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QUESTION
1:
Is goitre due
to lack of iodine in our diet? Should I eat kelp to get rid of this
goitre?
ANSWER:
Iodine deficiency is the most common cause of goitre in the
world but NOT in this country. We have had iodized salt for
two generations, and there are many other sources of iodine now
in our diets so that, if anything, we are receiving more iodine
than in most places in the world. There is no point whatsoever in
adding more iodine to the diet and that includes kelp, a form of
seaweed high in iodine often sold in health food stores. The problem
is that too much iodine is just as dangerous as too little iodine.
Excess iodine can also cause goitres and can either cause a low
thyroid state, (hypothyroidism) or excess output of thyroid (hyperthyroidism).
It also aggravates Hashimoto's thyroiditis. In Canada it is a mistake
to ingest kelp.
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QUESTION
2:
I have been on
thyroxine for many years for the control of my hypothyroidism. However,
at times I get very nervous and irritable or very fatigued and I
believe it is my thyroid "kicking up". What should I do with my
dosage of thyroxine?
ANSWER:
It is a curious fact that, when patients have had an illness
of any kind, they will then ascribe any type of symptom to the original
illness. Thus patients who are well treated for their thyroid disorder
will continue to ascribe variations in mood, fatigue, etc. to their
"thyroid condition". The facts are that if you are on an appropriate
dosage of thyroxine, the levels of thyroid hormone in your blood
stream and in your tissues will be normal and you cannot have any
symptoms related to your thyroid disease whatsoever. What you are
really experiencing are the usual variations in well-being that
any normal person has to endure. In some people, these variations
are very wide indeed, but they cannot be attributed to the thyroid
status.
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QUESTION
3:
I have been feeling
very fatigued for many years. I also complain of constipation, lethargy,
inability to concentrate and weight gain. I have seen several doctors
including an endocrinologist; they have tested my thyroid with blood
tests on many occasions. The tests always come back completely normal.
Yet, I have been reading that these tests are not accurate and that
measurements of body temperatures are more accurate. Moreover, I
understand that I should be taking thyroid medication for these
symptoms despite normal thyroid function tests.
ANSWER:
Actually the routine blood tests for thyroid function are extremely
accurate and precise. Moreover, the blood tests for thyroid stimulating
hormone (TSH) (which is the pituitary hormone that stimulates the
thyroid even more when it is failing) is extremely accurate. It
is the first test to rise when thyroid function is at all low. Indeed,
it will go up even before the thyroid hormone levels are detectably
lower. This is a category termed "compensated" hypothyroidism. In
that state, the thyroid hormone levels are still normal, the patient
still feels normal but the TSH is already an indicator that the
thyroid gland itself is in trouble. In your case, with a normal
TSH, hypothyroidism is completely ruled out. It is important to
remember that many other conditions can mimic hypothyroidism, most
particularly chronic anxiety, depression and stress. Some psychiatrists
use T3 (Cytomel, triiodothyronine) but usually not thyroxine, with
antidepressants. How useful this combination is, remains to be proven.
It is true, however, that such people who do not have thyroid disease
can "benefit" from taking thyroid medication. The reason they are
benefiting is that the thyroid medication is a "placebo". The drug
itself has no intrinsic benefit to them, but if people think it
is going to help them, then it does. It is like fooling yourself
by taking a pill that looks identical but is completely inert. If
we convince ourselves that there is some good in it, then we feel
much better. Sometimes this placebo effect is truly remarkable and
long lasting. More often, however, it lasts for only a short time
and disappears. Taking thyroxine when you do not need it, is also
of some danger and cannot be encouraged. Finally, skin temperatures
are of no value in diagnosing hypothyroidism despite assertions
to the contrary by some. It has been clearly proven they are totally
misleading and really useless. While it is true that patients with
hypothyroidism do have cool skin, so do people with many other conditions.
These include people with poor blood supply, severe stress, anaemia
and others.
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QUESTION
4:
I have been taking
thyroxine 0.15 mgs. per day for some years. I felt well most of
this time but recently I have had some rapid heart beating and sweating.
My doctor found the serum thyroxine (T4) to be elevated and has
cut my dosage of thyroxine down to half. Now I am feeling quite
tired. What is going on?
ANSWER:
It is entirely likely that your rapid heart beat and sweating
have nothing to do with your thyroid status or thyroxine medication.
