Terrible Complications of Hypothyroidism the high slows of thyroid disease

Online Health Chat with Dr. Christian Nasr and Dr. Joyce Shin

January 24, 2019


Cleveland_Clinic_Host: Your thyroid is a butterfly-shaped organ that weighs about an ounce and is located at the base of your neck. This endocrine gland secretes hormones into your blood that control many important functions, including your body’s metabolism. Terrible complications of hypothyroidism the high slows of thyroid disease

The Highs&Lows of Thyroid Disease

Most people never give their thyroid a thought until something goes wrong. Yet, more than 20 million Americans have some type of thyroid disorder – such as hypothyroidism, hyperthyroidism, thyroid nodules and goiters, or thyroid cancer. In this online chat, endocrinologist Dr. Christian Nasr and endocrine surgeon Dr. Joyce Shin will answer your questions covering the entire spectrum of thyroid disease, as well as medical and surgical treatment options.

Cleveland Clinic is a national leader in caring for patients with all types of thyroid conditions, from the routine to the complex. Our patients benefit from access to a multidisciplinary staff, the most advanced technology, and the latest clinical trials for thyroid conditions.

Dr. Christian Nasr is co-director of the Cleveland Clinic Thyroid Center and a staff physician in the Endocrinology & Metabolism Institute. He is board certified in Endocrinology, Diabetes & Metabolism. A graduate of the Saint Joseph University Faculty of Medicine, he completed his residency at Staten Island University Hospital and his fellowship in endocrinology at Cleveland Clinic. Dr. Nasr’s specialty interests include thyroid nodules, thyroid cancers, and flushing syndromes.

Dr. Joyce Shin is an endocrine surgeon in the Endocrinology & Metabolism Institute. A graduate of State University of New York School of Medicine, she completed her residency in general surgery at Albert Einstein College of Medicine/Montefiore Medical Center and her fellowship in endocrine surgery at Cleveland Clinic. Dr. Shin’s specialty interests include endocrine surgery (thyroid and parathyroid), advanced laparoscopic surgery, laparoscopic adrenalectomy, neuroendocrine tumors, thyroid/parathyroid ultrasound, intra-abdominal ultrasound, and laparoscopic radiofrequency thermal ablation of liver tumors.

To make an appointment with Dr. Nasr, Dr. Shin, or any of the other specialists in the Endocrinology & Metabolism Institute at Cleveland Clinic, please call 216.444.6568 or call toll-free at 800.223.2273, ext. 46568.  You can also visit us online at www.clevelandclinic.org/endocrinology.

Cleveland_Clinic_Host: Welcome to our Online Health Chat with Drs. Christian Nasr and Joyce Shin. We are thrilled to have them here today for this chat. Thank you, doctors, for joining us today. Let’s begin with the questions!

sugarcookieI had my first baby two months ago. At the six-week check-up, they found a thyroid nodule. The ultrasound was “inconclusive.” The endocrine appointment is in five weeks, and I’m thinking the worst. Can you offer me any hope?

Dr__Joyce_Shin: A thyroid nodule read as “inconclusive” can mean a couple of things, depending on where it was read. It may mean that there weren’t enough cells aspirated to determine a diagnosis. Therefore, it may require another biopsy. It may also mean a follicular neoplasm. Unfortunately, a follicular neoplasm can be either a follicular carcinoma (cancer) or a follicular adenoma (benign). The only way to figure that out is to undergo surgery. There is about a 20 percent chance that a follicular neoplasm will turn out to be cancer.  Here at the Cleveland Clinic, we no longer use the term “inconclusive.”  If it is an inadequate specimen (not enough cells), then the reading is “nondiagnostic or unsatisfactory.”

Cali: Sometimes I feel like my throat is tight. I have no difficulty swallowing, and I can breathe just fine, but I still feel tight. No polyps have been detected, and there is no swelling. Is this a symptom of thyroid disease?

Dr__Joyce_Shin: If your thyroid is enlarged, you can get compressive symptoms, such as the sensation of being choked, difficulty swallowing (needing an extra gulp to swallow food or pills), and difficulty lying down flat to sleep. An enlarged thyroid gland can be diagnosed on physical examination and even better on ultrasound. (Some thyroid glands are large but can’t be seen on physical examination.) If you continue to have these symptoms, it may be worth it to get a neck ultrasound.

