skilled surgeon. Estimated that I may have apx 5percent thyroid tissue remaining.

Thanks much in advance for your opinion and happy holidays.

Answer

Dear Ms

You are in good hands at Georgetown. I would have a radioisotope scan in due course and if there is any uptake in the neck I would have 30mci. This is enough to ablate a trace uptake and should not cause any significant side effects. You are right that my colleagues in the Mayo are generally against giving radioiodine in this situation based on their very long term experience. I would tend to give it in your case because you had multifocality of disease and also i would feel more confident of follow up with measurements of serum thyroglobulin.

Yours sincerely

Hashimoto

I was diagnosed with Hashimoto’s hypothyroidism over 20 years ago and for the past 10 to 15 years I have had over 6 endocrinologist’s and have had a constant struggle with weight gain and getting my thyroid levels to be consistant. My current endocrinologist has come to the conclusion that I have been overmedicated for over 2 years now. I was on synthroid and my dosage I was on was .137mcg twicea day. I had been on that dosage for over 2 years. My TSH has been 0.01 for over 2 years and no one has ever questioned whether or not I was taking too much. I am now taking .137mcg one a day and will have my bloodwork redone in 6 – 8 weeks to see if any of my levels have changed. I would like to maybe someday feel like a normal person and have energy that lasts more than 2 hours and was able to drop the 50+ pounds I have gained in the past 10 years. I am now at my heaviest weight ever and am getting very depressed and am seeking some help. I have been going to the gym at least 4 days a week and instead of losing weight i have gained weight. I have tried every diet possible with no avail.

PLEASE IF YOU CAN GIVE ME ANY KIND OF DIRECTION POSSIBLE I WOULD WELCOME ANY SUGGESTIONS.

PLEASE HELP!!!!!!!!!!!!!!!!!!

I am going to 50 years old this year and I feel like I am 90 years and am looking like I have aged more than I should in the last couple of years. I AM DESPERATE.!!!!!!!!!!!!!!!

Thank you for listening

Answer

Certainly there is no benefit in taking thyroxine twice a day. The drug lasts a long time in the body. In addition to checking your TSH your T4 and possibly your t3 level should be checked. It is quite reasonable to have a T4 level above the normal reference range when on T4 therapy but the T3 level should be within the normal range. The TSH should be about 1 .. a bit less is also ok. If your thyroid levels are ok your body should respond to calorie restriction ie dieting. Some other autoimmune diseases are associated with Hashimoto’s eg Celiac and Addisons and Diabetes. If necessary these should be checked for.

QUESTION: DURATION OF TREATMENT WITH CARBIMAZOLE

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 10mg 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 of cases 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 if reducing symptoms?

Many thanks Jane Sinclair

RESPONSE:

Dr Ms Sinclair,

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

QUESTION: NEED FOR RE-TREATMENT WITH I-131

I was diagnosed with Graves’ disease two years ago (September 2005) (can’t remember the numbers, but my pulse was over 120 resting, I was jittery and uncontrollably emotional/irritable, lid lag, the whole nine yards of symptoms shown to the nth degree). My T4, at that time was over 8, T3 was about 6x normal range and TSH was unmeasureable, with thyroid uptake scan showing about 88%). I was treated with I-131 to ablate my thyroid in December 2005. The pre-ablation ultrasound used to determine an approximate dosage showed a normally-sized thyroid, so they calculated 6 microCuries and that’s what I received. The radiologist said I could still have hyperthyroidism, it could be low or I could be euthyroid after the treatment.

It’s now two years later; my TSH is still fluctuating between 0.05 and 0.1, but my T3 and T4 are absolutely normal and I feel great–I mean I feel 100% of myself. My endocrinologist is now starting to suggest that because the therapy was failed that I need to have a repeat ablation therapy to stave off another course of Graves’ disease…and another thyroid storm.

I will do it if I absolutely have to, but since I was not diagnosed with cancer, I feel GREAT (for 53 years old…active with horses and dogs and dog shows and horse training), I am utterly post-menopausal and am not on hormone replacement therapy, and my lab results have been VERY stable (I am a MT..to me the TSH fluctuation could very well be due to hormonal or analyzer fluctuation) since about 5 months after the ablation therapy, I am really resistant to the idea. I have not had to take ANY thyroid medication of any kind. I am on simvastatin (low dose) and HCTZ, 25mg PRN…I have been taking it daily on the advice of my endocrinologist (cholesterol high at 235, normal at 208 for me, and never low in the past 20 years….it’s familial through my Dad’s line).

I’ve done a lot of research on the internet, but I have not found anything that conflicts with my desire to NOT repeat the ablation therapy. I really don’t care that the therapy failed according to the medical definition of ‘failure’ in this case; I know I feel great, I have great, but not inappropriate, energy, and my lab results are normal with the exception of the decreased TSH…..I want to, and WILL say,”no”, unless I find VERY convincing evidence that I am endangering my health by not repeating the RAI.

Do you have any evidence (and how strong is it) that says I NEED to repeat the ablation? I do NOT want to kill off all my thyroid altogether right now if I don’t HAVE to. All the documentation I have found says that it’ll eventually probably decrease to zero over the next 8-10 years, but that data was published in 2000.

Can’t I just worry about it when it happens? What is the risk that my horrible symptoms will come back? Thanks for answering this Hoosier.

Pam in Kokomo, IN, USA

RESPONSE:

Dear Pam,

Thank you for your email. You have had radioiodine and your T3 and T4 are absolutely normal. Therefore I would not be concerned with your TSH levels. They can remain low in Graves’ disease for quite some time. They do usually return to a normal level after two years or so. Nevertheless I do not believe there is any specific indication for a repeat radioiodine and I would agree with you that if you feel well I do not believe there is any indication for a further therapy.

There is a concern that people with low TSH levels may be at risk of cardiac arrhythmia and bone loss. What I would suggest is that you check your TSH every six months or so and arrange a bone dexa scan in a year if it is still on the low side. At that time it may be worthwhile having a 24 hour holter monitor tape to check for average heart rate, but once again I would certainly not administer radioiodine at this time.

Yours sincerely,

Professor JH Lazarus

QUESTION: WHAT TO DO ABOUT A RETRO-STERNAL GOITER

I have a Retrosternal goitre, diagnosed approximately 6 yrs ago, and asymptomatic of this.

A Fine needle biopsy showed a benign multinodular goitre with a tracheal deviation to the left. All TFT’s were within normal range, and was advised to monitor the growth regularly, and check TFT’s.

14 months ago I suddenly began to experience pain bilaterally in the Achilles tendon area. This would start first thing in the morning after being in bed overnight. I had to adopt this shuffling gait until I.’Warmed up’ approximately 2 – 3 hrs, now the stiffness never actually never leaves me. I now find that if I sit for a period of time ( 15 – mins. ), I am as bad as I am first thing in the mornings. ( My husband affectionately calls me the ‘Penguin’ in the mornings.) Plus, my gait pattern, even at the end of the day is ..a conscious effort to walk as normal as the people I am passing by. I have NO history of Back Pain or any other soft tissue trauma.

Overall, It’s getting worse, ( which is why I am writing to this website)

I am now experiencing a type of Laryngeal Stridor ,this occurs if I tuck my chin down into my chest.to apply jwellrey, style hair etc. etc and if I do any moderate physical activity…such as going for a brisk walk or climbing stairs…surely not too much to expect from an otherwise healthy, 175 cm tall / 69kg 50 yr old !!

The size of the goitre appears not have grown to much, but the Achilles Tendon / shuffling gait / stiffening up after only a short period of sitting has me totally confused.

My GP perceives it as an ‘Injury’ that I do not remember doing.but bilaterally ??? plus I have not done any moderate or extreme exercise to cause this type of injury,(I walk our dog, but not on uneven surfaces or the beach, and tentatively, trying to present a ‘Normal gait Pattern’ to the public at the same time…) however, my GP did admit that to injure the Achilles Tendon’s bilaterally did not quite fit the picture.

Incidentally, a recent TFT was abnormal.raised I believe, but only slightly..

Some other symptoms may include..anxiety, weight gain..or am I going mad ??

Regards

Sharon Bassell

RESPONSE:

Dear Ms Bassell,

I do not think that your bilateral achilles tendon pain is related to anything to do with your thyroid. It sounds like a rheumatological problem or clearly connective tissue disorder.

As far as your thyroid is concerned, it sounds as if your retrosternal goitre has indeed enlarged a bit and, most importantly, because of your abnormal thyroid function you are mildly thyrotoxic.

Because of the enlargement and because of the overactivity, it would seem to me that you need to have surgery to this goitre. You should not have surgery if your thyroid tests are high. You should start on antithyroid drugs until the tests are normal and then have the surgery.