The problem is that the serum thyroxine is not useful for monitoring
patients who are taking thyroxine by mouth. For that purpose, the
total serum triiodothyronine (total T3) is the best measure of the
appropriateness of the dosage. Another problem is that the term
"T3 test" means different things to different people. There is a
test called the T3 resin uptake which has nothing to do with the
total serum T3. Even physicians get these tests confused. The total
T3 is performed by a technique called radioimmunoassay (RIA). We
like this test to be in the middle of the normal range, which is
1.2-3.4 nmol/L, i.e. around 2.1-2.8 nmol/L. If the total T3 is in
that order, the dosage of thyroxine is appropriate.
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QUESTION
5:
An aunt has papillary
thyroid cancer and was treated. Several months ago my family doctor
found a thyroid nodule on my neck and referred me to a specialist.
I understand thyroid cancer is hereditary and although my doctor
reassures me, I am frightened that I too may have thyroid cancer.
ANSWER:
It should be emphasized that most thyroid nodules prove to
be benign. Only about 20% of thyroid nodules turn out to be malignant,
and most of these are papillary carcinoma of the thyroid which usually
has a good prognosis. Carcinoma of the thyroid is generally NOT
hereditary. Only one comparatively rare form is inherited and it
is called medullary carcinoma of the thyroid. It only accounts for
about 5% of all thyroid cancers.
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QUESTION
6:
A little over a
year ago my doctor discovered a nodule and advised me that he would
watch it and possibly prescribe thyroxine. Since then I developed
another nodule and a cyst and experienced pain in my throat. At
this time the physician I am seeing is not considering treatment
with thyroxine but is suggesting surgery. I am 70 years old and
am resisting this treatment. Am I taking a risk by avoiding surgery?
A needle biopsy proved negative. Is there any other treatment for
my condition?
ANSWER:
Physicians are concerned if thyroid nodules tend to enlarge
over time, or cause pain, or cause compression of the windpipe.
For any of these reasons, surgery might be considered. Of course,
if the physician felt that there was a possibility that the nodules
were cancerous, that is clearly another reason for surgery. Generally
nodules do not shrink with thyroxine therapy, and there is no other
medical therapy which is useful in most nodules.
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QUESTION
7:
I have been taking
thyroxine 0.15 mg for the past 30 years. At my last appointment
with my new family physician, I was told my dose is too high. I
feel very well and don't look forward to the possibility of changing
my hormone level. However, I understand there are risks of osteoporosis
when thyroid hormone levels are too high. I wonder how great these
risks are and whether my current sense of well-being should be taken
into consideration when making a decision to change my dose of thyroxine.
ANSWER:
The treatment with thyroxine can be for two purposes, either
to suppress thyroid tissue or merely to treat hypothyroidism. It
would be appropriate to suppress TSH in the case of a goitre or
previous treatment for thyroid carcinoma. A low (subnormal) TSH
may be due to pituitary damage, or may be due to excess production
of thyroxine or T3, or excess intake of these agents. In the latter
situation, the TSH is supressed. However, when one is trying to
treat hypothyroidism, the ideal treatment would be to bring TSH
down into the normal range, but not suppress it necessarily. Nevertheless,
concerns which many physicians have expressed over the past few
years about osteoporosis if TSH is suppressed by thyroxine have
proven recently to be incorrect. Studies have shown NO reduction
in bone mineral density, and no osteoporosis when thyroxine is taken
even in suppressive doses. Only when patients have had actual Graves'
disease -- "overactive thyroid," is there a risk of osteoporosis
and even that risk is small. Nevertheless, one should strive for
ideal therapy and the ideal for hypothyroidism is to have all tests
of thyroid function normal.
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QUESTION
8:
I have an overactive
thyroid, yet my sister has an underactive thyroid, just the opposite.
Is it not strange that these two conditions have occurred in our
family?
ANSWER:
Both of these are termed "autoimmune" thyroid diseases: that
is, they are both due to antibodies. In the case of the overactive
thyroid, the antibody that has caused that condition stimulates
the thyroid, and thus causes Graves' disease. On the other hand,
your sister with hypothyroidism also has antibodies but these have
damaged the thyroid and caused it to be unable to function at a
normal level. Although these conditions are opposite to one another,
they are in fact very closely related.
