January is thyroid awareness month. This butterfly-shaped gland located in the front of the neck is small but powerful -- affecting metabolism, heart function, mood and more -- sometimes without causing obvious symptoms.
If you think a health issue you’re having may be due to a thyroid problem, listen in to this discussion with experts from Baptist Health South Florida, hosted by Jonathan Fialkow, M.D.
Guests:
· Pascual De Santis, M.D., an endocrinologist with Baptist Health
· Neeta Erinjeri, M.D., an endocrine surgeon at Baptist Health’s Miami Cancer Institute
January is thyroid awareness month. This butterfly-shaped gland located in the front of the neck is small but powerful -- affecting metabolism, heart function, mood and more -- sometimes without causing obvious symptoms.
If you think a health issue you’re having may be due to a thyroid problem, listen in to this discussion with experts from Baptist Health South Florida, hosted by Jonathan Fialkow, M.D.
Guests:
· Pascual De Santis, M.D., an endocrinologist with Baptist Health
· Neeta Erinjeri, M.D., an endocrine surgeon at Baptist Health’s Miami Cancer Institute
Announcer:
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Dr. Fialkow:
Welcome, Baptist HealthTalk podcast listeners. I'm your host, Dr. Jonathan Fialkow. I'm a preventative cardiologist and lipidologist at Miami Cardiac and Vascular Institute, where I'm also Chief of Cardiology at Baptist Hospital and the Chief Population Health Officer at Baptist Health. January is Thyroid Awareness Month. This butterfly-shaped gland in the front of the neck may be small, but it's powerful. Thyroid malfunctions can affect metabolism, heart function, and even bones and muscles, sometimes without causing obvious symptoms.
Dr. Fialkow:
So how do you know if a particular health issue is due to a thyroid problem? That was the central question in a recent episode of Baptist Health's Resource Live Program that I had the pleasure of hosting. My expert guests were Dr. Pascual De Santis, an endocrinologist with Baptist Health, and Dr. Neeta Erinjeri, an endocrine surgeon at Baptist Health Miami Cancer Institute. Let's hear what they had to say.
Dr. Fialkow:
So Pascual, let's start with you. The thyroid's a small part of the body, a small gland, but it's extremely important. How important is the thyroid? What are the effects of the thyroid?
Dr. De Santis:
The thyroid is an organ that controls, essentially, many functions in the body. You can think pretty much every cell in the body is a target for thyroid hormone, and it will affect energy expenditure, oxygen consumption. It is involved in development and growth in children. It affects the cardiovascular system, the contractility of the heart, the blood vessel contraction. It can affect the reproductive system. It is involved, very importantly, in development of the central nervous system, and nerve conduction as well, so it pretty much affects every function of the body.
Dr. Fialkow:
So, the thyroid gland is a small organ, it sends out hormones. We'll talk a little bit about what the thyroid abnormalities are, but what are the symptoms, or what are things that someone may feel, that might trigger, hey, they should get their thyroid checked out? That's to you, Neeta.
Dr. Erinjeri:
Absolutely, so because the thyroid affects so many different things with regards to the hormones it produces, there are a lot of symptoms that can be associated to the thyroid, but also could be caused by other things. And that's one of the things in medicine that we deal with, what is the actual cause? So with the thyroid hormone levels, when they are too high, they can cause a lot symptoms such as palpitations, elevated heart rate, excessive sweating, weight loss, diarrhea. It really can have a lot of effects, and it can happen and some people really don't notice it at all.
Dr. Erinjeri:
When the thyroid function is too low, this is what people worry about a lot, you can notice things like weight gain, feeling cold all the time, feeling very tired and lethargic, dry skin. These are all symptoms that can also be caused by other things, but it is often what triggers a workup and evaluation of the thyroid gland. We also see problems, then, that have nothing to do with the thyroid hormone production, but actually nodules within the thyroid. And depending on where those grow, how big they are, those can also trigger other effects, such as local symptoms, from it pushing on surrounding structures, being visible externally, or causing no symptoms at all but showing up on imaging that we do for other reasons altogether.
Dr. Fialkow:
So, Pascual, we don't want people jumping to conclusions with minimal symptoms, it should be part of a workup. So explain to us the role of the primary care doctor when someone may suspect a thyroid disorder. Also, when should they go to an endocrinologist? What should trigger that? And the other thing I'd like you to comment on is, is it possible to have thyroid disorders and feel nothing? So lots of questions there, Pascual, but this is your expertise. So can you feel nothing? If you're concerned, what's the primary care doctor's role? When should it trigger an endocrinologist?