Professor JH Lazarus

QUESTION: NEED FOR THYROXINE REPLACEMENT TREATMENT

Hope you are doing well. I have a thyroid related question for you. In Aug 2006 I had a partial thyroidectomy. I had this procedure because after I had my second child I developed a goiter and my endocrinologist attempted to shrink or stop its growth by having me take synthroid. That never worked, so after a year of that I decided on surgery. At that time and now my blood tests for thryoid levels have always come back NORMAL. However, I have been taking 50mcg of Synthroid ever since my surgery. My questions for you are:

1) My doctor says I will need to take synthroid forever. Is this true? (I don’t have thyroid disease, but she thinks I should continue synthroid to prevent another goiter).

2) Would having another child affect my thyroid? Would it make me get thyroid disease or possibly another goiter where I might have to have a total thyroidectomy?

3) What are the long term effects of taking synthroid at the dosage I’m taking? Do those who have had a partial thyroidectomy eventually develop thyroid disease?Thanks so much for your time. I appreciate your feedback.Best,

Anna Durrani

RESPONSE:

Dear Ms Durrani,

After your partial thyroidectomy you have been taking Synthroid without affect. It is not clear what the diagnosis is and what the histology of the thyroid was when it was removed. The answers to your questions are:

(1) Synthroid is probably not necessary to take for ever, it does not always prevent the recurrence of goitre, but your thyroid levels should be checked regularly.

(2) Having a child can affect the thyroid but it is not clear whether it would affect yours. If you have thyroid antibodies then there is a possibility that it could be affected but it would be unlikely that you would require a further operation on the neck.

(3) The long term effects of taking Synthroid at the dosage you are taking are nil or minimal. It is unlikely that you would develop further thyroid disease having had a thyroidectomy for what is called a non-toxic goitre. However one cannot absolutely guarantee that recurrence of a goitre would not occur even when one is on Synthroid.

Professor JH Lazarus

QUESTION: NEED FOR TREATMENT OF HYPOTHYROIDISM

im a girl of 17 suffering with hypothoridism.my problem started from a yr. first my limbs were swollened ,then my full swelled it went on for 3 months ,when i consulted our local doc ,he pridicted it to filaria gave medicines for it.even after using them there was no change in my condition .he suggested me to consult a rhemotologist.rhematologist said my nerves are weak and i have a problem in spinal cord &gave me treatment which broght no change in my condition.

at a doc said im suffering from hypothroidism & started treatment .sir nearly from 2months im taking treatment near him .im not yet cured .that gave his hands saying that he could not understand my condition.

i have severe pain in my throat, my hands & legs are swollen

plz doc help me out plz……….

my symptoms:

1.hairfall

2.poor memorary

3.swollen limbs

4.pulffy skin

5.pain in throat & hands docter my life is in your hands plz save me. hope so you can my prodlem

thankyou,

RESPONSE:

If you are definitely suffering from hypothyroidism then you require a full replacement dose of thyroid hormone. The amount to take depends on the blood test and how you are feeling. If you take the correct dose the symptoms you are complaining of should disappear. Sometimes it takes more than two months.

I also do not have an explanation for the pain in throat and hands, and it may be that after you have taken treatment for three months or so you should have another examination if there are still things wrong. There may be another condition from which you are suffering.

Professor JH Lazarus

QUESTION: HYPOTHYROIDISM AND ADRENAL ADENOMA

Is there any link between Hypothyroidism and adrenal adenomas? I had an MRI recently that incidentially found the adenomas and I didn’t know if some how this was linked to my Hypothyroidism. I currently take 125MG daily of generic brand synthroid. My weight over the past 3 years has ballooned from 130lbs to 190lbs. Is there any link to these issues?

Thanks for all your assistance.Shelley Green

RESPONSE:

Dear Ms Green,

There is no definite link between hypothyroidism and adrenal adenoma. Often an adrenal adenoma is a so-called incidentaloma, not related to any other condition.

In addition to the TSH level while you take 125 mgs of Synthroid, you need to also check your T4 level and make sure it is at the top end of the normal range. This may help your weight.

Professor JH Lazarus

QUESTION: BREAST FEEDING WHILE ON PTU

I was diagnosied with Graves disease in June 2006 following the birth of my second son in February 2006. I was told to stop breastfeeding immediately which I did and I was treated with PTU as I had a reaction to the first medicine I was on.. I became preganant again in July, 2006 and was treated for Graves disease using PTU throughout pregnancy. My daughter iwas born in APril 2007. SHe was tested for hyerthyroidism a few days after birth and her levels were fine. However I have been breastfeeding her exclusively until recently when I have started her on solids.(she is just over 5 months) My question is she is very hyper. On average she sleeps for about 45 minutes from 7am till 7 pm. She will sleep for about 3 to 4 hours at night. (wakes at least 3 times during night). She has been like this nearly since birth. I have found out in past 2 weeks that I am once again hyperthyriod and am wondering if my daughter could be slightly too. SHe has not been tested since birth. As her bloods were ok after birth is there any need to have her rechecked.

Thanks

RESPONSE:

Firstly there is normally no problem to the baby when you breastfeed with Graves’ disease even if you are on PTU.

It is very unlikely that your second child is hyperthyroid, but it would be quite in order to have the baby checked just in case. The antibody that stimulates the thyroid could possibly appear in the breast milk. A study has reported this in 2006, therefore you should have your child checked.

Professor JH Lazarus

QUESTION: PHENOBARBITAL AND THYROXINE DOSAGE

I have been prescribed 64.8MG Tablets of Phenobarbital to be taken by mouth twice daily. I have been faithfully taking this medication to treat “space-outs” or mild secondary epilepsy related to meningioma in 2001.

I had successful surgery in June 2001 after a Grand Mal Seizure. However, without the above medication I continue to have “space-outs”. The “space-outs” usually last less than 2 minutes and I have not had a “space-out” in over two months.

My question: Does Phenobarbital contribute to a high thyroid reading? My medical doctor performed the simple blood test for thyroid and he said I had a “high” thyroid reading I do not believe I have any symptoms of hypothroidism.

Thank you.

C. C. Guthrie (60 year old female)

RESPONSE:

Dear Mrs Guthrie,

Phenobarbital can interfere with the metabolism of thyroxine and may precipitate a problem with the thyroid in some individuals. You should probably have one or two readings before making a decision to go on to thyroxine if “high” indicates that your thyroid is failing.

Professor JH Lazarus

QUESTION: WHEN TO TAKE THYROXINE TABLETS

SHOULD ELTROXIN BE TAKEN IN EMPTY STOMACH EARLY MORNING OR IS IT OK TO TAKE IT 30 MINUTES BEFORE FOOD ? CAN CALCIUM & OTHER VITAMIN TABLETS BE TAKEN AFTER FOOD ?

RESPONSE:

Eltroxin can be taken any time. There are some things that interfere with it’s absorption, namely soya, iron and some indigestion tablets. Calcium and other vitamin tablets can really be taken at any time.

Professor JH Lazarus

QUESTION: POSSIBLE ALLERGIC REACTION TO THYROXINE

My daughter had a complete thyroidectomy a few weeks ago, one nodule on each gland which were cancerous.

She was started on thyroxin (levoxthryoin) and seems to be allergic to the medication (this according to the allergic reaction stated on the patient information sheet given by the pharmacist). She spoke to the pharmacist who informed her that she did seem to have the allergic reaction as listed. The sheet said to see her Dr immediately if she had certain symptoms (rash, muscle pain, etc). Her Dr says no one can be allergic to thyroxin and he won’t see her until her return scheduled appointment but she is getting more sick daily. Dr also told her to quit reading the infomation sheet as they mean nothing.

Please address the issue of allergic reaction to thyroxin and what should be done and how quickly should she be seen and the medication adjusted? A quick response will be much appreciated.Karen

RESPONSE:

Dear Karen,

It is possible to be allergic to throxine. It is certainly unusual. One option would be to change the tablet maker. There are other pharmaceutical companies in America that make thyroxine. It may not so much the actual thyroxine but the one or more of the components used in the manufacture.

An alternative is to take tri-iodothyronine. This is less satisfactory, but in the circumstances it may be the only option.

Sometimes the symptoms of an allergic reaction can be confused with hypothyroid (under-active thyroid symptoms) although a rash is not usual with those.

Professor JH Lazarus

QUESTION: GRAPEFRUIT JUICE AND SYNTHROID

Hello – we have all heard that Grapefruit juice is not advisable to drink when taking medications. Is this true with the medication “Synthroid”? Would like to drink it but I do not want to negate the benefits of the medication.

Thanks for your helpSusan Colwell

RESPONSE:

Dear Susan,

You are correct that there are some medications (certianly not all) where grapefruit juice is not advisable to drink. This is not true with Synthryoid. I believe you are quite safe to drink grapefruit juice with this medication.

