Fertility after the pill

I recently referenced a NY Times article summarizing a study showing a link to stress and fertility problems.   As an Internist and Primary Care Physician, I am often asked fertility questions by my patients that are trying to conceive.  “I’ve been on the pill for years and now I want to get pregnant.  Will it be hard for me to conceive?” is an incredibly common question.  The answer depends on many factors.   The main determinants of fertility are age and the regularity of ovulation before and after oral contraception use.

Does duration of pill use affect fertility?

The amount of time a woman used oral contraceptives prior to attempting conception has little to do with time to recovery of their prior cycle.  Most physicians recommend waiting for a cycle off the pill before attempting conception, however, it is possible to get pregnant right away.  Therefore, if you do not wish to get pregnant right away, an alternative, non-hormonal, method of contraception is recommended.

Oral contraceptives use hormones to suppress ovulation.  If a woman does not ovulate, she can not get pregnant.  Once oral contraceptives are stopped, the hormones from the pill are out of the system in 3-4 days.  After that, the body’s own hormonal rhythm takes over.  So, if a woman had a regular ovulatory cycle before starting the pill, it is reasonable that she will resume that cycle shortly after stopping.  If the pill was being used to regulate an irregular cycle, then the ovulatory issues that existed prior to the pill will need to be addressed after the pill.

Fertility after the pill is mostly determined by fertility prior to the pill.  Duration of oral contraception use is not a major factor.  It takes the average couple about 8 months to conceive, so fertility testing prior to 1 year of attempting conception is not recommended unless there is an underlying issue that may be contributing to infertility.

How does this affect my practice?

A good history about why a person was using the pill, determining any risk factors for fertility issues is most important in answering the question of “will I have fertility issues after the pill?”  Once a sense of how regular a woman was before starting the pill, we can begin to predict what issues, if any, may need to be addressed.  A conversation with your doctor can lead to a plan, alleviate stress and allow you to enjoy the journey to a new part of your life.

The path to wellness begins with a proper diagnosis

Addiction and Substance Abuse

Of all the illnesses I treat, conditions I diagnose and problems I am presented with, one of the most difficult is addiction. Addiction can be to many things – alcohol, illegal drugs, prescription drugs, smoking, food, exercise, gambling and other behaviors. Addiction affects not only the person involved, but their entire network of friends and family.

One of the biggest challenges in diagnosing addiction is that the person may not admit there is a problem. A family member may speak to me, but the conversation usually ends with – “don’t tell them I spoke to you, I just wanted you to know what is happening…” I can not force a patient to come speak to me, nor can I tell that family member anything about what I may have discussed with the patient (without their permission). After awhile, their addiction becomes a palpable element in the room that no one can speak about. I will ask about it, but if the patient will not acknowledge an issue, there is little to be done.

What causes addiction?

Addiction is defined as a chronic, relapsing disease characterized by compulsive drug seeking and use despite harmful consequences as well as neuro-chemical and molecular changes in the brain.    Addiction crosses lines of race, economics and education.  In 2010 it was the 15th leading cause of death in the United States.

When exposed to a potentially addicting substance, the brain produces a substance called dopamine.  This activates the brain’s “reward circuitry” which will begin to create cravings.  Some people are genetically predisposed to be more susceptible to this, so addiction can run in families.

In addiction to the reward center, cognition and understanding are affected.  The prefrontal cortex of the brain – the higher brain involved in thinking and reasoning becomes affected as well.  A phenomenon called Restricted Awareness occurs – the addicted person becomes unable to fully grasp the deficits their behavior has created – so there is a neuro-chemical issue and not just denial at work.  Similar changes are triggered by high fat/high sugar foods as are by drugs.

Drugs of abuse - from the National Institute of Drug Abuse
Drugs of abuse – from the National Institute of Drug Abuse

Physical effects of addiction

The changes in the brain are consistent across substances.  Different substances can have different effects on other parts of the body.  While this is not a comprehensive list, some commonly abused substances and their physical consequences are:

  • Marijuana can damage the lungs just as cigarettes do
  • Cocaine increases plaque building in the arteries, increasing the risk of heart attacks
  • Heroin suppresses breathing
  • Prescription pain killers slow down the digestive system, as well as potentially cause liver and kidney damage
  • Alcohol damages the liver
  • Any drug that is injected, especially when needles are shared, increases the risk of Hepatitis B and C (which can cause liver failure and liver cancer) as well as HIV

How is addiction treated?

Treatment for addiction begins with a patient recognizing that their behavior is affecting their life in a negative way, and that they are unable to control it without help.  Treatment programs can be inpatient – meaning admission to a facility for detoxification and treatment with 24/7 monitoring or outpatient – meaning going to appointments with physicians and counselors while remaining in the community.