Dr. De Santis:
People who have a very mild form of abnormality, either in the hyper range or the hypo range, and depending on their age, they may be perfectly asymptomatic. There are these very low levels of hyper or hypo called subclinical, which you have a very specific definition biochemically, in which people may not actually feel any symptoms. In terms of when somebody has a concern, a patient has a concern that they may have a thyroid problem, the first person they need to go to is their primary care doctor. As Neeta explained, when symptoms are very vague and unspecific, it could be caused by anything, but certainly could be related to a thyroid hormone abnormality. In that situation, both the ATA, American Thyroid Association, and the American College of Physicians, they have a very specific simple way of screening for thyroid function abnormality, which the primary doctor can easily order. It's not a fancy test or anything, it's just a blood test, and that will immediately alert the primary doctor as to whether there is a thyroid function abnormality or not.
Dr. De Santis:
The kind of function abnormality that does require, I think, a reflex referral to an endocrinologist is when people have hyperthyroid, because that's a bit more concerning since it can be a little more dangerous, depending on the progression and how severe it is. Long-term, the management of hypothyroidism, once everything is stabilized and everything is okay, then can remain with a primary doctor, and occasional consultations with the endocrinologist if things go wrong. When people do have thyroid nodules and symptoms of obstruction, like Neeta was saying, then I think it's another reflex referral to the endocrinologist as well. They can order a preliminary ultrasound or something, and then send the patient to the endocrinologist.
Dr. Fialkow:
Let's bring it back a level to just hypo and hyper. Can you talk a little bit, we used the term a couple of times, you mentioned a couple of the symptoms. What goes on when you're hypo? What goes on when you're hyper? And maybe even a little bit about TSH and T4? We use those terms, and what they really mean, because they are a part and parcel how we determine what the thyroid conditions are, what we look for, for treatment benefits.
Dr. Erinjeri:
Absolutely, so as the names would suggest, hypothyroidism is really where the thyroid gland is not producing a sufficient amount of thyroid hormone compared to what your body needs. And how to determine that as, as we mentioned, there's a lot of symptoms that may or may not be related to it, but how we truly determine that is looking at TSH levels, which are basically coming from the pituitary gland, which is our body is telling us, it's trying to stimulate the thyroid more, or basically trying to tell the thyroid to slow down a little, depending, and T3 and T4, which are produced within the thyroid gland themselves. So T3 and T4 are the hormones that your thyroid gland actually makes, versus TSH, which is the regulatory factor. So with hypothyroidism, you actually get elevated TSH levels because the pituitary is trying to tell the thyroid to do more, because whatever the levels are, it's getting the signal that it's not enough for what your body needs at that moment, at that time.
Dr. Erinjeri:
And again, as Pascual said, those levels, it has to be repeated because in any moment you will have these fluctuations, the thyroid is affecting the whole body, and we go through different simulations throughout our lives, throughout every day, that these levels can be up and down a little. But when it's a sustained, elevated TSH level, that is really the body saying that, listen, this is not enough for what I need, and the pituitary gland is trying to stimulate thyroid to do more and sustain high levels, it's basically saying that it's unable to, because despite that stimulation, the levels have not come up from the thyroid to where they need to be, and that would be hypothyroidism. Whether the T3 and T4 levels technically fall within the normal range or not, this is where you get into subclinical versus clinical hypothyroidism, that TSH value is, the combination we use, but the TSH value is really kind of our own body saying, this is not enough for what we need right now.
Dr. Erinjeri:
Hyperthyroidism then is the opposite. For any number of reasons, the thyroid gland in that moment is producing more hormone than is necessary. That again, more excess levels of T3 and T4, compared to what your body actually needs. So the pituitary gland reduces the amount of TSH, so thyroid stimulating hormones. Sorry, basic, reduces the amount of stimulating hormone that it is producing, trying to tell the thyroid gland, slow down, I don't need this much. Your body doesn't need this much, and it's actually causing the stress on the body by having those levels too high. Again, if the T3 and T4 are normal, and the patient is asymptomatic, despite the TSH being low, this is again a subclinical state, but as Pascual mentioned, the hyperthyroidism, because of the effects that it has on whole body, even in a subclinical state, is something that warrants a little bit more in depth evaluation compared to hypothyroidism because of the long term downstream effects that hyperthyroidism can have.
Dr. Fialkow:
So let me ask you a follow-up, two follow-ups. First one is, if someone is asymptomatic, hypothyroidism, TSH a little high, saying we need a little bit more, but they feel fine, do those people generally go on and it never progresses to anything more than that? Or is there a tendency? And again, these are treatable conditions which we'll get to, is there a tendency for them to then become more symptomatic over time? Or could people go long periods of time where they're asymptomatic, but that stimulation is a little higher than we would consider normal?