Professor JH Lazarus

QUESTION: VARIABLE TSH LEVEL

I have been feeling miserable.I saw an endo for thyroid and said that my tsh level was 3 and that my thyroid was in the process of failing. retested in 6 weeks and now thyroid is normal. can you tell me why this could have happened? any help would be greatly appreciated. thanks kay

RESPONSE:

Dear Kay

Your original TSH level of 3 was within the normal range, therefore it is liable to fluctuation and is now a little less than that. You possibly have thyroid antibodies and that’s why your endocrinologist thought your thyroid might be failing. You also need to see what the serum level of thyroxine is. Tests should probably be done in three to four months

Professor JH Lazarus

QUESTION: DIAGNOSIS OF HYPOTHYROIDISM

I am 28 weeks pregnant and 26 yrs old.In my recent blood report TSH level has been found high at 4.46 .Free T4 is at 0.9 and Antibody Screen is Negative.Doctor has advised me for further Thyroid tests.I have read on internet that problems related to thyroid can lead to low IQ child.This is my first child.

Pls advice.

Thanks, Aditi

RESPONSE:

Dear Aditi,

I think your doctor was right to advise you for further thyroid tests and if the TSH is at that level or higher, you should take thyroxine. Your current tests do not indicate definite hypothyroidism, so I would not be too concerned. At this stage of pregnancy the baby is making it’s own thyroxine, although it does still need some from the mother.

Professor JH Lazarus

QUESTION: POSSIBLE HYPOTHYROIDISM?

I was recently diagnosed with a thyroid nodule, I am not sure of the size but I do know it was not that large. My thyroid level was original 0.5, I went back to the doctor a few months ago and it was 0.4, as of last week my TSH is 0.2 uIU/ml. I have gained a significant amount of weight, I gain at least 5 – lbs. a week, I am very weak, tired, my legs are very week and tired, I am tired and I have been dieting and exercising with no results, I am still continuing to gain weight. I don’t know what else to do, my doctor wants to see me back in 10 weeks, I was hoping you can tell me if you think I have mild hypothyroidism.

RESPONSE:

Your TSH level does not suggest that you have hypothyroidism or even mild hypothyroidism. In order to further investigate this you should actually have a T4 and a serum T3 level. Also if there is a nodule you should have a fine needle aspiration biopsy.

Professor JH Lazarus

QUESTION: THYROXINE AND HAIR LOSS

Can Levothyroxine cause hair loss? I am also taking Cardizem cd and amiodarone. My hair iscoming out and is getting thinner and thinner. Can you help me?

RESPONSE:

Sometimes hypothyroidism itself is a cause of hair loss. Levothyroxine usually does not cause hair loss. We do see hair loss in some thyroid patients and frankly it is very difficult to treat. I would suggest you see a dermatologist, but I do not hold out a lot of hope for any specific treatment. It usually settles down.

Professor JH Lazarus

QUESTION: OVERWEIGHT AND HIGH THYROXINE DOSAGE

I am a 49 year old female, I was diagnosed with hyperthyroidism Graves Disease in 1990 and I had my thyroid destroyed with radiation in the form of a pill.I was put on .1 milligram of synthroid daily, and I took that dose until I was pregnant then it went to .125 then back to .1 milligram.here is my problem within the past 2 years I have put on about 140 pounds.With no change in my eating habits or lifestyle, so my Dr. Upped my meds to .125 then .175 then .2 as of now I have been taking .3 milligrams daily for the past year. I am due to go back for more blood work. My Dr. Stated at my

present dose I should be in a state of having an overactive thyroid but I do not have any of the symptoms.My Question is is it possible for my body to be so used to the synthroid that it no longer works and is there something else I could try.I am at my wits end anything you might be able to tell me would be greatly appreciated

Thank You for your timeSincerelyKaren

RESPONSE:

Dear Karen,

Sometimes the body can indeed make antibodies to thyroxine. This means that when you take your Synthroid much of it is bound to the antibody in the blood and very little is available for the body. This means that you may have to increase the dose of thyroxine to quite high levels, e.g. .4, .5 or .6 mgs a day. When you do this the bloods should be checked, both for TSH and serum T4.

Of course you need to check that there is no other cause for putting on a large amount of weight, for example, diabetes.

Professor JH Lazarus

QUESTION: CONGENITAL HYPOTHYROIDISM AND TREATMENT

My son is now 10 1/2. He was diagnosed at 4 days old. He had no thyroid. He has been on synthroid since then. A couple of years ago, he began having crying spells. We tested his levels and they were low. Once on the higher dose, the crying stopped. The crying spells have begun again and we tested the levels but it is in normal range – his TSH is 2.79 and his Free T4 is 1.5. Do you have any recommendations that I should do to help him ?

Thank you.

RESPONSE:

It is difficult to definitely relate the crying to inadequate replacement therapy. However as his TSH is 2.79 it could be argued that it should be lower, i.e. around 1 and therefore his thyroxine could be increased. It does not matter too much if his T4 is above the normal reference range, as long as his T3 is normal. Also his growth should be charted regularly to ensure no excessive growth occurs.Professor JH Lazarus

QUESTION: GRAVES’ DISEASE AND A CAT

Good Evening,

I would really appreciate if you could take time to give me some information, I have asked my Doctors, and searched the web for such answers but to no avail.

I’m a 30 year old Female recently been diagnosed with this so called over active thyroid (Graves Disease). I have 2 questions

1) Is this transferable? I ask this as my cat also has the disease about the same time i developed it.

2) Is there a specific cause to this disease? I have not been able to find this anywhere, I did however come across a report to say that it was due to the environment that you live in??, also can be caused by tumours. I’m just curious about these questions.Thank you for you time. Ninni

RESPONSE:

Dear Ninni,

You have Graves’ disease, the answers to your questions are:

(1) No, it is not transferable. The cat may be overactive from the thyroid point of view but it will not have Graves’ disease. The cause of the cat’s overactivity is different from the human. Graves’ disease however often runs in families although it is not directly a hereditary disease.

(2) The specific cause of the condition is stimulation of the thyroid by an antibody (protein molecule) made in the body directed against a portion of the thyroid cell, which causes it to be overactive. While we know a lot about that we do not know about the overarching cause of the condition. However there is some evidence that a stressful life event can trigger the condition in persons so pre-disposed by immune and some genetic factors. Your comment about the environment possibly relates to the iodine status. Some people who ingest a lot of iodine may develop Graves’ disease in appropriate circumstances. It cannot be caused by tumors.

Professor JH Lazarus

QUESTION: THYROID CANCER TREATMENT

Background: I was diagnosed with thyroid cancer in 1983 (papillary) and had a total thryoidectomy followed by radiation treatment to destroy residual thyroid tissues. I was 26 at the time and am now 51. I recently realized my levels were out of whack, got my TSH levels checked and have had my dosage of levothyroxin increased to 0.2. My TSH level was 8.65. I had a variety of the classic symptoms including weight loss, fatigue, loose stools, insomnia, slow healing and heat intolerance. The one that shocked me and has stirred me to some greater research was my mood. Terrible mood swings. My various doctors over the years have almost always done my prescriptions on 6 months cycles with TSH testing every 6 months.

Over the years I can’t remember a time I questioned the adjustments. I often didn’t even concern myself with the numbers. My does has ranged from 0.15 to 0.2. My last TSH test was about 4.5 months ago. Maybe this time I was more acutely aware of the mood swings than before. Anyway it prompted me to start looking back at the records I had available and I am finding some correlation to rough or emotionally charged periods in my life and high TSH levels. My records are somewhat spotty but seem to have a trend. Significant turmoil in my life seems to correspond to high TSH levels. What kind of studies are out there on thyroid levels and mood swings? What about stress and TSH levels? I have found articles with discussions on absorption rates and I am aware that stress can affect absorption. I am now considering asking my doctor to check my levels quarterly and intend to become more involved in the actual numbers, aiming for a TSH level of 2.0 based on the latest information.

I would like to find out more about the affects of TSH levels and mood swings if you can provide any information.

Regards,Dennis Thatcher

RESPONSE:

Dear Mr Thatcher,

It is true that some aspects of mood can be related to thyroid function tests. It is not specifically related to TSH but of course high TSH indicates a generally hypothyroid state (under-active thyroid). That state can be associated with mood alterations.

From your point of view it is advisable to make sure that the TSH is suppressed by taking an adequate dose of thyroxine. As far as finding out more, in fact any textbook on thyroid disease often includes a chapter on psychological effects and thyroid, indicating that hyper as well as hypothyroidism has psychological effects. More recently, even persons with normal thyroid function, but with positive thyroid antibodies have been shown to have more depressive episodes. These findings have been confined to women.I hope this helps.Professor JH Lazarus

QUESTION: DURATION OF ANTITHYROID TREATMENT

Good Morning,

I was diagnosed with Graves Disease in 2002 and have been taking Tapazole ever since I am currently taking 20mg/day. I am 26 years old and found out that I am pregnant. I stopped taking the Tapazole after 6 weeks of pregnancy. Are there birth defects that I need to be aware of? If so what is the rate of occurrence of these birth defects?Thank you,Lindsey

RESPONSE:

Dear Lindsey,

If you have been taking Tapazole since 2002, it is probably time you stopped it anyway.

As far as the pregnancy is concerned, probably PTU is safer than Tapazole, but Tapazole is quite safe. However there have been some birth defects associated with Tapazole. They are very, very rare. One of the defects is a punched out area on the baby’s scalp called aplasia cutis, the other one is even rarer and is called methimazole embryopathy and consists of defects in the mid-line. There are a lot of women who take Tapazole right through pregnancy with no problems. I hope this is reassuring.