Regardless of the setting, treatment involves

  • Detoxification – stopping the substance of abuse and treating physical withdrawal
  • Counseling to help the addicted person process what they have been through and develop coping strategies for the stresses that led to the addiction
  • Medications may be used either short or long-term to block the effects of drugs of abuse, prevent activation of the rewards center in the brain or treat other issues related to substance abuse

Successful treatment can reverse the brain changes that occur with addiction, just as smoking cessation reduces the risk of heart attack, stroke and lung cancer.

Brain scan showing near normal activity after14 months of sobriety
Brain scan showing near normal activity after 14 months of sobriety. Source: National Institute of Drug Abuse


How does this affect us?

Substance abuse takes many forms, and I need to be alert to signs that there may be issues – clues from behavior as well as physical findings.  Direct questions from a physician are usually answered with some truth.  That can begin a conversation about starting a treatment program.

In the case of prescription drug abuse, physicians have some additional tools.  Several states have databases that physicians can register for to see if prescriptions are being filled by multiple doctors and from which pharmacies and on what dates.  When you can show a person what their behavior has been, it again can be the beginnings of help.  A physician also needs to have a plan about stopping addictive prescriptions to prevent or end the cycle of abuse a person is in.  As a friend of mine who once became addicted to prescription pain killers told me that he hoped that a doctor would “catch” him so that he could get the help he knew he needed but did not know how to ask for.

If you or someone you know needs help:

National Institute of Health information of drugs of abuse – http://www.drugabuse.gov/publications/term/160/InfoFacts

Narcotics Anonymous – https://www.na.org

Or see your physician and ask for help!

The path to wellness begins with a proper diagnosis

Vaccines for HPV – Lies, Damn Lies and Statistics

In 2006, a new vaccine was introduced in the US – a vaccine for the Human Papilloma Virus (HPV).  This virus is responsible for most cases of cervical cancer, some throat, penile and anal cancers, as well as genital warts.  The vaccine is effective against the 4 strains of HPV that cause the majority of cervical cancer and genital warts.  It is given as a series of 3 shots over a 6 month time period, and is approved for females and males, ages 11-26.  There are two brands of vaccine, Gardisil and Cervarix, currently FDA approved in the US.  Recently, there has been a lot of media attention to HPV vaccines, leading to a lot of confusion about what the vaccine does and how safe it is.  As the father of a 12 year old girl, I thought I’d share my views and research.

What is HPV?

Human Papilloma Virus is the most common Sexually Transmitted Infection and responsible for most cervical cancer, as well as genital warts in both sexes.  It can also cause throat, penile and anal cancer.  The 4 strains of the virus that cause the most harm are 6,11,16, and 18, which are the strains in the vaccine.  HPV causes almost 34,000 cancers a year, with about 2/3 of them in women.  Almost 12,000 of the cancers are cervical cancer, which is usually treated by removal of the cervix and uterus (hysterectomy) which makes it impossible for a woman to have children.  Over 14 million people per year get infected with HPV.
HPV can be tested for in women during a PAP smear, hopefully identifying lesions before they become cancer.  However, there is no reliable test in men, other than doing a biopsy on a wart or other visible lesion.

What is the controversy?

Mark Twain once said, “There are 3 kinds of lies: Lies, Damn Lies and Statistics.”  All three have been used in the argument for and against vaccines.  Vaccines in general provoke very strong reactions from many people. Vaccines have been blamed for many conditions and reactions completely separate from the diseases the vaccines were meant to prevent.  There have been vaccines that have been recalled and discontinued because the risk of side effects was higher than the disease rate – a vaccine for Rotavirus and for Lyme Disease have both been discontinued.  There are immune reactions that are possible that can have serious health consequences, but these are not very common.  Allergic reactions to a vaccine are possible, just as they are possible with other medications or foods.  These reactions need to be considered and a good medical history obtained before they are administered.  However, I think that as medical science has progressed, we have lost sight of the devastation these preventable diseases  caused.  
I want to be very clear and state that there is NO LINK BETWEEN VACCINES AND AUTISM.  There was one scientist who made that claim and published research making that claim.  His research has been shown to be falsified, the journal that published the study issued a retraction and the scientist has had his medical license revoked.
Out of 57 million doses of HPV vaccine given through March of 2013, there have been 22,000 reactions reported.  Of those, less than 1800 have been considered severe reactions, mostly headache, nausea and fainting.  Enough people fainted that it is recommended that people wait 15 minutes after the vaccine before leaving the doctor’s office.  There have been about 30 deaths reported after the vaccine – but  none of those deaths have been shown to be directly related to the vaccine.  For example, if someone died in a car accident after receiving the HPV vaccine, it is reported.
Much of the recent controversy regarding HPV vaccine comes from 2 events in the past year.  In one, a physician submitted a case report of a 16 year old girl with irregular periods and eventual ovarian failure – with the symptoms beginning a few months after receiving the vaccine.  There was no evidence linking her condition to the vaccine, and it is known that in cases of early ovarian failure a cause is only found 10% of the time.  In addition, the reporting physician had strong personal beliefs that may have biased her reporting of the case.
The other event was when Katie Couric had a physician on her talk show who was involved in the development and testing of the HPV vaccine.  This doctor in several interviews did not question the safety of the vaccine or it effectiveness, but rather called attention to the fact that it is not yet known how long the vaccine lasts, and a booster may be needed.  She also questioned the need for the vaccine when PAP smears could detect the cervical cancer early.  However, HPV causes 20,000 cases of non-cervical cancer per year which would be missed.  Her statements also assume a much higher rate of women going for PAP smears than is likely to occur.  Ms. Couric did not give equal airtime to her own medical expert, her comments supporting vaccination were on the show’s website.  Ms. Couric did issue an apology after the show aired acknowledging that not enough airtime was given to talk about the benefits and safety of the HPV vaccine.