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QUESTION
9:
I have very prominent
eyes associated with my Graves' disease. The Graves' disease was
treated with radioactive iodine and indeed my goitre disappeared
and I feel generally much better. I am now taking thyroxine therapy
for an underactive thyroid resulting from the radioactive iodine.
However, I expected my eyes to improve and they have not. Should
I change my dose of thyroxine?
ANSWER:
There is no point in changing your dosage of thyroxine, as
it will not influence the progress of your eye disease either pro
or con. The eye disease is not influenced by the state of your thyroid,
or by the treatment for it. Indeed, it is my own personal view that
the eye disease is only related to the thyroid disease through the
basic cause of each. That is, the basic cause of each disturbance,
the overactive thyroid on the one hand and the eye disease on the
other, are very closely related, but treating the thyroid disease
does not treat the eyes. It will do "its own thing". In some instances,
Graves' Ophthalmopathy appears early in a mild form, and then clears
up with treatment for Graves' disease. The eye disease usually reaches
a plateau within a year after onset and in most instances does not
progress further thereafter. The important point is that if it is
severe enough, it should be treated by a good ophthalmologist who
is familiar with this disorder.
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QUESTION
10:
Could the physical
and emotional stress caused by a car accident trigger Graves' disease
in a patient with no previous thyroid problems?
ANSWER:
It cannot be proved beyond doubt that any particular physical
and emotional stress is the precipitant triggering Graves' disease.
However, there is much circumstantial evidence that such stresses
adversely affect the immune system and thus can tip the balance
in those genetically susceptible to this disorder.
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QUESTION
11:
I have Graves'
disease and was treated with propylthiouracil four years ago. My
goitre shrank and after one year the propylthiouracil was discontinued.
I have been feeling well since. Do I need my thyroid checked further?
ANSWER:
Yes. Although you may stay in remission the rest of your life
and be perfectly well, one cannot predict that. Your thyroid status
should be considered unstable and it should be checked at least
once a year. You may slowly go on into a state of hypothyroidism,
or hyperthyroidism could also recur. The tendency to recurrence
will be aggravated by severe stress.
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QUESTION
12:
I have read drug
information sheets on anti-thyroid medication for Graves' disease
from the pharmacist and feel very apprehensive about these drugs.
My doctor did not go into such detail but I have heard there can
be serious side effects. Should I ask my doctor to try a different
treatment strategy because of these risks?
ANSWER:
Anti-thyroid drugs are generally safe. There is about a 1%
incidence of serious side effects and a 3-4% incidence of minor
side effects. The most severe side effect is that of a sudden drop
in the white blood count to extremely low levels which is indeed
very dangerous. It is heralded by a very severe sore throat and
mouth and high fever. If the patient immediately stops the medication,
upon suffering these symptoms, recovery is usually swift. However,
it is very important that cessation of the medication should be
quick upon the development of such symptoms, although quite often
the white count proves to be normal, and the pills can be taken
once again. Very rarely, toxic hepatitis can occur, whereas rashes
and joint pains are somewhat more frequent. They are not so serious.
Patients who commence anti-thyroid
drugs should be warned of the side effects and told to discontinue
the medication should they occur. In the other 97% of patients,
there are no side effects.
Anti-thyroid drugs do constitute
a very useful form of treatment, since somewhat less than half the
patients can go into a permanent remission after a year's therapy
with anti-thyroid drugs. It is therefore often used as a first line
treatment.
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QUESTION
13:
My doctor wishes
to prescribe radioactive iodine for the treatment of my overactive
thyroid. However, I fear this treatment as it may make me sterile
or cause cancer. Moreover, I am fearful that I will be a danger
to other people.
ANSWER:
When radioactive iodine is used to treat an overactive thyroid,
the dosage is usually quite moderate, and there is no danger to
other people. Indeed, the radioactivity is mostly in the form that
can only travel very short distances of 2 mms. or so. This is less
than one eighth of an inch. It does not even damage structures next
to the thyroid gland itself. There is no increased incidence of
cancer of the thyroid or other organs after radioactive iodine therapy.
Moreover, there is certainly no sterility, and indeed no danger
to unborn children. It is quite safe to have children after radioactive
iodine although it is recommended that you wait six months after
the radioactive iodine therapy has been administered, before becoming
pregnant. Your doctor will give you some simple guidelines to follow
for a short time immediately after your treatment (usually no more
than 2-5 days).