Professor JH Lazarus

QUESTION: ANTITHYROID PILL DOSAGE

I have been taking Propylthiouracil for the last three years, but after

the birthday of my son (11 months ago) my thyroid has been very hyper.

I went from taking 50mg of Propylthiouracil before and during pregnancy

to 400mg now – 11 months later. I feel like it is doing nothing and my

numbers really arent coming down at all. My doc has again suggested

RAI, but I am wondering if trying another drug would help.Any suggestions are greatly appreciated.

Thanks in advanceDeanna Olsen

RESPONSE:

Dear Deanna,

A full dose of PTU should be around 150 – 200 mgs three times a day. It is important to take it three times a day as it has a shorter half-life than methimazole (tapazole). Tapazole is alternative antithyroid drug, and you may wish to try that. It seems as if you are not possibly on full doses of PTU. Best wishes,

Professor JH Lazarus

QUESTION: HASHIMOTO’S AND CHANGING THYROID TESTS

Dear Sir,

Thank you in advance for answering my questions. I am a 39 year old woman with a 16 year history of Hashimoto’s. I was diagnosed in 1991 after becoming severely hypothyroid. At the time of diagnosis, my anti-microsomal test was highly positive. I have been maintained on the same dosage of synthroid since 1991- .1mcg. In January of 2006, my TSH was 3.12. TSH done in May of 2006 was .42. TSH was recently checked 8/07 and was noted to be .09 (after not having thyroid medicine times 1 week). I have been having some symptoms such as heat intolerance, bounding pulse, easily agitated, tremors, and increased appetite. In the last 3 weeks, I have had some pressure in my neck- can’t really call it a sore throat but feel something when swallowing. There is a hard, marble size nodule on the right side. Complicating all this, is I have narcolepsy and take Ritalin LA daily. I have been even having some insomnia (very unusual for me!) My family doctor has ordered a thyroid scan and uptake which can not be done for 6 weeks due to synthroid usage. He has stated in his 20 years of practice, he’s only seen a handful of hashimoto’s patients and he has no idea why this is occurring. While the TSH is low, I understand it’s not severe but I feel my Ritalin is probably contributing to symptoms. What would you suggest as a follow-up. Should there be a T3 and T4 level drawn? Should I request a referral to an endocrinologist? I am concerned about this and do not feel well.

Thank you, Tammy

RESPONSE:

Dear Tammy,

Thank you for your letter. Quite uncommonly some patients with Hashimoto’s disease like yourself who have been on thyroxine, actually develop hyperthyroidism, therefore from what you describe I would suggest you stop the thyroxine for 4-6 weeks and then get a T4 and T3 level done. This situation is confusing for both the patient and usually the medical attendant. It was first described in 1972 and we see a few cases every so often. If that is the case, then your Ritalin is not contributing to the situation. You are right and the scan cannot be done for six weeks due to the Synthroid. It is not clear what your nodule is on the right side, and it may be that you need a fine needle biopsy aspiration of this in due course.Professor JH Lazarus

QUESTION: HYPERTHYROIDISM AND PREGNANCY

I am sure you have received tons of emails on this subject but I really appreciate it if you can spare a minute of your time to reply.

I was diagnosed with having hyperthyroid – albeit mild – in May last year. I believe that I experienced symptoms 1 or 2 months prior to this diagnosis. Anyhow, I had given birth to my son in September 2005 and I was still breastfeeding at the time of diagnosis. I was treated with PTU – I can’t remember how many tablets a day – think it may have been in the range of 4 a day but this only started in June. Since August last year I have been told that I have normal levels (TSH, T3 & T4) and besides mine was not severe thyroid problems. My glands were barely swollen in that you couldn’t tell that they are if you looked at my neck. My symptoms were just easily aggrevated/short tempered, feeling hot, and nervousness.

Anyhow, it has been a year now of taking a daily does of 2 tablets a day and my husband and I have been trying to get pregnant but with no success. I have read somewhere that thyroid problems lead to insufficient copper and iron which are important in getting pregnant. Is this true? I am also a beta thallesimia carrier and thus I do have iron deficiency already anyway – would the thyroid problem have made this worse and is still making it worse even though I am ‘normal’?

I have started taking clomid again this month to increase my chances of getting pregnant (I had to take clomid to get pregnant with our son – 1st pregnancy) which I take along with PTU and a multi-vitamin tablet (Pharmaton).

Somewhere in the back of my mind I have a feeling that this thyroid problem is causing my not getting pregnant. Can please you shed some light into mycase?Help!Thank you and look forward to hearing from you.Collyn Slade

RESPONSE:

Dear Ms Slade,

I apologise for the delay in replying, but I have been on vacation.

Firstly, if you only had mild hyperthyroidism and have been taking PTU for a year, it would seem to me that you should stop the PTU and get a blood test 2 or 3 weeks later to see if you have relapsed or not.

It is true that if you are hyperthyroid it is difficult to conceive. It is also true that if you are hypothyroid the same applies. It is possible the PTU could have driven down your thyroid a little too much.

Thyroid problems do not lead to insufficient copper and iron. As long as your thyroid function is normal, this should not interfere with your getting pregnant. If you do get pregnant it is very important to get your thyroid function checked as soon as possible. It is likely that the thyroid condition will not recur during the pregnancy, but may indeed recur after delivery.Professor JH Lazarus

QUESTION: REPLACEMENT THERAPY AFTER RAI FOR GRAVES DISEASE

Dear Doctor,

I hope and pray that you can help me with my medical damages which have become permanent. I will give you a little background first about when I was first diagnosed with Graves Disease and the onsuing years until my permanent medical damages.

I was diagnosed with Graves Disease in 1994. I was given 7 milicuries of radioactive iodine. This left some thyroid tissue still active. I was given Synthroid. After 6 months my doctor changed my prescription to Thyrolar. While on thyrolar I had to have my dosage adjusted many times and was finally put back on Synthroid in March of 2003 along with Cytomel. My thyroid bloodtests were never truly normal for 9-10 years.

After a few months I was taken off Cytomel but continued to take Synthroid.

In August of 2005 my endo diagnosed me with “thyroiditis” and took me off Synthroid completely because my TSH was .04. He told me to take a bloodtest in 3 months and revisit him in 3 and a half months. Almost immediately I started feeling just the opposite of “hyper”…I became very sluggish and sleeping most of the time, then within 2-4 weeks was almost comatose. I could not move out of my bed. I needed help in getting to my privvy which was less that 10 feet away.

I decided on my own to get a blood test right away (approximately 3-4 weeks after seeing my endo). Well my TSH was up to 138 (one hundred and thirty eight).

Since then (Sept . 15th, 2005) I have been diagnosed with Fibromyalgia and have been unable to return to work since my muscles have been so weakend (especially my calf muscles). I can only stand for approximately 10 minutes, sit up right for about 20-30 minutes; after this I must return to bed in a reclining position. I get muscle twitches all the time, and I am no longer the same person I was before the TSH rose to 138.

Can you please help me by telling me what the affects of the extremely elevated TSH can have on the body…and how they can be cured. I am suffering so and no one seems to know what to do for me. I hope you can please help me.

Thank you kindly,Carol Jacomo

RESPONSE:

Dear Ms Jacomo,

You were treated with radioiodine and because your TSH is elevated your have post radioiodine hypothyroidism (under-active thyroid) therefore you should certainly need to take replacement thyroxine therapy. There is no evidence that taking a combination of thyroxine and cytomel is more beneficial than thyroxine alone. I would suggest that you return to taking Synthroid or some other preparation of thyroxine.

If you have not been taking thyroxine, then fibromyalgia or similar complaints can certainly occur as the underactive thyroid can certainly affect the muscles, joints, etc. Once your TSH is back in the normal range, I would expect these symptoms to improve although it may take some time.

Professor JH Lazarus

QUESTION: SYMPTOMS WHILE ON THYROXINE TREATMENT

Hi,

My name is Anisa and I had a thyroidectomy on September 28, 2006 due to toxic multinodular goiter and a family history of thyroid cancer. After the surgery I was put on levothyroxine which I had a lack of energy while I was taking it. My aunt who had the thyroid cancer was taking Armour and felt a noticeable difference from the the Synthroid. I asked my doctor if I could be put on Armour also. I have been on Armour for a few months now and my lab tests continue to show high tsh levels which have caused the doctor to continue to increase my dosage. I am now taking 2 1/2 grains a day and my most recent lab test came back with an elevated TSH level of 16.4. I have an appointment next week with my doctor which I assume he will increase the dosage again. I have missed a few days, not consecutively though, of my Armour. Would that cause my TSH levels to be elevated that high? I am worried because I honestly don’t want to be put back on Synthroid because I felt

so sluggish with it but I don’t also want to be taking a high dose of Armour that can be damaging to my heart. Do you have any insight as to why my TSH level is still so high with taking 2 1/2 grains of Armour a day? Any help you could provide would be greatly appreciated. Thanks, Anisa

RESPONSE:

Dear Anisa,

There is no evidence that the combination of T4 and T3 is better than T4 alone. You are right that a high T3 level which armour will give you may be damaging to the heart.