How does this affect us?

Our ability to treat disease has advanced tremendously in the past 100 years.  The rate of mothers dying during childbirth was reduced dramatically by having doctors and nurses wash their hands prior to delivering the baby… simply by preventing infection!  Today, it is accepted that by not smoking, maintaining a healthy body weight, normal blood pressure and cholesterol, we can prevent heart disease.  If we stop preventing disease, a healthy life and life expectancy would be very different from what it is today.  The CDC estimates that if we stopped preventing diseases with vaccines:
  • 13,000 – 20,000 people a year, mostly children, in the US would contract polio, requiring braces, crutches, wheelchairs and breathing machines
  • Almost everyone in the US would get measles, 20% of whom would need to be hospitalized, and 450 would die per year in the US, and 2.7 million worldwide
  • Haemophilous Influenzae (Hib) would cause 20,000 cases of meningitis or epiglottis in the US, killing 600 people per year.  About 1 in 200 children under 5 would be infected, and those that survive are often left deaf, with seizures or mental impairments
  • Almost all children would contract whooping cough, with about 9000 deaths per year
  • Pneumococcus would infect 63,000 Americans yearly, killing 10% of those infected
  • Rubella, while mild in most children and adults, causes birth defects in 90% of children whose mothers got infected while pregnant, causing heart defects, deafness, cataracts and mental retardation
  • Mumps would infect 300,000 people a year, and causes deafness in about 6% of cases.  It also caused miscarriages in women infected while pregnant
  • Hepatitis, Diptheria, Tetanus and Chickenpox are all diseases with potential long term consequences that we are preventing with vaccines
Vaccines are some of the most closely monitored treatments in medicine, both because the diseases they prevent are serious, and the consequences of not getting it right are real as well.  This is a great conversation to have with your physician during an Annual Physical.  My daughter will be getting her vaccination shortly.
The path to wellness begins with a proper diagnosis

Diagnosis of Arthritis

One of the most common reasons people go to the doctor is for joint pain.  “My knee hurts and swells after I walk, it hurts when it rains or it takes me awhile after I wake up before I can move well” are all often heard symptoms in patients with arthritis.  In a recent Center for Disease Control publication  22.7% of adults (52.5 million people) reported being told by a doctor they had arthritis, and 9.8% (22.7 million people) stated that their activity levels were reduced because of arthritis.

But what is arthritis?  Arthritis is inflammation in a joint.  There are multiple causes and types of arthritis, each with its own set of symptoms, complications and treatment recommendations.

The two main types of arthritis are Osteoarthritis and Autoimmune Arthritis.  They share some features and are very different in others.  Common symptoms between the two types are pain, joint swelling and stiffness.  Which joints are involved and the pattern of swelling and stiffness can differentiate between the two.  In addition, X-ray and blood test results are different in Osteoarthritis and Rheumatoid Arthritis (the most common form of Autoimmune Arthritis).


Osteoarthritis is generally referred to as “wear and tear” arthritis.  It occurs when a damaged joint fails to repair itself.  Osteoarthritis can effect only 1 joint, a few joints or be generalized.  It is the most common joint disorder.  It’s major symptoms are:

  • joint pain
  • restricted movement in the joint
  • loss of function

In general, osteoarthritis pain gets worse with use and improves with rest.  There can be stiffness in the morning which usually improves in under 30 minutes.  Usually, the appearance on an X-Ray does not match the symptoms – so a person with osteoarthritis could have significant pain but a normal X-ray.  Blood tests show normal to minimally elevated signs of inflammation.

