Thyroid Disease – a little gland – big effects

January was Thyroid Disease Awareness month and thyroid disorders are very common.  Unfortunately, it’s usually not the answer to the 10 pounds you are trying to lose.

What is the Thyroid?

The thyroid is a gland located in the neck near the “Adam’s Apple”.  It’s job is to produce Thyroid Hormone (T4, T3) – which helps set your metabolism and plays a role in almost all of your bodies’ functions.
Your thyroid gland is regulated by another gland called the Pituitary Gland, located in the brain. The pituitary acts as a thermostat to control the thyroid – the technical term for this is a “negative feedback loop.”  The pituitary measures the amount of thyroid hormone in the body.  Based on this measurement, it secretes either more or less Thyroid Stimulating Hormone (TSH) telling the thyroid gland to increase or decrease thyroid hormone production.  So TSH goes up when the pituitary senses low levels of thyroid hormone and goes down for high levels.  That is why when your thyroid is tested, the doctor looks at both the level of thyroid hormone in you blood as well as the TSH level.  This allows assessment not only of how your thyroid gland is working, but also how hard it is working to maintain a level.
Based on the values of the TSH and T4 we can begin to tell if the problem is in the thyroid gland itself or in the pituitary gland regulating your levels.  Testing T3 levels can be helpful when the TSH/T4 levels are borderline or someone’s symptoms and the test results don’t make sense – but most people can be diagnosed and managed without it.

Thyroid Disorders

There can be structural issues of the thyroid – nodules, cysts and tumors (both cancerous and benign).  These may or may not affect the overall functioning of the thyroid, but may be felt on physical exam or found when evaluating other neck issues.  I can write more about those issues in a future post if people are interested.  The remainder of this article will focus on the two major functional thryoid disorders – hypothyroid (underactive) and hyperthyroid (overactive).  There can be many causes of of hypo- and hyper- thyroidism, which is part of the challenge – determining your diagnosis – specifically what is your thyroid issue?

Hypothyroidism

This is the most common of the functional thyroid disorders.  Hypothyroidism means an underactive thyroid gland.  Symptoms include fatigue, constipation, dry skin and hair, weight gain, swelling, depression or change in concentration.  The symptoms can also be variable.  Many people are diagnosed with minor hypothyroidism (called subclinical) when their tests are abnormal during a routine exam.  There are many causes of hypothyroidism.
If the pituitary gland is not working properly and cannot produce TSH, then the thyroid gland, although normal, will not produce thyroid hormone.  This is usually due to an abnormal growth in the pituitary such as an adenoma (a benign tumor). This type of hypothyroidism occurs in about 1% of cases.
Autoimmune thyroiditis – also known as lymphocytic or Hashimoto’s Thyroiditis is the common cause of hypothyroidism.  The body’s immune system recognizes the thyroid gland as foreign and starts to attack it by making antibodies against it.  As the structure of the gland gets damaged, it is unable it produce thyroid hormone and you develop hypothyroidism.  Your blood tests will show a high TSH and a low T4.  There is also a blood test to detect the anti-thyroid antibodies, which, if present, confirm the diagnosis.
Other forms of hypothyroidism are more difficult to find a direct cause for, but they are all diagnosed by a high TSH and a low T4.

Hyperthyroidism

When the thyroid gland is overactive – making too much thyroid hormone – a person is Hyperthyroid.  The most common cause for hyperthyroidism is Grave’s Disease – another autoimmune disease of the thyroid gland.  In Grave’s Disease, the body makes antibodies against the thryoid gland like in Hashimoto’s Thryroiditis, but instead of destroying the gland, these antibodies stimulate the thyroid gland to continue producing thyroid hormone regardless of what the pituitary gland tells it to do.  These antibodies are called Thyroid Stimulating Immunoglobulins (TSI) and can be tested for in the blood.
The symptoms of hyperthyroidism are feeling keyed up (over caffinated), diarrhea, weight loss, rapid heart rate and hair loss.  Grave’s Disease can also cause the eyes to bulge due to antibodies building up in the muscles behind the eyes.