Although you state that you were not good on the Synthroid, it may be worth trying this again to titrate it such that the TSH is low or even slightly suppressed, as long as the T3 level is not high. The T4 level however could go above the normal range and not be a problem. One may also try Levoxyl.

Professor JH Lazarus

p.s. Your TSH is probably high on armour because the dose of T4 in the armour is not very high.

QUESTION: ENLARGED NECK LYMPH NODES

Hello! First of all, thank you for taking the time to read my question.

I am a 30 year old female. A few months ago I noticed a lump in my neck. I didn’t say anything for awhile but I started to get numbness where it was and my throat felt tight. So I finally told my doctor who ordered a CT. The findings were as follows:

6mm soft tissue nodule at right lateral neck. The lymph node is anterior to the carotid and jugular vessels on the right. There are small, non pathologically enlarged lymph nodes within the neck bilaterally.

Small lymph node anterior tot he jugular-carotid vessels on the right, at site of patients palpable abnormatily. while this is small and deep, this is the only abnormatiliy appreciated in the are of the patients symptomatology.

Small lymph nodes present within the posterior triangle bilaterally, right greater than left, with no pathologic enlargement appreciated.

Should I be concerned with the numbness in my neck, right on the right side, where the lymph node is large. Its hard to explain but the best way to describe it is pressure and numbess. Also should I be concerned about cancer?

I know it’s hard to answer these questions without seeing me, any info would be helpful. Thank you and have a great dayS Haulter

RESPONSE:

Dear Ms Haulter,

From your description you have enlarged lymph nodes but no definite problem with the thyroid gland. The enlargement of the lymph node or nodes could cause a discomfort in the neck as you describe. You should indeed seek medical attention. There are many causes of enlarging lymphnodes, one of which could be cancer, but there are other things. If necessary the lymphnode may have to be removed to examine it.

Cancer cannot be excluded from your description but neither can it be confirmed without further testing.

Professor JH Lazarus

QUESTION: POSSIBLE COWDEN’S SYNDROME

Dr. Lazarus

I was first diagnosed with Hashimoto about five years ago.

I had a goiter, was tested, and then was ignored by the first doctor because it came back normal. It took three painful needles and many blood tests before they figured out I had Hashimoto’s. The right half of my thyroid was removed and now the left has grown. I have a hardtime breathing, swallowing and talking yet they tell me “it’s normal” for the remaining thyroid to grow. I still fell bad even though they tell my blood work is normal. I mentioned my father having Cowden’s yet only one doctor new what that was and was unwilling to test me.

I’m at my wit’s end. Could you tell me what to do to make these doctors listen to me. Is there anything I can ask them to get the right treatment and start to feel at least half way normal again?

Thank you for your time.

RESPONSE:

Normally, patients with Hashimoto’s thyroiditis do not require surgery although it is occasionally necessary. The usual treatment if the goitre is growing is to administer thyroxine therapy.

If your father has Cowden’s syndrome then you should certainly be tested for this. Cowden’s is an autosomnal dominant inheritance. Unfortuantely it can be associated with thyroid cancer, so that it may be necessary to have the other half of your thyroid removed if, after fine needle biopsy, any suspicion of cancer is raised.

As far as I know there is no particular association with Cowden’s syndrome and Hashimoto’s disease.

I may well be of course that you do not have Cowden’s syndrome but have just developed Hashimoto’s disease as you describe.

Therefore I would suggest:

(a) You inform your doctor that if the other half of the gland really is Hashimoto’s and growing you should try thyroxine suppressive therapy.

(b) That you have a family history of Cowden’s and demand to be tested for this because there is a risk of thyroid cancer.

Professor JH Lazarus

TESTING FOR THYROID HORMONE LEVEL

I am, 43, female. I take Synthroid (.125) and just had a TSH of 5.28. I have significant PVCs (EEG shows every other beat) and am very breathless. I have very low blood pressure and slow heart rate. Is the thyroid problem related to the PVC, etc., problem? I feel miserable. I am a hard worker, parent and would like to feel better.

RESPONSE:

You do not say what the upper limit of your TSH assay is, it may be 5.5. Also I would suggest you have your T4 and T3 measured to get a fuller picture of the hormones that affect the heart, i.e. T3.

It may well be that you require cardiac work up. I doubt whether your thyroid problem is related to your PVC. When you have a repeat TSH with T4 and T3, a better decision could be taken. If you need drugs to remove the PVC maybe Verapamil may be effective.

Professor JH Lazarus

QUESTION: THYROXINE DOSAGE

My TSH remains at 29 despite 300 mcg of Synthroid daily. I am also a Vit b12 deficient at 286. I had gastric bypass surg over a year ago with a 120# weight loss. I am tired with a vague headache all the time. I have the joint aches as well. I am awaiting an endocrine appt, but can these levels produce the symptoms I feel? I have a 4 month wait to see the endo guy. I want to see him yesterday as I feel drained all the time. Am I asking too much not to wait so long?

ThanksNancy

RESPONSE:

Dear Nancy,

Your TSH may be high because you may not be absorbing all of your Synthyroid. This may be because of your gastric surgery. I would suggest that your Synthroid be increased in increments of 50 mcgs, until your TSH is at an appropriate level, i.e. around 1. I would agree that you should not wait so long and start increasing the dose as soon as possible.

Professor JH Lazarus

QUESTION: LUMP AFTER THYROIDECTOMY

I had a total Thyroidectomy 1 week ago and I feel like there’s a lump in the back of my throat and at the front of my neck in the middle of the incision you can feel a lump underneath the skin. Will this go away? And how long is this going to take? Looking on other web sites it says this should last 24-72 hours after surgery, I’m feeling this a week after! I was really swollen and wonder if I just didn’t notice before? The feeling of this lump drives me crazy!! Can you help me to know the possibilities? Thank you,

Heather

RESPONSE:

Dear Heather,

If you are only a week after surgery you may well feel the impression of a lump under the skin. This may be a small haematoma (collection of blood), which in time will go away. The trouble is the time is variable and every minute you can feel it. If it gets bigger you need to go back to the surgeon.

QUESTION: PALPITATIONS, PROPRANOLOL, AND THYROID

I am a 57 year old female. I have been treated for hypothyroidism for 28 years with synthroid, then levoxyl. Although I have never felt “great”, I have had my lab numbers in the normal range. Several years ago I begain to have chest pain, shortness of breath and palpitations and had all the cardiac tests done. All were normal. My doctor prescribed propranolol one year ago, a small dose of 20 mg. twice a day for the palpitations. I don’t think it is really helping me that much. Other than propranolol, nothing has changed in my routine.

In this past year my t3 has plummeted to 74 (87-178), but my TSH is now showing hyperthyroid at 0.05 (0.28-3.89) and FT4 is 1.24 (0.58-1.64)

I have read in several different places that propranolol can interfere with the conversion of t4 to t3 but all of my doctors say this is not the case because my dose is too small. None of the docs are able to say why my t3 has suddenly after all these years gone below normal but want me to try cytomel in addition to the levoxyl and propranolol I already take. I am not looking forward to adding yet another pill to my regimine.

My two questions are:

1. Would you agree that it is possible that the propranolol is the culprit with the low t3 reading (3 separate readings already done, all are in the 70’s)? Could you suggest something else that would not interfere with t4 to t3 conversion?

2.Because cytomel is so expensive, wouldn’t it be possible to try a small dose of armor while lowering the levoxyl a little bit and adding just a small amount of armour? I understand that it is still an approved drug in the USA, although not prescribed as much as the synthetics. I have read their website and it seems that they are required by law to be consistent from dose to dose. It is so much cheaper to buy, I just don’t understand why I can’t just try this if I have to use a t3.Thanks for any help you may have to offer. I’m so tired of feeling tired.

RESPONSE:

I agree that it is a small dose of propanolol, but it could be playing a part in the fall of T3. A similar fall is seen in people with other illnesses or taking other drugs which I assume is not the case in you.

I think it would be possible to try actually increasing your dose of levoxyl to the point where the FT4 level is actually above the upper limit of the normal reference range. This is quite in order. On this kind of dose the T3 may come up to within the normal range. You may need to take more propanolol, e.g. 40 milligrams twice or three times a day.

Of course this may depress the TSH further and there are admittedly two risks to this. Firstly, the palpitations which you are already getting, but which may be controlled by the beta-blocker. Secondly, there is a possible risk to bone, although this is still somewhat debated. Therefore I think if you did take this strategy it would be justifiable to do a DEXA bone scan to see what the state of your bones is and also a 24 hour holter monitor tape to see what rate your heart is going at the whole day and night.