Osteoarthritis of the hands involving the end of the fingers

The most commonly affected joints are:

  • Knees and hips
  • Junction of the fingers and hand
  • Finger joints and bunion joint of feet
  • Joints at the base of the neck (cervical spine) and the lower back (lumbar spine)

Other joints can certainly be affected, especially in the setting of a prior injury.

Another specific characteristic of osteoarthritis is the pattern of joint pain.  Osteoarthritis tends to involve one joint at a time, where as rheumatoid arthritis tends to involve joints on both sides of the body at the same time.  The knee is the most common joint affected.

In terms of treatment, the guiding principle is to focus treatments based on a patient’s symptoms and functional issues.

  • Weight loss and exercise can improve knee and hip pain dramatically
  • NSAIDs (ibuprofen, naproxen)
  • Topical pain medications (capsaicin, topical NSAIDs)
  • Joint injections
  • Supplements – there is some evidence but the quality of the studies is poor
    • Vitamin D
    • Glucosamine-Chondroitin
    • Tumeric, Paeony and Miatake have been shown to have properties similar to NSAIDs

Rheumatoid Arthritis (RA)

Like all the autoimmune arthritis syndromes, RA is an illness that affects more than just the joints.  It is characterized by inflammation that causes joint tissue damage.  There is a genetic predisposition as well as environmental triggers that are not well-defined.  The peak age of onset is between 30-50 years of age.

A typical patient will present with some of the following:

  • Pain and stiffness in multiple joints – usually the wrist and fingers first
  • Morning stiffness that lasts for more than 1 hour
  • Fatigue, fevers, weight loss

In 2010, the American College of Rheumatology updated the criteria for making a diagnosis of RA.  It is a point based scale that  take aspects of multiple features including joint pain, physical and lab features of the illness to give a score that helps make the diagnosis.  The updated criteria can be found here

Hand changes from severe Rheumatoid Arthritis

Blood tests for RA are not an absolute requirement, but two specific tests, Rheumatoid Factor and Anti-citrullinated protein are positive in about 50-60% of people.  In addition, a test for inflammation like C-reactive protein or sedimentation rate can be used to follow disease activity.

X-rays of the hands and feet are usually done at the time of diagnosis to check for joint damage.  Once the diagnosis is established, treatment should be quickly and aggressively started – studies have shown that treating aggressively early in the disease can lessen permanent damage.

The goals of treatment are:

  • Minimize pain and swelling
  • Prevent joint deformity and damage
  • Maintain quality of life
  • Control non-joint symptoms

Treatments for RA are called DMARDS – Disease modifying anti rheumatic drugs – are grouped into Biologic and Non-biologic treatments.  Non-biologic treatments are medications such as methotrexate that are used to reduce inflammation.  Biologic medications are newer treatments that block cytokines – chemicals that promote inflammation – such as Tumor Necrosis Factor (TNF).  They are usually given either intravenously or by injection.  Steroids and joint injections can also provide relief.  All treatments have potential side effects that patients need to discuss with their doctors to determine their proper therapy.

Some supplements have been shown to be effective at improving symptoms – fish oil when combined with DMARDS improved results over medication alone.  The supplements with NSAID like activity can also improve symptoms.  Exercise has been shown to decrease inflammation in joints as well as improve joint function, and should be part of every treatment regimen.

How does this affect my practice?

It takes a good history to differentiate Osteoarthritis from RA.  So working with someone to get a sense of their type of pain, and how it affects them on a daily basis is essential to a proper diagnosis.  Arthritis is a diagnosis with many subtleties – each variation carries its own specific issues, treatments and side effects.  The proper diagnosis provides the foundation for safe and effective treatment.

The path to Wellness begins with a proper Diagnosis

Test me for everything

An Annual Physical is one of my favorite visits. It’s an appointment specifically designated to review your health – both where you are now and where you are heading. It’s the body’s status update. It’s also where I feel I get to know a person a little better, more about your life in general, not just your blood pressure or back pain. Besides having a conversation about your health, a blood test is usually performed. Often, when we get to drawing blood at a physical exam, a patient will say, “Test me for everything.”  Obviously, everything is not possible – so a discussion of what “everything” entails is needed. 

Often, patients use “everything” as a signal for testing for sexually transmitted diseases (STDs).  It is important to know that HIV can not be tested for without your request – so do not assume it is being tested – ASK FOR IT!

Other STD tests usually include HIV, syphilis, gonorrhea, chlamydia and Hepatitis B & C.  Herpes can be tested for in the blood as well, but the test only shows whether a person has been exposed to the Herpes virus, it does not give information on contagiousness or disease activity.