Dr. Erinjeri:
Yeah, so they can go very long periods of time without actually ever becoming symptomatic or reaching a clinical level, but here the most common cause of hypothyroidism is a condition called Hashimoto's thyroiditis, which is why Pascual was mentioning checking antibody levels and things like that, because it could be an autoimmune related disease. And the thing about Hashimoto's is that over time, it does tend to progress. So, even in the moment, it may not be anything and it may not cause anything at that time, and in general with the thyroid, most things with thyroid are slowly progressive, it's not something that goes from one week to the next, or even necessarily from one year to the next, that you'd notice a big change, but it's something that, if noted, it needs to be followed because you do anticipate that, again, this being the most common cause of hypothyroidism, that over time, it would get worse, and eventually reach the point where it would require treatment.
Dr. Erinjeri:
Easily treated with thyroid hormone, you don't have to take anything, with it being autoimmune, you're not on immunosuppressive drugs or anything like that, it's actually just supplementing it with thyroid hormone when it gets to the level that you become clinical, the T3 and T4 are actually of a level that you need to start supplementing it.
Dr. Fialkow:
Then speak for a second, so you mentioned Hashimoto's, I was going to ask you about that, because that's a very common term because it's a very common cause for hypothyroidism. How about Graves' disease? Just mention to the viewers who may have heard that, or try to put into prospective what would be Graves' disease?
Dr. Erinjeri:
Sure, so Graves' disease is another autoimmune disease, but rather than slowly causing too low thyroid function, with Graves' disease, you actually get hyperthyroidism. And this is treated in a few different ways, but again, because hyperthyroidism has a little more serious downstream effects, with Graves' disease you actually start treatment to try and keep you at a thyroid level, and it's with thyroid blocking medications. And the goal with that is to return you to a normal thyroid state with these medications. It's often, but not always successful. And those medications, as opposed to thyroid hormone supplementation, which is very well tolerated, those medications do have some more serious side effects when you are on them for long periods of time. So with Graves' disease, while the primary and initial treatment to get the levels under control is with medications, such as methimazole or propylthiouracil, that is a disease that may end up being treated with surgery or with radioactive iodine, depending on the severity of disease, when you're diagnosed, and the other sequela of disease that you have.
Dr. Fialkow:
Pascual, a couple of quick questions before we move on to thyroid structural abnormalities. Is one or the other, hypo or hyper, more common? In your experience or in the data? In the population?
Dr. De Santis:
I have to say, like Neeta was suggesting, both of them, in North America at least, the most common risk for both is autoimmune. And you can think of this like a big spectrum of disease in which the same autoimmune background could lead to both. And in fact, this is rare, we don't typically see this, but you can see people flipping from one to the other. This is, again, this is not common, but I've seen it, and it's reported. Of the two, the hypothyroidism and Hashimoto's thyroidism, that is far more common than hyperthyroidism. And you can have somebody with coexisting, several autoimmune conditions in the thyroid at the same time, but to answer your question specifically, yes, hypothyroid and Hashimoto's is far more common than hyper.
Dr. Fialkow:
Neeta, let's switch gears for a second, talk about, again, structural thyroid nodule, so I want to talk about thyroid cancer, which is not uncommon. So in the context of thyroid cancer, first thing is, do most people with thyroid nodules or even cancers, feel it themselves? Or is it picked up by a doctor's office or a different way? Secondly, if someone feels a lump in their thyroid, or describe where the thyroid is, what's the likelihood that it becomes something that warrants further work up? And specifically then get into thyroid cancer.
Dr. Erinjeri:
Sure, so first of all, thyroid nodules are extraordinarily common. And obviously because of the risk of cancer or the concerns about cancer, as soon as a patient knows they haven't thyroid nodule, it triggers a good amount of anxiety, which is understandable. But thyroid nodules are extraordinarily common in the population in general, and we do notice, more common as people get older, and thyroid nodules are more common in women compared to men, but we see it in every age range in reality. The vast majority of them are completely benign.
Dr. Erinjeri:
So I start with that, I start with that with my patients as well, because usually that at least allays the initial fears when we're talking about things. But, it does warrant work up. Now a lot of thyroid nodules are found on imaging that is done for some other reason, or from somewhat nonspecific symptoms that could or could not be related to the thyroid that triggers this evaluation and workup of the thyroid, like we mentioned, a lot of these symptoms can be related to many things. So we see them found incidentally on imaging that was done, for example, from a neck injury, or a posterior neck pain, carotid imaging-
Dr. Fialkow:
Carotid ultrasound, we see that in cardiology, we see the nodules, we tell the person.
Dr. Erinjeri:
Exactly, and it triggers the workup. But it's also found a lot by physicians who are palpating the thyroid on routine physical exam, or by patients who self palpate, or present with symptoms just based on the location. There is really a wide range of ways in which people present with these thyroid nodules, and it just triggers the workup. The initial workup starts with blood work to see how the thyroid is functioning, a physical exam done by primary care physician, endocrinologists, but your clinician and an ultrasound, and then we use the results of those studies to further decide what else needs to be done.