Cali: Can thyroid disease lead to thyroid cancer?

Dr__Joyce_Shin: Sometimes, the thyroid gland develops nodules. If the nodules are larger than a centimeter, most of them require a biopsy. Only the biopsy can tell us if it is cancer or not. People who are hypothyroid have a slightly higher chance of harboring a malignancy within the thyroid nodule. Most hyperfunctioning nodules are benign. Regardless, most nodules that are larger than a centimeter need further evaluation.

snyderbd: I had a delayed (two year) thyroid cancer diagnosis (2.8 cm tumor) that resulted in parathyroid damage after the completion thyroidectomy. It’s been over three years since the completion thyroidectomy, and my TSH, calcium, and parathyroid hormone levels don’t appear to be stabilizing. What do you recommend as a course of action to stabilize the levels in my blood? If TSH is lowered enough so I have an adequate energy level, my calcium level drops and I get muscle spasms. If I take more calcium, I get severe neck pain. Increasing vitamin D has minimal impact on calcium level.

Dr__Christian_Nasr: There is no relationship between the thyroid level and the calcium/parathyroid level. One should be able to control them with separate interventions. Your TSH should be kept low. I am not sure what kind of vitamin D preparation you are taking, but I hope it is calcitriol. Also, make sure you do not take any calcium within three hours of the levothyroxine. Swings in the serum calcium should be avoided because that would be associated with symptoms. Your serum calcium should be kept at the low end of normal or slightly below normal, otherwise you would risk kidney stones or damage to the kidneys from calcium precipitation within.

coshocton: What does it mean when your lab result reads TSH third generation, and it’s elevated? Thank you.

Dr__Joyce_Shin: If your TSH is high, that means you are hypothyroid (your thyroid isn’t making enough thyroid hormone). In addition, other thyroid function tests will be LOW (free T4 and free T3). Your doctor should also check free T4/T3 to see if you need medication (Synthroid).

mombutterfly: What is the normal range for TSH?

Dr__Joyce_Shin: It depends on each laboratory. At Cleveland Clinic, it’s 0.4 to 5.5

scubadiva: I have had two biopsies done. I have requested the lab results on two occasions. There seems to be no lab run. My symptoms have worsened. Should I be concerned that the biopsy was not sent to a lab to look at the cells?

Dr__Joyce_Shin: If a biopsy was done of your thyroid nodule, you should request the results. There are several possible results: benign, suspicious for papillary thyroid cancer or follicular neoplasm, inconclusive, etc. What symptoms do you have?

coshocton: What does it mean when lab results TSH, third generation is elevated? And I do so much better when I’m not taking my prescribed dose of 75mg Synthroid? Thank you for your time, 63-year-old female diagnosed with hypothyroidism five years ago.

Dr__Christian_Nasr: Third generation TSH means that it is a more sensitive test compared to the previous ones from one to two decades ago. It can detect hyperthyroidism earlier than the previous generations of tests, but it does not make any difference as far as hypothyroidism is concerned. If you are doing well without taking your prescribe dose of Synthroid, this tells me that you probably never had hypothyroidism. We need to confirm or rule that out by checking your TSH after being off Synthroid for six to eight weeks. You should discuss with your doctor.

rpbland7: What are the percentage rates for recurrent pheochromocytoma, parathyroid hyperplasia, and medullary thyroid cancer from MEN 2a?

Dr__Joyce_Shin: This is a very difficult question to answer. There is not a lot of literature on recurrence rates due to the rarity of MEN2A syndrome. Generally, the disease behavior (aggressiveness) is unique to each family with the genetic mutation. To give you a general idea of the recurrence rates:

Pheochromocytoma occurs in 30 percent to 50 percent of patients with MEN2. Approximately 31 percent of patients develop recurrent pheochromocytoma in either the same or opposite adrenal remnant. The interval to developing recurrent disease has a median of 83.5 months (range, 1 to 375 months).

The recurrence rate for medullary thyroid cancer (MTC) depends on the stage it was discovered (was the thyroid removed prophylactically before any disease was noted?), the age of the patient, what the pathology revealed, and if the patient is biochemically free of disease (undetectable calcitonin level) after surgery. It is hard to give you a specific percentage rate for recurrence of MTC.