Professor JH Lazarus

QUESTION: CYST ON THE THYROID

My doctor found 4 small cysts on my thyroid gland. I had a thyroid scan done and she said there is nothing to worry about. But the cysts really bother me, it feels like something is always stuck in my throat and sometime have troubles breathing and swallowing, and there is alot of pressure inside. Should I be considering getting them removed surgically? If I do get them removed, does this increase my chances of not being able to conceive a baby? I am 28 and plan to start a family soon, and I heard your thyroid affects your fertility. If i get my whole thyroid gland removed, can I still get pregnant? Are there certain food/drinks that would bother the cysts to make them hurt more sometimes and less other times?Thank you very muchMs Pettyjohn

RESPONSE:

Dear Ms Pettyjohn,

It is unlikely that 4 small cysts could cause you problems with breathing. However if the symptoms persist and your doctor feels there is significant compression on neck structure such as your windpipe or gullet then surgical removal is the only treatment.

If you did have an operation on your thyroid, it would not increase of your chance of not being able to conceive a baby. I assume that your thyroid tests have been done that you are normal from the thyroid point of view. If your thyroid is removed you may need to take thyroid replacement therapy. The thyroid can affect your fertility if you are overactive or underactive. If you have your whole thyroid gland removed you can still get pregnant. If you are taking thyroxine you would need to increase the dose of thyroxine during the pregnancy.

There are no foods or drinks apart from iodine supplements themselves that would bother the cysts to make them hurt more. The reason they hurt is possibly because they bleed inside.

Professor JH Lazarus

QUESTION: SUICIDAL FEELING AFTER THYROIDECTOMY

Can u please tell me what the suicide rates are? i had a subtotal tyroidectomy in jan 2006 and my quality of life is horrible. it’s existing it’s torture it’s not living. i know i am not the only one feeling this way. i am on no synthroid because they say my levels are normal. but they’ve always been normal even though i had a 3cm nodule and a 3cm cyst on my thyroid.Ms Sanchez

RESPONSE:

Dear Ms Sanchez,

I am sorry you are feeling as you describe. To answer your question there is no increase in suicide rates in patients on thyroxine compared to normal controls. It sounds as if you do not require synthroid if your levels are normal. Very often patients with a nodule in their thyroid have entirely normal thyroid function and do not need thyroxine.

You certainly need some attention from your physician to deal with your unfortunate feelings at present, but I doubt whether they are related to your thyroid.

Professor JH Lazarus

QUESTION: DURATION OF TAPAZOL TREATMENT

Dear Dr. Lazarus’

I have been taking Tapazole for about 6 years. I started on a daily dosage and my numbers progressively got better so I am taking 1 tablet on Mon. Wed. and Fri.The dosage is 5 MG.

My doctor says that a person can continue to take Tapazole for the rest of their life, but I have a few friends and relatives that also had Graves Disease and they were told that it cannot be taken for a long period of time without damage. Within the past year I have been experiencing skin sensitivity on my body but also in my vaginal area. I have been to the gyno for an explanation but have only been told that it is hormonal due to menopause. I am taking a hormone replacement vaginally and it has not reduced the sensitivity.

Any help you can give me would be appreciated.

Thank You

Mary Clarke

RESPONSE:

Dear Ms Clarke,

It is true that some people take tapazole for a long time. My own view and that of several other thyroidologists is that it is unsatisfactory generally to take tapazole for a long time. 5 mg every other day is hardly going to do anything and I would be tempted to stop it and review your thyroid function two or three weeks later. If your over-activity comes back I would suggest you be treated with radioiodine therapy.

Professor JH Lazarus

QUESTION: MANAGING A THYROID NODULE

Hello! I would like your opinion. I am a 39 year old female with normal TSH levels. I have had 2 FNA on a complex thyroid cyst. Both FNA came back benign. My question is this–do I need to continue having ultrasounds on this complex cyst annually or not? I do not have any health issues or symptoms of thyroid problems. Also, is there a high risk of these complex cysts becoming cancerous over a period of time? Thanks for your advice in advance. Looking forward to hearing from you! Annie in Louisiana

RESPONSE:

Dear Annie,

I do not think you need to continue having ultrasounds on this thyroid lump. However, you should see a physician every so often, and especially if the lump starts to grow. If that happens another FNA would be indicated. A chance of cancer arising in this problem is very low. Normally if cyst fluid is withdrawn by an FNA and recurs more than once, then usually operation is indicated.

Professor JH Lazarus

QUESTION: THYROID TESTS WHILE ON CARBIMAZOLE

I was diagnosed with an overactive thyroid 3 years ago. It had made my heart beat too fast and I now suffer from time to time with AF. I stopped taking propanadol last year and have been continuing to take carbimazole 5mgs, warfarin, metoprolol tartrate 50mgs and diltiazem 60mgs 3x daily. Two months ago my ECG and thyroid function were normal, so the consultant stopped the carbimazole.I am worried that the thyroid will start to “overact” again. I also suffer from COPD and am feeling breathless again.I don’t sleep well and am continually feeling hot. I don’t know if this is all mind over matter (it has been rather hot lately ) or whether it is my thyroid. I am also feeling rather anxious as I don’t want to end up in critical care again. My main concern is that the blood test which showed normal thyroid function was taken whist I was still taking the carbimazole. Once I stopped taking the medication is it likely that the thyroid would malfunction again so quickly?

Ms Ferry

RESPONSE:

Dear Ms Ferry,

Your concern about the blood test while on Carbimazole is fully justified. It is possible that your thyroid may indeed malfunction after you stop taking the medication. It can even malfunction after two weeks, therefore I would urge you to get your thyroid function checked as soon as possible. If it is normal, then the time period for the next thyroid test could be extended a little, and so on. If your thyroid does become overactive, I would recommend radioiodine treatment.

Professor JH Lazarus

QUESTION: MEANING OF POSITIVE ANTIBODIES

Hi.

I just want to know what is the significance of an elevated throid antibody test. Mine is over 100 but my blood count and thyroid hormone test are normal. Do I need ro to have ultrasound in my thyroid?

Thanks

Mr Tofiles

RESPONSE:

Dear Mr Tofiles,

If your antibody levels are elevated, it implies that you could develop an underactive thyroid in the future, but this is not necessarily the case. It is not essential to have an ultrasound, but you should have your thyroid levels monitored every six months to a year.

Professor JH Lazarus

QUESTION: PROPER THYROXINE DOSAGE

I AM ON LEVOXYL 25 MG/DAY. I’VE BEEN EXPERIENCING INCREASE HAIR LOSS ESPECIALLY LONG STRANDS OF HAIR. I WENT & HAD MY LBS DONE BY MY ENDOCRONOGOLIST. HE INCREASES MY THROID MED TO 37.5MG/DAY. I’VE BEEN TASKING THIS DOSAGE FOR THE PAST FEW DAYS & MY HAIR LOSS HAS EVEN INCREASED DRASTICALLY. WHAT IS YOUR RECOMMENDATION? DECREASE OR STOP TAKING IT AL ALL? PLEASE RESPOND. MY LABS ARE: FREE T4 1.3, TSH, ULTRA SENSITIVE TSH 4.16.

Jeanne McGee

RESPONSE:

Dear Ms McGee,

From your laboratory reports your TSH is still too high, and should be down near to 1.0. Hair loss does occur in thyroid disease and all that we can recommend is that you take an adequate amount of thyroxine for optimal replacement. In most cases the hair grows back, but I certainly cannot guarantee this.

Professor JH Lazarus

QUESTION: POSSIBLE HASHIMOTO’S IN A CHILD?

Hello.

Thanks for your site. I live in Virginia, USA. Have a 10 year old daughter with Hashimotos. I find no literature on treating children this age even before the body changes. I have found no articles nor links. We have 1 doctor in the area that sees kids. Amazing.

If you any advice…. would appreciate.

Mary V

RESPONSE:

Dear Mary,

Thank you for your mail. Hashimoto’s disease can arise in children. It is not very common but there is certainly literature about it. Bascially if the child is underactive from the thyroid point of view thyroxine should be given and the dose carefully monitored with blood tests. It may be necessary to monitor the growth of the child as well in addition to noting any alterations in puberty. However if thyroxine is given and the child is normal from the thyroid point of view there should be no problem with puberty.

Professor JH Lazarus

QUESTION: REGROWTH OF THE THYROID

Is it possible for a thryoid gland to grow bak again once it has been removed – I had mine removed 4 years ago – but now am showing signs of my thyroxine level being too high

RESPONSE:

Dear Ms Bateson,

It is possible for the thyroid to re-grow because when you had the operation it is probable that not every last bit of thyroid was removed. Therefore there is a small amount left and that can re-grow.

Professor JH Lazarus

QUESTION: THYROXINE ABSORPTION AND EXERCISE

Hello,

I was first diagnosed with hypothyroidism when I was in my 20s. At that time, I was put on levoxyl and t3 by an endo. who believes that many people do better on both T4 and T3 replacement. I felt fine for many years, went through three successful pregnancies w/three healthy kids, etc. About three months ago, I started a vigorous running program, and all of a sudden, I am having a lot of anxiety and depression. I wonder if there might be a correlation between t3/t4 absorption and exercise? Thanks,KH Swenson

RESPONSE:

Dear Ms Swenson,

I don’t think there is any correlation between T3/T4 absorption and exercise. You should have your T3 and T4 levels checked. There is actually no evidence base for giving T3 as well as T4.