Dr. Fialkow:
So what about thyroid cancer? If someone actually has thyroid cancer, talk a little bit about how it may present, what are our treatment options? How do we generally work up thyroid cancer?
Dr. Erinjeri:
Sure, so with thyroid nodules, about 95% are benign. So you just have this small percentage of thyroid nodules that present that are thyroid cancer, or risk of thyroid cancer. And they often present, thankfully, in the same way, in that they're presenting with small nodules that are found through a routine workup. And they warrant a full evaluation and then intervention, but there are not necessarily specific symptoms that are more likely caused by thyroid cancer than a benign thyroid nodule. Feeling a mass in the neck, having an enlarged nodule in the neck or a growing nodule in the neck, unless it's rapidly growing, is not more attributable to a thyroid cancer compared to a benign thyroid nodule. They both present in very similar ways.
Dr. Erinjeri:
A rapidly enlarging thyroid mass, and I mean, over weeks, or a sudden onset of voice changes like a horse raspy voice, that's unrelated to an illness such as strep throat, but those things are more concerning for a thyroid cancer, but otherwise, fortunately or unfortunately, they do tend to present in the same way. It doesn't generally present with abnormalities in hormonal function, so having normal function or abnormal function does not mean that you have a thyroid cancer, and it doesn't always present with a mass that is necessarily symptomatic to the patient.
Dr. Fialkow:
You guys have really given us great information, and it's very complex, it seems pretty simple, I have an overactive or an underactive thyroid, but obviously, the underlying presentations and mechanisms and consequences are broad, and it is very common, so a great job. A couple of questions from the audience before we wrap up. For Pascual, what is the connection between thyroid health and fertility? Is there a connection? If so, can you discuss it a little bit?
Dr. De Santis:
So yeah, so when you have overt thyroid dysfunction, meaning you're not in the subclinical area, but you have significant hypothyroidism or significant hyperthyroidism, you can see, actually, menstrual irregularity, ovulation issues, and that's going to, of course, interfere with the ability of a woman to become pregnant. In the context of a clinical overt situation, there's no question, it needs be treated. In addition, once a woman becomes pregnant, they do have an increased requirement of thyroid hormone, about 20 to 30% more. So if you have somebody with a normal thyroid function, but you know there is some degree of thyroid tissue has been destroyed by this autoimmune condition, perhaps this sort of stress test on the thyroid during pregnancy, the thyroid may not be able to keep up with the demands.
Dr. Fialkow:
So maybe I'll ask each of you this final question. And again, I appreciate your responses. And Pascual, I'll ask you about hypothyroidism, and for Neeta, I'll ask you about hyper. Just speak to your experiences, when people come to you for the various conditions, or what you've seen, very symptomatic, not feeling well on the low or high side, tell us how they respond when they get treated medically. So, Pascual, do you find people with hypothyroid and they continue to live the rest of their life with these horrible symptoms? Or, tell us the efficacy of the treatments.
Dr. De Santis:
So, when people are overtly hypothyroid, they have a severe degree of hypothyroidism and you treat them, they, I would say a hundred percent of the time, they experience improvement of the symptoms, once you normalize it. Now, once the person has been treated and their thyroid function tests have normalized, about 20% of patients do not feel completely okay. And it's a little hard to pinpoint why that is. I mean, as Neeta was alluding to before, sometimes even in that situation, many patients are going to try to blame the thyroid for things that are going on at the same time, even though the thyroid function does have normalized on the treatment. Well, at that point, it's a bit more difficult to argue that whatever symptoms they're having are truly associated with the thyroid. Typically at that point, those symptoms are going to be back to being vague and unspecific, that could be associated with multiple other things. So, things that overlap with the symptoms of thyroid disease are going to be sleep apnea, anemia, iron deficiency, you name it, I mean, there's a myriad of things that can do it.
Dr. Fialkow:
So they need to be followed continuously, we don't just forget about it, but generally the majority respond. Then, Neeta, briefly again, on the hyperthyroid state, we talked about medications and then sometimes other options, more definitive, do people tend to get better?
Dr. Erinjeri:
Absolutely. I mean, the easy answer is yes, once you normalize the thyroid hormone, those hyper symptoms decline. Some people don't... You like a little mild hyperthyroidism so they don't often enjoy the fluctuation, but you lose the extremes of hyperthyroidism to stabilize your weight, your heart rate, everything. It gets you back to normal state, and that's really where you want to be, and they get that, either from medications or additional treatment when necessary.
Dr. Fialkow:
To our listeners, remember that you can send us your comments and suggestions for future topics at baptisthealthtalk@baptisthealth.net. That's baptisthealthtalk@baptisthealth.net. On behalf of everyone at Baptist Health, thanks for listening, and stay safe.
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