For hyperparathyroidism, the remnant that was left behind after performing a subtotal parathyroidectomy (three and half glands removed) has the potential to regrow. Patients are monitored after surgery with laboratory studies (calcium, PTH, vitamin D levels) to assess possible recurrence. Again, it is hard to give you an exact percentage for recurrence. The most important thing is that patients with MEN2 need to have life-long follow-up to detect recurrence as early as possible.

jdsrmr: Recent lab results indicated a low level of T3 while on 137 mcg levothyroxine. Is there any alternative to correct the deficiency?

Dr__Joyce_Shin: It sounds like you may need to increase your dosage of medication, but you also have to look at the TSH and free T4 level. If TSH/free T4 levels are in the normal range, the dosage can remain the same – if you’re not having extreme hypothyroid symptoms.

dcmna3: Do nodules in the thyroid present themselves in some way, or should an ultrasound be part of a yearly checkup?

Dr__Joyce_Shin: Big nodules can be felt on physical examination, but most are found on imaging studies (CT scan, MRI, ultrasound). If your doctor feels a big thyroid/nodule, then you should have an ultrasound performed.

CMB: Is the TSH study enough to properly diagnose a thyroid disorder? I read that some people’s TSH comes up normal, but they really have a problem.

Dr__Christian_Nasr: The TSH is a good screening test for thyroid disorders. If your doctor still suspects there is a thyroid problem despite a normal TSH, the doctor could check T4 and/or T3 levels, depending on the clinical situation. If those came back normal, then there would be no thyroid disease.

Chicago0319: I am a 35-year-old woman with an underactive thyroid for the last six years. For the first three years I was on .025 of Synthroid, and then my thyroid went out of whack. My TSH scored a 94, and it took more than seven months to get it under controlled at .100 Synthroid. A year later, it went out of whack again, and for the last three months, I have been on .188 Synthroid. My question is: what is causing my thyroid condition to worsen? Is it stress? Is it drinking diet coke? Is it eating products with artificial sweeteners? Otherwise, I normally eat fresh fruits and veggies, and I try to limit eating out. However, in the last three years, I’ve gained over 70 pounds. Please help me understand what is going on.

Dr__Christian_Nasr: Thank you. I am sorry, but the 70-pound weight gain cannot be solely related to the thyroid state. I wonder when you started working on trying to do something about the weight. Did you try at 20 pounds? at 30 pounds? You should be able to lose weight even with an underactive thyroid. What happened in your case was that your thyroid continued to fail over time and you needed a progressive increase in the dose of levothyroxine. None of the things you are doing is causing your thyroid to fail. It is just the natural progression of the disease. Note that as you get heavier you needed more levothyroxine because the dose is relative to the body weight.

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amj1951: I have underactive thyroid disease (diagnosed in 1997) with a very small goiter, and I began taking Synthroid 100 mcg. In 2008, a thyroid nodule was discovered, and ultrasound placed it at 2.0 centimeters. (If greater than 2.0 it would have been surgically removed.) Synthroid was increased from 100 mcg to 112 mcg, and an ultrasound was repeated six months later. The nodule was the same size. Now I must have the ultrasound repeated every two years, and TSH every year. Will I need ultrasound every two years for the rest of my life or can I just have the nodule removed?

Dr__Joyce_Shin: Most nodules greater than 1 cm should undergo ultrasound-guided fine needle aspiration biopsy. If proven to be benign, it can be monitored long-term with serial ultrasounds (here, we repeat the ultrasound annually). If proven to be cancer or suspicious for cancer or suspicious for follicular neoplasm, surgery is indicated. The nodule itself cannot be removed without removing the thyroid gland (one side or both). The fact that you have hypothyroidism (underactive thyroid disease) suggests the nodule may actually not be a nodule, depending on what the thyroid itself looks like. Patients who have hypothyroidism have a very distinct appearance on ultrasound that may make things look like a nodule (when it really is not). If you truly do have a nodule within your thyroid gland and if you’ve never undergone a biopsy, I would recommend that first.


Katelynn: Is some degree of hypothyroidism an expected part of the aging process?