Treatment

Hypothyroidism is treated mostly with levothyroxine, which is synthetic T4.  It is an exact match for what the body naturally produces, as opposed to earlier treatments which used animal thyroid glands.  There are many dosages available, allowing us to match the dosage given to what your body needs.  We measure success by following the TSH.  Based on your TSH level and how you feel, we can be sure to get the dosage specific to your needs.  There are a small percentage of patients who do not tolerate levothyroxine, and may use  different medications.

 

Hyperthyroidism is treated in a few ways.  Firstly, if a person’s heart rate is very rapid, medication to block the effect of excess thryoid hormone (called beta blockers) can be used to treat the symptoms while treatment to regulate the thyroid gland takes effect.  There are medications called methimazole and propylthiouracil (PTU) which can be used to reduce the production of thyroid hormone.  Radioactive iodine can be given to destroy a portion of the thyroid, reducing its ability to produce hormone.  The thyroid gland can be surgically removed as well.  Surgery and radioactive iodine have a high rate of making someone hypothyroid, which would then require lifelong levothyroxine.

How does this affect MY practice

Thyroid tests are something I order as part of general physical exam.  Because the symptoms can be subtle, we can diagnose and begin treating a problem before it gets too severe if we screen for thyroid disorders.  Thyroid tests are also ordered when someone complains of the symptoms of either hyper or hypothyroidism.  When the tests come back abnormal, I order the antibody test – if the cause of thyroid disease is autoimmune it is important to know – as people with one autoimmune disease are at higher risk of developing another.
If a person is hypothyroid, they are usually given levothyroxine, and a TSH level is repeated in about 6 weeks, then, based on those results the dosage is adjusted until symptoms are controlled and the TSH is in the proper range.
Many people ask me about over the counter thyroid supplements instead of prescription levothyroxine.  I generally advise against this for a few reasons:
  • They are not FDA regulated
  • The dosages can not be as finely tuned as levothyroxine can.  They are usually made up from animal thyroid glands and can contain impurities
  • A recent NY Times article quoted a study that showed 9 out of 10 thyroid supplements tested at random contained 2-3 times the starting dosage of thyroid hormone – which should only be dispensed with a prescription
When hyperthyroidism is diagnosed, we immediately focus on controlling the symptoms such as anxiety, heart palpitations and tremor.  Then a discussion as to the best means to control their thyroid gland’s production – medication, radioactive iodine or surgery.
Thyroid problems are very common and can have a large impact on  a person’s sense of well being.  By using a person’s own control systems to dose their medication, we can come very close to restoring their thyroid levels to what their body needs.  Together, doctor and patient can review symptoms, get tests and most importantly, get a diagnosis.  Then a treatment plan and healing begins.

 

The path to wellness begins with a proper diagnosis

Cold, Flu, Allergies or worse – what’s my diagnosis?

I’ve been sick for 2 weeks, nothing is helping!

It is the peak of cold and flu season and it is likely that you and at least 3 people you know have probably said this.  Regardless of the climate you live in, it’s cold and flu season, not to mention allergies.
Do I need antibiotics?  Am I contagious?  Can I fly?
How do we figure out what is the cause of your suffering?  What is your diagnosis?
For these seemingly simple symptoms and problems a proper diagnosis is key.
  • A cold will get better on its own
  • The flu can be treated with specific medication
  • A bacterial infection such as strep throat should be treated with antibiotics
  • Allergies can be treated with specific medications
So calling your doctor for a “z-pak” will only work at best 25% of the time – the rest of the time you may improve around the same time as you finish the antibiotics – not because of it.

What in a history can clue the doctor into your diagnosis?