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QUESTION
14:
I am concerned
about taking thyroxine for the rest of my life. Can I take it during
pregnancies? Can I take it with other medications? What if I miss
a pill? What if I take an extra pill by accident? Why can't I take
the natural product rather than a synthetic preparation?
ANSWER:
Thyroxine, although it is synthetic, is identical to the hormone
made by your own thyroid gland. It is one of the safest medications
that one can take. Because of this, many symptoms that patients
ascribe to the thyroxine are in fact due to their own anxiety about
taking medication rather than the medication itself. Thyroxine can
be taken through pregnancy and nursing and does not affect either
of those situations at all. It does not cross the placenta and thus
does not reach the baby in the womb. It does not get into the milk
except in negligible amounts as it would in any nursing mother producing
her own natural thyroxine. It can be taken with any other medication
as there are seldom drug interactions. If you miss a pill one day,
nothing will happen or if you take two pills the next day, nothing
will happen. It does not matter what time of day the pill is taken
since it does not begin even to work for about a week. It can be
taken throughout a patient's entire life without fear.
There is no advantage, only a disadvantage
in taking the natural product, desiccated thyroid. (Occasionally
it is prescribed for the RARE allergic reaction to the binder or
dye in thyroxine). The shelf life of desiccated thyroid is much
shorter, it is not assayed in as precise a fashion and there is
considerable variation from lot to lot in its effectiveness. Thyroxine
is therefore very much to be preferred.
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QUESTION
15:
How does hypothyroidism
affect memory loss?
ANSWER:
Severe hypothyroidism can induce temporary memory loss. However,
only in the congenital form of the disease is the memory loss permanent.
In hypothyroidism occurring even in childhood, and certainly in
adult life, any memory loss related to hypothyroidism is completely
returned to normal when the patient is treated with thyroxine. As
long as they take sufficient thyroxine to maintain them in a normal
state, all functions related to thyroid activity are also normal.
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QUESTION
16:
Is there any possibility
that migraine headaches could be connected with the thyroid malfunctioning?
ANSWER:
True migraine headaches are not caused by hyperthyroidism or
hypothyroidism. However, both high and low levels of thyroid hormones
can aggravate any kind of headache. Once the thyroid tests have
been normal for several weeks, then any persistent headaches cannot
be attributed to the thyroid status.
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QUESTION
17:
What non-allopathic
(i.e. homeopathic, etc.) treatments are available for hyperthyroidism?
ANSWER:
There is no proven homeopathic means of treatment for autoimmune
thyroid disease. Graves' disease however, can go into remission
spontaneously (a 30% occurrence). This may occur as a result of
sedation, relaxation, or rest.
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QUESTION
18:
What elements
or chemicals in drinking water are considered problematic to thyroid
conditions?
ANSWER:
It is true that in some parts of the world, there has been
a relationship between drinking the water of those areas and goitre
prevalence, although this has not been documented in this country.
These studies indicate that goitrogenic organic compounds contaminate
the water supply in certain areas. Sources of water-borne goitrogens
are sedimentary rocks rich in organic matter, coals, shales, cherts,
etc.
Over 30 organic compounds have been
identified in activated carbon extracts of water from Columbia with
anti-thyroid activity. Resorcinol and other parent phenolic and
phenolic carboxylic compounds have particular goitrogenic effects.
I would emphasize once again that
we generally have not been aware of water-borne goitrogens of much
significance in water in Canada. We do not see endemic goitre in
this country, and most of the thyroid conditions that we do see
are not due to such factors.
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QUESTION
19:
Where is the most
advanced medical research carried out on thyroid problems? What
research is being done at present?
ANSWER:
There are many types of investigation being performed in many
laboratories around the world. These are looking at different aspects
of these diseases such as genetics, the basic immune cause, the
way the abnormal immune cells interact with the thyroid, the cause
of the eye disease and treatment. Researchers hope to discover the
cause of these conditions, as well as how they can be treated better
or even how they can be prevented. The queston adding T3 to T4 is
not yet proven. Thyroxine, given alone leads to normal T3 and TSH.
Adding T3 may lead to subclinical hyperthyroidism.