Dr__Joyce_Shin: Hypothyroidism can occur at any age. There are different degrees of hypothyroidism. Once a person has been diagnosed with hypothyroidism, it may require medication at the time of diagnosis or eventually down the road, depending on the degree. But no, it is not always part of the aging process.

AirAl: My son has hypothyroidism. How did his thyroid start dying? Is this an environmental issue?

Dr__Joyce_Shin: The #1 cause of hypothyroidism is autoimmune, and it is called Hashimoto’s thyroiditis. Your own body’s cells attack the thyroid gland so it no longer functions. It’s not caused by an environmental factor.

dcmna3: I understand that hypothyroidism may contribute to a higher risk of osteoporosis. Does that mean I should consider a different recommended dose of daily vitamins D and C (higher dosage?) knowing I have a thyroid condition?

Dr__Christian_Nasr: Hypothyroidism does not contribute to a higher risk of osteoporosis. You should be on vitamin D as recommended by the Institute of Medicine and FDA. 800 to 2000 units of vitamins D2 or D3 daily should suffice.

Bella22: Are high DHEA levels associated with hypothyroidism? And what else can be done if TSH levels come back to normal while on Synthroid, but you still have symptoms (slow metabolism, low energy, heavy menstrual cycles, skin issues, etc.)?

Dr__Christian_Nasr: Thank you. DHEA levels are not affected directly by thyroid state, at least not high levels. If the TSH levels and thyroid hormone levels are normal but you are still having problems, look outside the thyroid.

Scebbit: What is your experience with patients with normal thyroid function studies but with classic textbook hypothyroidism?

Dr__Christian_Nasr: Those do not have thyroid disease. Look for other causes of their symptoms.

Hashimoto’s Disease

Cali: What is Hashimoto’s disease? Are all hypothyroid cases Hashimoto’s disease? If not, what makes Hashimoto’s disease different?

Dr__Joyce_Shin: Hashimoto’s is the most common cause of hypothyroidism. There are other causes. It is an autoimmune process, where your own blood cells attack the thyroid gland. The treatment is medical – prescription Synthroid.

Jerome: I had an ultrasound after being diagnosed with Hashimoto’s disease, and it showed the gland was normal. Is any follow-up necessary?

Dr__Joyce_Shin: Depending on the degree of your Hashimoto’s, your thyroid gland may or may not look normal on ultrasound. If there is a big goiter, then yes, you should have a repeat ultrasound in a year. If you have a nodule on your initial ultrasound, yes, you need to be followed.

mysticangel: I have Hashimoto’s and I still have certain symptoms, such as hair loss and fatigue. I am on medicine, but I am wondering what kind of nutrition will help with it? I am allergic to all seafood, so I can’t eat it. Thanks.

Dr__Christian_Nasr: You are welcome and thank you for the questions. I am going to assume you have hypothyroidism and you are asking how come you still have symptoms when you are on medication. You need to make sure your thyroid level is good. No specific nutrition is recommended. If you have Hashimoto’s and you are not on thyroid replacement, make sure you do not take foods with high iodine contents. You do not have to eat or avoid seafood but make sure you avoid kelp or seaweed for example. Make sure nobody lures you into using high iodine formula because they could make your hypothyroidism worse. Also try not to consume a lot of soy products (like living on soy). Otherwise, you do not have to worry so much about your diet.

Iola: My daughter was diagnosed with Hashimoto’s disease when she became pregnant and was given Synthroid. The doctor said it was inherited. I have been on Synthroid (now up to 88 mg) for over 15 years but my generalist never tested for Hashimoto. Should I start to see a specialist?  Is Hashimoto’s disease inherited?

Dr__Christian_Nasr: All autoimmune thyroid diseases are inherited, and they favor the female gender. The cause of hypothyroidism is Hashimoto disease. We do not have to look for it because we know it is there. If you feel your physician is not doing a good job, then seeing an endocrinologist might be a good idea.

Jen62590: What could cause my hypothyroidism to get worse so quickly? I was on 50mcg when last tested a couple of months ago and now – four months later – I have to take 100mcgs.

Dr__Christian_Nasr: This is due to the progression of thyroid destruction by the Hashimoto’s process (thyroiditis). This could happen over years or decades or over a few months.


prasekk: For hyperthyroid, are the only treatments medication, iodine to kill the thyroid, or surgery to remove it? Are there statistics on patients that show other health issues because they had one of these procedures? What about 5, 10, or 20 years after the procedure?