Some key questions will guide the doctor toward the answer.
  • How long have you had symptoms
  • Fever? Chills? Night sweats?
  • Type of cough?  Nasal congestion
  • Body aches?
  • Are the symptoms worse at night or first thing in the morning?
  • Anyone else sick at home?
Based on the answers to these and other questions, the likely diagnoses can be ranked.  After examining you, the doctor can see if there are other specific signs of infection like an ear infection or pus in the throat, giving more or less support to the diagnoses on their list.  Tests like a strep or flu test can be ordered and a diagnosis made, treatment given, and you can start to feel better and get well!
If you are given the wrong treatment, such as unnecessary antibiotics, you are exposing yourself to medications with side effects, perhaps creating resistant bacteria in your system and NOT improving your health.
Determining the cause of your symptoms, getting the right diagnosis, is essential to giving proper treatment.

How does this affect MY practice?

The key to determining the need for antibiotics is a good history.  There are several factors that lead me to decide what treatment is best for you.

  • How long have you had symptoms?
    • sick for a month or longer suggests allergies as opposed to an infection
    • cold symptoms for more than 10 days may need antibiotics
    • very sudden onset of symptoms should be seen sooner rather than later
  • Were you getting better and then seemed to relapse – this may indicate a second infection
  • Body aches with cold symptoms suggest the flu
  • Do you have a weakened immune system due to other illnesses or medications?

Combining this type of information with the findings on a physical exam and quick office lab tests for strep and flu make the diagnosis and treatment plan one that hopefully helps you feel better with a low risk of side effects!

The path to Wellness begins with a proper Diagnosis.

What is a Diagnosis? A rose by any other name?

You go to see a doctor with a painful shoulder. You tell the doctor that you can’t sleep because of the pain, and the doctor starts to make assumptions about your symptoms.  Before you get a chance to tell the doctor your story, you are told you slept on it wrong, and given a prescription for anti-inflammatory medication.  You don’t really improve and so you see another doctor for a second opinion.  A full history is taken, and you tell the doctor that you play softball on the weekends and you collided with the catcher while trying to score.  The doctor examines you and tells you that you likely have separated your shoulder.  An x-ray is ordered and it shows a shoulder separation.
Unfortunately, quick, easy answers and assumptions frequently lead to an incomplete diagnosis or a misdiagnosis.  These carry costs – your time and your money spent finding the correct answer, but more importantly, your health – which is why you go to the doctor in the first place.  Your story is like a puzzle, separated pieces that depict your diagnosis – the doctor has to put them together.
Your doctor needs to ask the right questions and listen to you to put your puzzle together.  It is what I am trained to do – make a diagnosis.  But what is a diagnosis?

  • A label
  • A code
  • A starting point for treatment

A diagnosis is a term with medical meaning.  It is comes from a physician’s synthesis of a patient’s symptoms, history, physical findings and laboratory findings.  A proper diagnosis is essential to begin a journey towards Wellness!

How does a doctor approach making a diagnosis?  We start by making a list – called a “differential diagnosis.”  As we take a history from a patient we start listing diagnoses that fit the symptoms.  As more of the story unfolds, the list is adjusted, the order is changed, items added and removed.  Then we examine the patient, and again revise the list based on our findings.

Tests are then ordered to do two things.

  • Definitely remove an item from list.
  • Confirm items on the list.

The approach to testing, however, doesn’t always focus on the most likely – there are other factors that determine the order of the tests.  If being wrong about a diagnosis has severe consequences, it may be tested for first even if less likely.

Finally, all the information gathered from the history, physical and diagnostic testing are put together and the list is put into a final order and a diagnosis is made.

If a treatment works, it confirms the diagnosis choice from the list.  If a treatment doesn’t work, the list needs to be re-examined and the history revisited to see what information was missing or not emphasized.  This is a crucial time in communicating with your doctor – they need to know what you are experiencing.  Based on that re-evaluation new tests may be ordered to further refine the list, and so on, until the final answer is revealed.

So what?  Why is this important?

First and foremost it determines treatment.  A diagnosis of Strep Throat requires treatment with antibiotics; a cold does not.
The diagnosis is what is used by insurance companies to approve tests and medications.
Diagnoses determine life insurance rates!