Professor JH Lazarus

QUESTION: POSSIBLE HYPOTHYROIDISM??

I found your homepage while browsing for my information and was wondering if you can answer a question for me. I am 35 female and weigh 128 lbs and a couple of months ago my TSH was a bit higher than the normal 5.50 so I had two of the T3 and two of the T4 tests which came out in the normal range. So what does this mean? Is my TSH okay or I still need to have my TSH checked as well?

Thank you so much

RESPONSE:

Dear Madam,

You infer that you are overweight at 128 lbs you do not give your height so it is impossible to calculate your body mass index (weight in kilograms divided by height in metres squared). Your TSH is slightly high, and it would be reasonable to get your thyroid antibodies measured. If they are elevated this would suggest that you have autoimmune thyroiditis. However, current guidelines suggest that patients with a TSH of between 5 and 10 should probably not be treated, but merely observed regularly to see if their thyroid is going to go underactive or not. Therefore you do need to have your TSH checked from time to time.

Professor JH Lazarus

QUESTION: THYROID ANTIBODIES AND MISCARRIAGE

I am 35 years old and had two miscarriages very early on in the pregnancy. One was at 6 weeks and the other was at 8 weeks. The doctor said it was a blighted ovum. Since the miscarriages, I had some bloodwork done and the only thing that came back abnormal was “high thyroid antibodies.” I have had an underactive thyroid since 11 years old and my TSH levels are fine (I take a thyroid supplement). I have asked several doctors if the thryoid antibodies can be the cause of the miscarriages and some doctors thought it could be but the one fertility doctor said absolutely not. I have done some research on my own and it seems that there is indeed a link between high thyroid antibodies and miscarriage. Do you know of anyone out there who had high thyroid antibodies and had a normal pregnancy? Could this be the cause of the miscarriage or was it just bad luck?

Thanks for any info. possible. Karen

RESPONSE:

Dear Ms Koerner,

The possession of thyroid antibodies (anti TPO antibodies) are indeed associated with miscarriage, although the precise mechanism of this is not clear. In yourself this does not exclude any other causes of miscarriage and it may be that you should be tested for other known causes, (e.g. lupus anti-coagulant). You are on thyroxine, but you should know that when you become pregnant, you need an increased dose of thyroxine.

Certainly women with a high titre of thyroid antibodies do become pregnant and do not automatically have a miscarriage.

I hope these comments help.

Professor JH Lazarus

QUESTION: RAI TREATMENT AND SUBSEQUENT PREGNANCY

I was diagnosed with Graves Disease April 19, 2006 after losing two pregnancies. I had Hypercogulation and very high uptake Scan. I went for the RAI and successful have been balanced out with the replacement medications of T4 and T3 daily.

I’m 38 years old and I have one Child (4years old). I’m very interested in finding out if you have research on successful pregnancies following RAI?

Thank you for your time,

Kerry Hendrickson

RESPONSE:

Dear Ms Hendrickson,

After radioiodine you should not conceive for six months. After this time there is no evidence that fertility is reduced, there is also no evidence of any affect of the radioiodine on the mother or fetus. The important thing is that your thyroid status is normal. In addition, if you are taking thryoxine because of hypothyroidism produced by the radioiodine, then when you become pregnant you may need an increase in the dose of thyroxine during the pregnancy. When the pregnancy is finished, the dose of thyroxine will return to that dose which you were on before being pregnant.

You mention that you are on both T4 and T3. I would recommend if possible that you should have T4 alone, as there is no evidence that the combination is any better for replacement therapy and may indeed be deleterious in certain respects.

Professor JH Lazarus

QUESTION: NEED FOR THYROXINE TREATMENT

Hello.

I found your site while researching the internet and hope you can advise me. I am a 46 year old woman in Australia, who was diagnosed with long-standing untreated Hashimoto’s two years ago.

My doctor put me onto a dose of 50mcg Oroxine (thyroxine sodium) per day,and for the most part my health has improved significantly. My pulse rate has risen from a resting rate of 46 beats per minute to an average of 61, mypreviously uncontrolled hypertension has stabilized at 130/90, and I have lost 15 kg of weight even though I am eating a lot more than I ever did. Plus I’m warm all time rather than cold. With all this improvement it seems churlish of me to have a complaint, but this is it: in the information leaflet accompanying my medication,one of the side effects is hair loss. And I have hardly any hair left now, with masses falling out every day. I stopped taking my Oroxine for a month. All the previous nasty symptoms came back within a short time, but my hair began to regrow!

Is there any replacement medication I can take for Hashimoto’s which will give me the benefits without the hair loss? I look forward to your answer!

Thanks!

Alison Venugoban

RESPONSE:

Dear Ms Venugoban,

From your letter you indicate that you were hypothyroid due to Hashimoto’s disease and that thyroxine therapy has improved your general condition very well indeed. Unfortunately, hair loss can occur with autoimmune thyroid disease. It is not really related to the thyroxine treatment. There is no replacement medication you can take for an underactive thyroid, other than thyroxine. I would not advise stopping your thyroxine. It is possible that the hair might regrow, but I cannot guarantee this at all. It would be worth it for you to see a dermatologist although they do not have very much to offer in this regard. I am sorry to be rather negative about this, but I think you will have to have patience, and in time it is possible there will be some stabilisation and hair regrowth.

Professor JH Lazarus

QUESTION: RELATION OF THYROID ANTIBODIES TO HYPOTHYROIDISM 09/04/2007

After the birth of my second child I was found to have borderline hyperthyroidism, followed by borderline hypothyroidism which then went back to normal after I was 6 months postnatal. I was however positive to TG Ab antibodies of 16.6 IU/mL (normal range <4.1) but TPO Ab was 1.7 IU/mL (normal range <5.6). When my TSH was back to normal (2.4) I got pregnant. At 5 weeks pregnant I was put on 25mcg of thyroxine daily but miscarried at 6 weeks. My TSH tested normal 1.5 but my TG Ab had increased to 36. At 5 weeks pregnant I was put on 25g of thyroxine daily. I recently saw an endocrinologist who was not convinced my thyroid antibodies were responsible for my miscarriage (however I have previously had 2 miscarriages in between my 2 healthy pregnancies) but suggested I take 50mcg daily while I try to conceive (based on a study recently in Italy about thyroxine decreasing chances of miscarrying). However after a week of taking this thyroxine I am feeling terrible and would like to stop taking it (I have muscle cramps, dizzy, headache, sight problems). My question is, do you think taking this thyroxine will decrease my chances of miscarrying? If so can I take it when I find out I am pregnant rather than when I am trying to conceive, and what dose should be taken. I feel 50mcg is too much for me at the moment (my TSH is 1.3). I read in the Italian study that the subjects only started taking the thyroxine at 10 weeks gestation. Is this correct? When should I start taking it do you think? Also do you think it relevant that I am only positive to TG Ab antibodies and not TPO which is what the subjects in the study were positive to?

Thanks very much for your time.

RESPONSE:

Dear Patient,

It is less usual to have just TG antibodies rather than TPO antibodies, but not unknown. The presence of antibodies is certainly a risk factor for miscarriage, but it is difficult to be dogmatic that because you have antibodies you had miscarriage. There could be other reasons. Nevertheless, the Italian study does suggest that people who have antibodies and take thyroxine reduce the chance of miscarriage. I think that it is reasonable to start thyroxine therapy before getting pregnant, or as soon as you find out you are pregnant. The thyroxine therapy should be preceded by a thyroid function test and, particularly in your case, another thyroid function test should be done 4/6 weeks after starting 25 mcgs of thyroxine. Remember that thyroxine therapy is not a guarantee that you won’t have a miscarriage, but if we believe the Italian Study (and it is the first major study to show benefit), then it is worthwhile trying. From what you say, 25 mcgs may be alright to start with, but the Italian Study used 100 mcgs and certainly 150 mcgs in pregnancy is not a problem, because most women who require thyroxine require an increased dose during pregnancy.

You developed classical postpartum thyroiditis with transient hyper and hypothyroidism after the birth of your second child. If you get pregnant again, you have a 75% chance of developing this syndrome again. We know that after seven years from that episode you have a 50% chance of developing permanent hypothyroidism (under-activity of the thyroid) where you will require to take replacement thyroxine.

Professor JH Lazarus

QUESTION: TREATMENT OF HASHIMOTO’S DISEASE

Dr. Lazarus:

I just discovered your website and have copied all the questions and answers to read later. I’d like to know your opinion of my taking inorganic iodine in the form of Lugol’s solution. I’ve had Hashimoto’s disease for decades and all the years of synthetic thyroid haven’t done much for me. As a matter of fact, I was in the dark regarding the symptoms of hypothyroidism and didn’t realize I had it until I tried to get pregnant in my twenties (I’m 58 now). In any case, since I’ve been on the Lugol’s my eyebrows have grown back and my hair as well. I shaved my legs for the first time in years!