Dr__Christian_Nasr: Thank you. These are the only three approaches to treatment. Surgery could be associated with permanent hypoparathyroidism requiring life-long replacement with calcium supplements or injury to the recurrent nerve that nourishes the vocal cords. To avoid those one needs to find an experienced surgeon. Regarding the radioactive iodine treatment, there could be a risk of secondary cancers decades later, but that has not been proven. There is always a concern with administering radioactivity to patients. Anti-thyroid medications can cause allergies or liver problems, which are usually reversible. The most feared complication is “agranulocytosis” which is lowering of the white blood count in the blood, which can be dangerous. Fortunately this happens rarely (0.3 percent).

Kriscooker: I have trouble staying asleep at night. Is there a chance it might be from my thyroid?

Dr__Joyce_Shin: It can be. If you were hyperthyroid, meaning you have too much thyroid hormone in your body, you may feel anxious and have trouble sleeping. To diagnose it, all you need is a simple blood test.

Graves Disease

B_90: I have Graves’ disease and my thyroid was burned out using radioactive iodine. Can you tell me what the current thoughts are on this condition as it relates to the post menopause female? And can you discuss the most current information on dosages for T4 and T3 replacements?

Dr__Christian_Nasr: Your questions require a long session. Menopause should not interfere with thyroid levels unless you decided to start estrogen treatment. In that case, you might need an adjustment in your dose of levothyroxine. Regarding the T4/T3 combo, this could be tried if the patient was asking for an improvement in specific symptoms, such as fatigue. This does not always work but could be attempted under supervision. This approach does not help weight, hair, or nails so be careful what to expect if you chose to go that route

jln2112: I was diagnosed with Graves’ disease 2/2010. I have since been treated with I-131 in July. Currently T4 is low normal, but TSH is either high one time and low the next. My dose of Synthroid changes every six weeks, I guess until my TSH becomes normal. My question is: what combination of drugs could be used to make my T4 a little higher than I seem to get out of Synthroid? This seems to be taking a long time to get regulated.

Dr__Christian_Nasr: Thank you. After radioactive iodine, the thyroid gland takes time to die out completely. This could take several years. Most of the time, however, it does die within a few weeks. It looks like your thyroid is dying slowly. If your TSH continues to be high or normal, your doctor should catch up by increasing the dose. Going to a different preparation will not change this process.

Aprilw22: I have Graves’ disease (positive antibody shown in lab work). I have severe eye swelling (and hands) in the morning, sometimes lasting all day. My thyroid levels are normal, but I have severe physical symptoms – severe tremors, panic and anxiety attacks, brain fog, weight loss, severe fatigue, muscle pain and wasting, severe hair loss, also a feeling of swelling in throat making it hard to swallow. I feel very cold in winter and hot and sweaty in the summer. This is not normal for me. I never used to sweat a drop in summer, not even in 100 degree weather. I was put on 75mg Synthroid last year. My doctor took me off because my labs came back abnormal. I had normal labs a few months ago. Why do I have all these physical symptoms that are making me disabled? If I remove my thyroid, or part of it, will my Graves’ go away?

Dr__Christian_Nasr: This is a very complex presentation. Unfortunately it does not look like a chat would solve this problem. All the history will need to be looked at with the relevant lab work, other studies, etc… .

ChyvonneB: I have Graves’ disease (GD), treated with RAI. I’ve been to several endocrinologists. It just seems that none of the endocrinologists I’ve seen have been very versed in autoimmune-related thyroid issues. It seems I’m lumped in with more general thyroid disorders. I go to the doctor and my TSH levels, etc. are read and that’s basically it – no mention of bone density issues (I now have osteoporosis) or anything related to GD. I ask questions, but don’t get much info. Most info I get about GD is from books and the Internet, and that’s not always dependable.

Why is this? Is there a lack of knowledge by endocrinologists in this area?  After many years of suffering on Synthroid, I realized from an online support group about Armour Thyroid. No endocrinologist (and I’ve been to many) ever mentioned Armour to me. When I finally asked to be put on it, there was resistance from my endocrinologist, and he told me to try Levoxyl, which made my symptoms worse. Now, I do take Armour Thyroid. Although, I am not feeling perfectly on Armour, I feel better in many ways. (No more depression, for one).