A diagnosis represents the last piece of the puzzle being put into place; it allows you and your doctor to chart a course of treatment and find direction after the confusion of not feeling well.

Without a proper diagnosis, you wander in the medical field, so remember:

The path to wellness begins with a proper diagnosis

 

Making a diagnosis – Who am I?

As you sit in the doctor’s office for the first time, your eyes note the array of diplomas and plaques on the wall. You have never met this doctor before, but your friend said they were good, or you picked them out of a book, or you were referred by another doctor, and you are about to share intimate details of your life with them. You have questions about how you feel, and you are going to get a diagnosis. But who is the person behind the plaques? What do all those fancy diplomas mean? After all, they call the person who finished last in the medical school class the same thing as the first – “Doctor”. Doesn’t it make sense that you know something about this person who is going to ask you personal questions and examine you? Shouldn’t you know more about this person you call “Doctor”? Well, I think the answer to this question is YES! So who am I? Keep reading…

All doctors are trained to make diagnoses, some within specialities – orthopedists, neurologists, surgeons, etc.  Most diagnoses are first evaluated by a primary care doctor.  There are several specialities that make up primary care doctors – who you see will depend on age, who practices where you live and possibly your gender.  Examples of primary care doctors:

  • Family Practitioner – a physician trained broadly to care for a person from birth to death
  • OB/GYN – a physician trained in women’s health and pregnancy care
  • Pediatrician – a physician who specializes in the care of children
  • Internist – a physician who specializes in the care of adults

How did I get here?

I am an Internist.  How did I come to call myself this?  Who am I behind other than the plaques on the wall? After graduating from college at Case Western Reserve University in Cleveland, OH, I attended the Albert Einstein College of Medicine, in the Bronx, NY, earning my MD with Distinction in Research.  I then spent 3 years as an intern and resident in Internal Medicine at New York University Langone Medical Center and Bellevue Hospital in New York City, completing the training to be a licensed physician.  I then served for an additional year as a Chief Resident for my program helping train the recent medical school graduates.  It was during this year that I took and passed an exam to become Board Certified in Internal Medicine by the American Board of Internal Medicine (ABIM).

 

I joined a prominent medical practice in NYC remaining on faculty at NYU School of Medicine.  During that time I refined my diagnostic skills, continued to train medical students and residents and eventually earned the rank of Assistant Professor of Medicine at the NYU School of Medicine.  After my first 10 years in practice as a Internist, I was tested again by the ABIM as part of a recertification process and again passing a comprehensive exam to remain Board Certified.

 

In 2012, after 13 years with my practice in NYC, my family and I decided to relocate to Phoenix, AZ where I joined Scottsdale Healthcare to bring my skills to a practice in the Arcadia area of Phoenix.  During my first year in Arizona, the American College of Physicians (ACP), which is the national society for Internal Medicine, elected me to Fellowship after a review of my professional work.  Doctors who have the initials FACP after their names have earned this distinction.

 

What is next?

This has been my path so far as an Internist.  I hope I have given you an appreciation of what the journey is like.  Along my journey I have worked with tens of thousands of patients to take the lead in helping them identify risks to their current and future health and well-being; prevent problems, and find the diagnoses that threaten their health today. It is with the realization that a proper diagnosis sets the foundation for all future health issues that I begin The DiagnosisMD blog.  My goal is to explain why a diagnosis matters, shed some light on the process a doctor uses to make a diagnosis, and explore interesting and timely topics in medical news.

So what is an Internist?  The ACP defines it as:

“Internal Medicine physicians are specialists who apply scientific knowledge and clinical expertise to the diagnosis, treatment and compassionate care of adults across the spectrum from health to complex illness.”

Or as one of my patients from NYC used to say, “You are a Doctor’s doctor.”

 

I hope you enjoyed this look into my journey as a physican so far, and look forward to sharing my thoughts and reading your comments along this journey.

 

The path to wellness begins with a proper diagnosis