HPV is tested for in women during a PAP smear.  It is a test done on cervical cells – it is not a blood or urine test.  There is no test for men for HPV, unless there is a lesion – usually a wart – that can be biopsied.

So what are the usual blood tests done at a physical?

It depends on your age and gender. The blood tests I order fairly universally:

  • blood count (CBC)
  • sugar (glucose)
  • liver function (AST, ALT)
  • kidney function (BUN, Cr)
  • lipid panel (cholesterol)
  • thyroid function (TSH, Free T4)
  • urinalysis

Often tested, but not “mandatory”

  • iron levels
  • vitamin B12
  • vitamin D

Other tests determined by age, gender or a medical condition

  • high sensitivity C-reactive protein (cardiovascular risk)
  • hemoglobin A1c (for further assessment of diabetes)
  • urine protein (for people with diabetes or hypertension)
  • prostate specific antigen (PSA) – this is ordered after a discussion about risk and benefits
  • other tests can be considered depending on individual risk – advanced lipid testing, imaging studies, stress tests – these depend on your specific medical needs and are not “one size fits all”

Do I have cancer?

One of the most common questions asked when we draw blood is can you tell if I have cancer? Blood tests for cancer or genetic information are not routinely done, with the exception of the PSA in men for prostate cancer.  While there are tests that exist for following some cancers, they have not improved diagnosis – especially the CA-125 test that is touted in many email chain letters for finding ovarian cancer – it is not a diagnostic test but rather a test for following someone with ovarian cancer. Using tests improperly leads to confusion, anxiety, more testing and misdiagnosis!

More cancers can be detected or screened for with specific tests other than blood tests. Colon cancer, breast cancer, cervical cancer and lung cancer all have screening tests (procedures) that improve detection. There are many guidelines as to when these tests should be done – the bottom line is that each person should discuss their individual risks with their doctor to determine what tests should be done, as well as when and how often!

This leads to the biggest issue of testing – interpreting the information in a meaningful way for you.  The FDA recently forced a home genetic testing company, 23 and Me, to stop marketing their kits due to quality and interpretation issues. As more tests are developed, our need to synthesize this information to make good decisions is becoming more apparent.

So, “everything” means different things to different people – so be specific if there is something you wish to have tested.  You can’t assume it is part of everything.  An Annual Physical gives you a snapshot of where you are, and serves as a guide for how to get to where you want to be. Have a conversation with your doctor about your health fears – an annual physical is the time to chart your path to health!

The path to wellness begins with a proper diagnosis

Testosterone Therapy – MANopause or Marketing?

Fatigue, weight gain, decreased sex drive and depression are very common complaints, especially as men age.  There are many diagnoses associated with such symptoms – obesity, diabetes and hypothyroidism are some examples.  They can also be associated with hypogonadism – which in men – is low testosterone or LowT.

What is Testosterone?

Testosterone is a hormone made in the testicles.  It’s production is controlled by other hormones in the pituitary gland, which senses the testosterone level in the body and directs production.  Testosterone is involved in genital development and other sex characteristics such as deepening of the voice, body hair, and sex drive.

How is Testosterone measured?

Testosterone is measured with a blood test.  There are two values that can be checked – total testosterone and free testosterone.  Free testosterone is the amount of hormone circulating that is directly and instantly available to the body, and not tied to another molecule in the system.

Normal levels of total testosterone range from 300-800 mg/dl.  One of the difficulties in measuring testosterone is that the value varies throughout the day and can be affected by a recent meal, exercise or the amount sleep you had prior to the test!

How is Testosterone supplemented?

Testosterone is not digestible, so it must be administered topically as a patch, cream, or gel, or injected into a muscle.  Each method has its pluses and minuses.

Topical medications are convenient, but may cause skin irritation.  There may be irregular absorption of the testosterone through the skin.  Also, if the testosterone is not completely absorbed it can be transferred to someone else’s skin – an important consideration if there are children or women (especially if pregnant).

Injections deliver a more precise dose and there is no risk of transferring the medication to someone else, but an injection every 2-4 weeks may be painful and less convenient – whether done at home or in a physician’s office.

How does Low Testosterone develop?

Damage or dysfunction of the testicles or pituitary gland either from medications, tumors or other problems can cause low testosterone.    Anabolic steroids – those used as performance enhancing drugs in sports – can lower testosterone levels among other side effects.  It was for severe deficiency around early development or testicular damage that synthetic testosterone was initially prescribed and FDA approved for – not for helping aging men feel 30 again.