In order to not overdo, I lowered my levothyroixine dose from .200 to .150. For the first time in years I’m sleeping soundly (perhaps too soundly. I need an alarm clock now). Sadly, I’m gaining weight. I’d like to know if iodine therapy causes weight gain. I’d read that it does the opposite, but not in my case. It seems to have stimulated my apetite.

In a couple of weeks I see a new endocrinologist, but fear he’ll think I’m another alternative medicine “kook.” As I said, I’m happy to have my thick hair back.

PS: I see where someone asked you about thyroid and lichen planus. REcently I was diagnosed with it and my dental hygienist said there’s a conection between the condition and the thyroid.

I’m hoping you can answer my questions. Many thanks in advance.

Sharon C. from Massachusetts, USA

Response

Dear Sharon,

I would not recomment taking Lugol’s solution for Hashimoto’s disease, especially if you are on thyroxine. The best treatment for Hashimoto’s disease is in fact thyroxine. If you were on 200 of Levothyroxine and this was considered to be a reasonable dose for you I would certainly not reduce it. Iodine therapy does not cause weight gain, but reducing the dose of thyroxine may well do. There is no point at all in taking iodine, as it is likely that your thyroid gland is not really functioning and therefore could not use the iodine anyway.

As far as lichen planus is concerned, it is possible there might be a weak connection with the thyroid but only weak.

Professor JH Lazarus

QUESTION: THYROXINE TREATMENT AND BLOOD TESTS

Hello!

I have a question that I hope you can answer for me. I have been on 0.025 of Synthroid for 3 days, and now my doctor decided she wants me to have the radioactive uptake and scan, but told me if I had taken the synthroid I wouldn’t be able to have the scan. Does 3 days of this little amount really affect the test? My test is in one week, so I will have a week to be off of it.

Thank you!

Jessica Brown

RESPONSE:

Dear Jessica,

I agree that it is a small dose, but the drug lasts for a long time in the body so that a week off it is not quite enough. Ideally it should be a month. The problem is that if your test is not as expected, it will not be clear whether the thyroxine affected the result or not.

Professor JH Lazarus

QUESTION: IMMUNE SYSTEM FUNCTION AND GRAVES DISEASE

i am desperately trying to find an answer to this question: I was diagnosed with Graves disease in 2001, had RAI, and am now on both levothyroxine and liothyronine….my question concerns the aspects of autoimmune disease/Graves… Do i still have an autoimmune disease or not? was it treated and now it’s gone? in other words, is my immune system compromised? do i need to be careful of highly infectious areas/people with serious infectious illness?

thank you for any insight you can provide.

Ms Baeli

RESPONSE:

Dear Ms Baeli,

The answers to your questions are as follows:

You do still have Graves’ disease and this is an autuoimmune disease. Therefore you could still be making the antibodies that stimulate the thyroid, but as your thyroid is now not working, these antibodies are not doing any damage.

In general your immune system is not compromised.

Your do not need to be more careful of highly infectious areas or people with serious infectious illness than anybody else.

Professor JH Lazarus

QUESTION: THYROGLOBULIN TESTS AFTER TREATMENT FOR CANCER

How can I have a re-occurrence? A month ago my thyroid was removed for 2 small Papillary cancers. Now the I-131 should take care of any remaning thyroid tissue. My lymph nodes were negativeThat in my opinion should take care of everything.If I did decide to have a thyroglobin blood test how often is it recommended? Personaly I think there is a thyroid madness out there.

Mrs Dennis

RESPONSE:

Dear Ms Dennis,

Re-occurrence can occur but in your case I would have thought that the probability of this is low. Standard management is indeed to have a thyroglobulin blood test, initially a few months after all the procedures have been completed and then lengthening this time out to make it an annual occurrence.

Professor JH Lazarus

QUESTION: NEED FOR INCREASED THYROXINE DOSE

dear dr:

i had iodine treatment 23 years ago and then went completly hypo.

i was placed on 150mg of thyroxin and things were fine for 18 years

now for no apparent reason the bottom has fallen out and i can’t seem to get enough thyroxin

am tired all the time

blood pressure is rising abnormally

weight gain that i can’t seem to controll

loss of appetite

bout of memory loss

constipation

depression

my retina even detached from my eye for no apparent reason

i am currently on 450mg of thyroxin

what are we doing wrong

please help

marlene

RESPONSE:

Dear Marlene,

It is not immediately clear why your dose of thyroxine has increased so markedly. It may be that you are not absorbing the thyroxine because you might be on iron, soya or an indigestion preparation. Alternatively you may have developed Celiac disease which may prevent absorption of thyroxine. This can be tested for with blood tests. There is another possibility, that is that you may have developed antibodies to the thyroxine. The dose should therefore be increased to counteract this.

I hope these comments are of some help.

Professor JH Lazarus

QUESTION: VITILIGO AND THYROID DISEASE

My sister in law has hyperthyroidism and vitiligo. She is 28 years old and is a couple of months pregnant. She was suffering from depression due to her vitiligo situation which had really started to spread in the last few months and now the added pressure of the pregnancy has caused her even more concern and her skin condition to spread. Her doctor has stated that her hyperthyroisdism is one of the contributing factors for her vitiligo and she is worried that it will worsen now that she is pregnant. She has always been really high strung and prone to depression so I would like to get some professional advise to ease all her concerns. I am convinced that she is totally mistaken. Who is correct?

I hope you can help me.Kind regards,Isabel Pavez S.

RESPONSE:

Dear Ms Pavez,

The vitiligo is an autoimmune condition and it is highly likely that her hyperthyroidism is also autoimmune (i.e. Graves’ disease). Of course the skin in pregnancy can undergo pigmentation, but I doubt whether the vitiligo will worsen significantly. Autoimmune conditions often get a bit better during pregnancy, but may get a bit worse after delivery. Vitiligo on the face can be disguised quite well with make-up products.

Professor JH Lazarus

QUESTION: DOSAGE OF SYNTHROID

Dr. Lazarus,

I have had radioactive iodine 4 years ago for a hyperthyroid. I was put on Synthoid. I have now been taking Cytomel 25mgs for about 4 months. I was just tested and my TSH was 27.4. They want me to now take 75mgs Cytomel. It was changed from the Synthoid for the mood elevation effect of Cytomel. I suffer from depression. I feel more like I have the hyperthyroid symptoms. Rapid heart beat, a skin rash that wont go away, brittle fingernails, I have not gained any weight and can eat all I want.

What is going on???

Thanks

A Fischer

RESPONSE:

Dear Anita,

Generally it is better if people are on Synthroid (or some other preparation of thyroxine rather than Cytomel, which is triiodothyronine). Therefore I would certainly suggest that you take 75 mcgs for a trial. This is a relatively small dose. After being on it for four to six weeks, you should have your TSH re-tested, as well as a T4 level. If the blood levels are too high at that stage, then one would have to reduce the dose. There is no good evidence that the combination of Synthroid and Cytomel is any better than Synthroid alone.

In summary, I think the first thing to do is to get your thyroid stabilised and steady, before further treatment of your depression.

Professor JH Lazarus

QUESTION: NO, DON’T TAKE IODINE

Dr. Lazarus,

Would it be all right if I start a natural healing process with liquid iodine while on my Synthroid medication. I’m at 75 micros.

Thank you.

Sandra Street

RESPONSE:

Dear Sandra,

I apologise for the delay. The short answer to your question is no, it would not be alright. Liquid iodine would not help at all. The only effective treatment for an underactive thyroid is thyroxine. Your thyroid is not working and therefore would be unable to utilise any iodine. Even if your thyroid was working, the administration of large quantites of iodine could be potentially dangerous.

Professor JH Lazarus

QUESTION: NEED FOR TREATMENT OF HYPOTHYROIDISM

I had some blood work done about 3 weeks ago and with my results everything came back normal except for TSH and cholesterol count. My TSH Lab came back as follows: TSH – 71.6 H (0.3-5.0 UIU/L). The way it looks is my test was very high. My total cholesterol was 332 H. However, my LDL was 225 which was high.

My doctor put me on cholesterol medicine (Lovastatin 40 mg twice daily) and on Thyroid medicine ( Levothyroxin 150 mcg). I hope this will help. But the question that I have is the total TSH doesn’t make sense, it looks too high. Can you tell me what UIU/L means? Thank you for your input.

Marie – Texas

RESPONSE:

Dear Marie,

Your TSH (thyroid stimulating hormone) level is indeed high at 71.6 international units per litre (it is not usually expressed as UIU, but as IU/L). This suggests that you are in fact hypothyroid (under active). You should have had an estimation of thyroxine level in the blood which would be expected to have been low. Your cholesterol is high because your thyroid is underactive, and at this stage I would be of the opinon that you do not necessarily need cholesterol medicine until this is re-checked after your thyroid has been treated and you are normal from that point of view. If, at that time, your cholesterol is still high, you would need the Lovastatin.

I hope this is helpful.

Professor JH Lazarus