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QUESTION
20:
I have had Hashimoto's
syndrome for almost ten years -- shortly after the birth of our
second child. Are my children at risk? If so, can I do anything
to minimize the risk?
ANSWER:
Your children are at some risk of developing Hashimoto's thyroiditis,
but this is not a severe or serious disorder as long as it is diagnosed
and treated. Girls are four times more likely to develop the disease
than boys. It may occur at any age, but is rare before puberty and
it is quite common for it to occur after the birth of a child. Indeed,
this form of the disease is termed postpartum thyroiditis.
There really is nothing you can do to minimize the risk, but it
should be kept in mind when your children are being seen by the
family physician and tests of thyroid function as well as thyroid
antibodies might be performed on them on an annual basis. This would
be more important after puberty.
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QUESTION
21:
During a CAT scan
I found I am allergic to iodine. Could this allergy have triggered
my autoimmune response?
ANSWER:
Even if you are allergic to iodine, this particular allergy
or any other allergy does not trigger your autoimmune response.
You should keep it in mind that Hashimoto's thyroiditis is quite
common in the population. As I mentioned above, it occurs most commonly
after deliveries and is related to an inherited immunological disturbance.
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QUESTION
22:
Does a person's
age affect the recovery rate from thyroid disease or the amount
of supplemental thyroid medication needed? What is considered a
"normal range" for TSH and T3 RIA readings?
ANSWER:
Certainly age will affect the recovery rate from thyroid disease,
both hyperthyroidism and hypothyroidism. The older the person, the
slower the recovery rate and indeed with hypothyroidism, it is necessary
to be extremely careful in older people about increasing the dosage
of thyroxine. The normal range for TSH depends on the type of assay
utilized. Currently with the sensitive assays now available, the
usual normal range is between 0.3 and 3.5 milliunits/L. For the
total serum triiodothyronine (T3RIA) once again assays vary a little
bit from laboratory to laboratory but the average range is 1.2-3.4
nmol/L.
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QUESTION
23:
I have been on
thyroxine for 4 years. Then quite suddenly I became hyperthyroid.
Is it possible that thyroxine can stay in the body for a while,
then act up rather suddenly? Would a stressful event precipitate
such a flare-up?
ANSWER:
This is extremely rare and only about 30 such cases have been
reported. However, what is quite common is that physicians do tests
of thyroid function on patients who are taking thyroxine and discover
that the serum thyroxine is elevated. This may be interpreted as
being "hyperthyroid". However, the total thyroxine is not an appropriate
test to measure on patients who are taking thyroxine by mouth. Rather
the total serum triiodothyronine is much superior to the serum thyroxine.
If the values of the total serum triiodothyronine are in the middle
of the normal range, then the symptoms that the patient is experiencing
are not due to the thyroxine. It is not possible that thyroxine
can stay in the body for a while and then act rather suddenly. Thyroxine
has a steady degradation rate in the body and nothing will change
that. As I mentioned, there have been a handful of people reported
whose own thyroid has become hyperactive while they have been taking
thyroxine but that is extremely rare. I strongly suspect that what
happened to the patient enquiring is that a serum thyroxine was
elevated and that the symptoms were actually unrelated to the thyroid
medication.
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QUESTION
24:
I have an inactive
thyroid and have been on thyroxine for 4 months. How long will it
be before I begin to feel well again?
ANSWER:
The answer to this is that if your symptoms were due to thyroid
insufficiency in the first place, and you were on an adequate dose
of thyroxine, it should take no more than six weeks to feel reasonably
well or at least greatly improved. It is NOT appropriate
for patients to adjust their own medication according to how they
feel, but rather to have it "tuned" by regular blood tests.
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QUESTION
25:
Do you have any
information on the connection between fluoride and hypothyroidism?
In a publication entitled "Vitamins, Minerals and Supplements" by
H. Winter Griffith, M.D., it states not to take fluoride if you
have underactive thyroid function. I have not heard of this before
and am wondering what the implications are.
ANSWER:
Fluoride is a halogen like iodine and is therefore briefly
picked up by the thyroid gland, but, unlike iodine, fluoride is
not incorporated into thyroid hormone. It does NOT interfere
with thyroid function in any way and there is NOT concern
about using fluoride even if a person is indeed hypothyroid. This
is, of course, particularly true if that patient is taking thyroxine,
which is certainly not interfered with by fluoride or any other
substance. |