Testosterone levels normally begin to decline by about 1% per year after age 30 – but this is very variable.  This decline, especially when blood tests became routinely available to check testosterone levels, gave rise to terms like andropause, male menopause or manopause.  In the past 10 years, testosterone use in men over 40 has quadrupled, and has become a multibillion dollar industry.

Similar to hormone replacement therapy (HRT) for women, restoring hormone levels to an earlier age has been marketed as a way of turning back the clock, restoring youth and vigor – and treating some very common, non-specific symptoms.  It wasn’t until after decades of HRT that a large study was done demonstrating that rather than helping improve women’s health, HRT increased rates of heart attacks, stroke, breast cancer and endometrial cancer!

Recently, several studies have been published linking testosterone therapy with an increased risk of heart disease.  These studies have called into question the wisdom of testosterone supplementation in the absence of true hypogonadism.  One study found that in men 65 and older the risk of a heart attack doubles in the first 90 days after starting treatment and goes up by 2-3 times in men under 65 with a history of heart disease.  This and other studies have prompted the FDA to review the safety of testosterone therapy and a large study similar to the one done for HRT is now underway to determine the benefits and harms of testosterone therapy.

How does this affect MY practice?

As with most diagnoses, a good history of symptoms is essential to determine their cause.  How long symptoms have been present, what seems to improve them, what else is going on in one’s life all contribute to weight gain, sex drive, energy and mood.  Diet and exercise habits need to be explored as changes  can have a huge impact on well-being, including raising testosterone levels without supplementation.

After discussing symptoms and a physical exam is performed, lab tests can be ordered.  I usually check a total testosterone first – it is much less expensive and the results come back faster.  If it is low or borderline, adding the free testosterone can be helpful to confirm or rule out the diagnosis.

Once all the data is back, we can review both symptoms and data together to decide if testosterone supplementation is likely to improve how one feels or if there is a different, more likely diagnosis.    Prior to starting supplementation I always check a blood count, cholesterol level, liver, kidney  and sugar tests as well as a PSA.  Supplementation can effect all these things which in turn can have health consequences.  For example, testosterone can cause the prostate to grow and may unmask an undiagnosed cancer – which is why supplementation therapy needs to be monitored.

At follow-up visits we assess the effect of treatment on both testosterone levels and most importantly, symptoms.  If the levels normalize and there is no change in how you feel, then as I wrote in an earlier post (What is a Diagnosis), treatment should be stopped and the diagnosis reconsidered.

The new evidence about the increased risk of heart attack will increase the conversations I have with my patients, especially those over 65 or with a history of heart disease, and likely increase how closely they are monitored.

Numbers from a lab without the context of symptoms don’t make a diagnosis.  Symptoms without the correlation of lab results often can not make a diagnosis.  Treating either in isolation does not improve health.  When used together, solutions can be found.

The path to wellness begins with a proper diagnosis

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?


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.


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.


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

Inflammatory Bowel Disease – a real pain in the…

December 1-7 was Inflammatory Bowel Disease (IBD) awareness week.  Though I had not launched this blog until after the week was over, those who know me know how important these illnesses are to me and my family.  I have served on the Medical Advisory Committee to the Crohn’s and Colitis Foundation of America (CCFA) both in NYC and Phoenix.  I have run 2 half-marathons (in Las Vegas and Virginia) to raise over $30,000 for the CCFA.  So even though IBD Awareness week has passed, I wanted to acknowledge it and review Crohn’s Disease and Ulcerative Colitis.

IBD is an autoimmune disease – meaning the bodies own defenses get altered and attack the intestines and other parts of the body.  IBD affects 1.4 million adults and children in the U.S.  70,000 people are newly diagnosed each year.  The peak age of onset is between 15-30 years old, and about 10% of patients are under age 18.  There is a genetic predisposition to IBD and it can run in families.  It is not clear what exactly triggers the illness in those predisposed.  Current theories revolve around an environmental trigger or an infectious one, or both.
The main symptoms of IBD are abdominal pain and diarrhea, sometimes with blood.  People with IBD can have more than 10 bowel movements per day.  One can imagine the effect this can have on a child in the early stages of development – especially socially.
The 2 most common diagnoses within IBD are Crohn’s Disease and Ulcerative Colitis (UC).  Once thought to be 2 completely different diseases, we have learned that they share some similar features and some patients have features of both Crohn’s or UC.


Ulcerative Colitis has the following features:
  • Diarrhea with mucus and/or blood
  • Spasms in the rectum (called tenesmus)
  • Fevers can happen when severe
  • People can usually maintain their body weight
  • Rarely develop tracts from the intestine to the skin (called fistula)
  • On a colonoscopy there are ulcerations (damage) to the surface layers of the large intestine
  • Inflammation and ulceration in the GI tract are only in the large intestine
  • For years it was thought that patients with UC were at increased risk of colon cancer, but recent studies have questioned this.
  • Eye inflammation can occur (called Iritis and Uveitis)
  • A form of arthritis in the spine, (called Ankylosing Spondylitis)
  • Painful, red skin nodules (called Erythema Nodosum)
Crohn’s Disease has the following features:
  • Diarrhea with a fatty consistency
  • Less spasms in the rectum (tenesmus)
  • Fevers
  • Fistula
  • Weight loss
  • On a colonoscopy there can be injury to any part of the GI tract, from the mouth to the anus, and the injury goes through to the deeper tissue of the intestines
  • Blockages (strictures) in the intestine from inflammation and scar tissue
  • Eye inflammation (Iritis and Uvititis)
  • Arthritis in the spine (Anklylosing Spondylitis)
  • Painful areas of skin breakdown (called Pyoderma Gangrenosum)
Both Crohn’s Disease and Ulcerative Colitis have some other associated symptoms, but they are less common.  In addition, the symptoms are not exclusive, as many people can experience either diseases symptoms as part of their illness.


Treatments for Crohn’s and UC include medications that reduce inflammation and balance the immune system, They are considered either non-biologic or biologic.  Examples of non-biologic treatments are anti-inflammatory (ibuprofen, naproxen), immune suppressants (6-MP, azithioprine), antibiotics and corticosteroids (prednisone).  Biologic treatments are injected or given intravenously and block certain parts of the immune system like Tumor Necrosis Factor (TNF).  Recent studies have looked at some alternative therapies like probiotics (bacteria found in certain foods like yogurt), using certain parasites (worms) to stop the immune reactions in the gut and even a “stool transplant” which is exactly what it sounds like!


IBD is diagnosed based on a person’s history of symptoms, a physical examination, and blood tests that can show signs of inflammation and certain antibodies that are common in IBD.  Imaging such as MRI or CT scan can be used and directly looking at the colon by a colonoscopy and obtaining biopsies is standard.


Why is the diagnosis important?  If the symptoms and treatments overlap, you may wonder why does making the specific diagnosis of Crohn’s Disease or Ulcerative Colitis matter rather than calling it IBD?  The diagnosis matters because certain treatments are more effective in Crohn’s vs UC and vice versa.  Additionally, since there are other symptoms outside the GI tract that are associated with specific forms of IBD, the proper diagnosis helps a doctor make the association that back pain may be due to Ankylosing Spondylitis rather than a muscle strain, or that rash on your leg may be Pyoderma Gangrenosum and not an infection.

How does this affect MY practice?

As an Internist, I will often be the first doctor someone comes to for unanswered symptoms.  So, in someone who has had ongoing symptoms that may be inflammatory bowel disease, I will order the studies that will either confirm or rule it out.  Since a colonoscopy is a necessary test in making the diagnosis, I will also refer people to a gastroenterologist who has expertise in IBD.

I also care for people who have already been diagnosed with IBD.  They also get colds, need general physicals and other everyday health services.  In addition, they often need information about new symptoms they may be experiencing – is it IBD related or something else?  Is it a side effect to their medication?  For them, I am a resource and a sounding board that sees them as a whole person, and not just an IBD diagnosis.

IBD can have multiple, seemingly disconnected symptoms.  In fact, the average time from the first symptoms to diagnosis is 2-3 years!  When the pieces are put together properly, the puzzle can be put together and reveal a diagnosis.  Knowing where you are starting from frames the conversations you have with your doctor, and help you tell your story and ask the questions you need answered to be an active participant in your healthcare.  Too often people with chronic illnesses are made to feel powerless, that health is beyond their reach and control.  In an illness that is painful, socially awkward and lifelong, information is power and can give a person a sense of control and direction.


The path to Wellness begins with a proper Diagnosis.
Helpful links:
Crohn’s and Colitis Foundation of America – www.ccfa.org
Center for Disease Control – IBD site – www.cdc.gov/ibd
My daughter’s video documentary of the 2010 Las Vegas Half Marathon to benefit the CCFA  –  http://youtu.be/F-1Qkoenv1E

The “new” cholesterol guidelines – what’s really the issue?

For decades people and doctors have been obsessed with cholesterol levels.  Books have been written, diets promoted, medications prescribed – all with the purpose of getting your cholesterol to “goal”.  You get your labs done and your doctor tells you your cholesterol is high.  You are instructed to eat a low-fat diet, exercise more and possibly start a medication.  Often you are not sure which numbers are high, or what they mean.  But you know that high cholesterol is a bad thing, and so you try to follow the doctor’s advice and lower your cholesterol.  
11/12/13 was a unique date – not only the second to last sequential month/day/year in our lifetimes; it is also the day the American College of Cardiology (ACC) and American Heart Association (AHA) released new guidelines for cholesterol management that recommend treating high cholesterol but not to any specific number.
This represents a change in over a decade of “goal oriented” recommendations which specified a level of bad cholesterol (LDL) to aim for, using multiple medications if needed to get there.
New Guidelines for Cholesterol:
  • Aim for cholesterol to be reduced by half
  • Only use a statin medication
  • Not necessary to add other medications if you don’t get quite there
Why were these changes recommended?
The theory behind the changes is that the guideline committee felt there wasn’t strong enough evidence supporting a specific target.  For example, if a person’s LDL cholesterol is reduced from 195 to 95, is there any real additional benefit in getting to the previous high risk goal of 70? Or is 95 good enough?
So what are the recommendations?
People are broken down into 2 risk groups in terms of deciding if a statin should be used
  1. High Risk:  people with a prior heart attack, bypass surgery, a stent or diabetes should take statins.  Statins are also recommended for those with very high LDL cholesterol (>190)
  2. Future Risk:  those whose 10 year risk of a heart attack is 7.5% or greater.  This number is calculated with a risk calculator that uses cholesterol, weight, blood pressure, smoking and other factors to come up with your number.
The High Risk group is not a  major change in terms of starting treatment.  The change is not recommending a target value for the LDL cholesterol.
The Future Risk group is different – the previous recommendations used a higher 10 year risk 15-20% before starting a statin.
Besides statin therapy, lifestyle changes are a cornerstone of the new recommendations:
  • No smoking
  • A health body weight
  • Exercise
  • A diet with lots of vegetables, fruits and lean protein
Not all doctors agree that the 10-year risk is the best guide for starting treatment – why not lifetime risk?  There also have been questions about the risk calculator itself – the formula used appears to overestimate risk – including more people needing treatment than may truly benefit.  In addition, several of the members of the guideline committee quit due to disagreement on the direction the committee was going with their recommendations.  The remaining committee members only considered evidence from very specific types of trials, ignoring other trials that made compelling arguments but did not meet their standard of evidence.  The committee also chose not to include other markers of cardiovascular disease such as LDL particle number, Apolipoprotein B, PLAC testing and LDL particle size.
So how will this affect MY practice?
I think the guidelines are an opportunity to talk to people about their real diagnosis – their risk of cardiovascular disease.  As I have told many patients – to a certain extent, I don’t care what your cholesterol is, I care about you having a heart attack or stroke.  Cholesterol is a marker of how much artery clogging gunk is in your system.  There are several studies that show that the standard cholesterol profile underestimates cardiac risk.  I think that using the LDL particle number (LDL-p) is a better marker for assessing that risk.  If we reduce your LDL-p, your risk for cardiovascular disease goes down.  Statins are a tool (a very powerful one) to reduce cardiovascular disease risk.
I’m also not a fan of 10 year risk as a cutoff for starting treatment – I prefer lifetime risk, as the process that blocks your arteries is ongoing.  If we know 20 years before you have a heart attack that the risk is there, why wait until a heart attack is only 10 years away to start reducing risk?
How do I assess risk?
Risk can be estimated with a good history, a physical and testing.
  • Prior heart attack, stroke or known cardiovascular disease?
  • Family history of heart attack or stroke – a male relative under age 55 or a female under age 65
  • Diabetes
  • High Blood Pressure
  • Smoking
  • weight
  • waist size – belly weight is riskier than just being overweight
  • blood pressure
  • leg swelling
Diagnostic Testing
  • Cholesterol Assessment
    • there are several tests for this besides the standard cholesterol (called LDL-c) test which I will be reviewing in a future article in detail.  There have been several studies that show that other tests like LDL particle number (LDL-p) are better predictors of risk.
    • LDL cholesterol particle number (NMR Lipoprofile)
    • Apolipoprotein B (ApoB)
    • LP(a)
    • PLAC testing
    • Cholesterol particle size
  • C-reactive protein
  • Glucose
Once we put together your history, physical and test results we can have a discussion not about your LDL number, but your real diagnosis – your risk of cardiovascular disease.  The goal of that discussion is to reduce your risk of having a heart attack or stroke.
How can we reduce risk?
  • Blood pressure control
  • No smoking
  • Maintain a healthy body weight
  • Control diabetes
  • Being physically active
  • Control cholesterol
So the benefit of the new guidelines is they can inspire a conversation that leads to a proper diagnosis – not treating a number, but treating cardiovascular risk.

The path to Wellness begins with a proper Diagnosis