What are your thoughts about Armour Thyroid, and why isn’t it more widely suggested, especially to patients who might not tolerate synthetic thyroid hormone as well? I eat pretty well, and take thyroid hormone. I’m also thin (very thin). And, my cholesterol is always on the high side (no less than 210). But, my blood tests show normal. I attribute it to my thyroid. Is this not possible (with my blood tests being normal)? Is there a support group for thyroid disorders and/or autoimmune thyroid related disorders?

Dr__Christian_Nasr: I do not know why you have not had any luck with any endocrinologists. Anyway, it is well known that long-standing Graves’ hyperthyroidism can cause osteoporosis, but the bone density should improve a few years after the treatment of the hyperthyroidism. So a follow-up is a good idea. I am glad you are taking the information from the Internet with a grain of salt. Most Internet sites are market-driven. So I wonder who prescribed Armour to you. Armour works for some patients, but not all. Most patients (I would say 90 percent) do very well on any thyroid preparation. Some patients are never happy, and they feel something is missing. Armour does help with depression and improving energy but not so much more. If your thyroid tests are good, then you cannot blame the thyroid state for the high cholesterol. I am not aware of any helpful support groups, and that is unfortunate because most patients do well and they go on with their lives.

Thyroid Medicines

Kriscooker: I have heard recently that you could take your thyroid medication just before bed and get better results. Is that true? I was diagnosed in May ’08 and been on Synthroid since then. I had a portion of my thyroid removed in Jan. ’10 and still feel the same – blah, tired, and always freezing. My doctor says my labs are all good, so he’s not willing to try any other meds. I also have long menstrual periods – eight to nine days on average. Should I be on another type of medicine other than Synthroid? I get tested every six months.

Dr__Christian_Nasr: This is a classical question because of the misinformation out there. TSH is used to diagnose hypothyroidism, and it is also used to adjust the thyroid medication. Pushing the diagnosis too far when the TSH is where it is supposed to be is wrong. It is true that some of the symptoms you described do suggest hypothyroidism, but once the TSH is confirmed to be good, then one should look for other causes for the symptoms. Switching from one brand of Synthroid to another one would not make a difference. Some patients might benefit from adding a low dose of liothyronine (T3), which could offer some improvement in the energy but does not generally improve other symptoms. This should be supervised by an endocrinologist.

There is nothing wrong with trying, but if that did not work you should go back to using only T4 (Synthroid, Levoxyl, or just levothyroxine). Do not take the levothyroxine at bedtime unless you are absolutely sure that your stomach has emptied completely. I am not sure where you read that, but taking the levothyroxine on an empty stomach is the recommended approach and it does make more sense than the alternative.

caseed: What percent of people go into remission after a two-year round of treatment of methimazole?

Dr__Christian_Nasr: Thank you for the question. There is no right answer to this question. There are factors that increase your chance of remission – small size goiter, thyroid hormones not too high at presentation, no thyroid eye disease, thyroid antibodies not too high. Overall, the chance of remission is about 10 percent to 20 percent.

meganmc18: How long does it take for the hormone medication to regulate and you start feeling back to normal after a thyroidectomy?

Dr__Joyce_Shin: Thyroid hormone lasts in your body for around two weeks, so even if you had your thyroid removed, it will take a while for your body to “miss” it. After a total thyroidectomy, we don’t check thyroid function tests until two months after. That is how long it takes most people to react to the dosage. If you only had one side taken out, you may or may not need thyroid medication, depending on how the remaining side is working.

caseed: What are the cons of being on methimazole for more than two years?

Dr__Christian_Nasr: The two-year magic number comes from the fact that remission would happen during that time period if it were to happen. No cons from being on methimazole, but we do not like to keep patients on high doses of methimazole (more than 5 mg) for a long period of time.

GV_1: My insurance program recently switched me to a generic form of Synthroid labeled l-thyroxine. What is your opinion about generic medications? I had an endocrinologist once tell me generics for Synthroid are very erratic in their dosage levels.

Dr__Joyce_Shin: Synthroid is from one manufacturer, so yes, they have the most reliable dosage in each pill, in comparison to the generic form.

Jerome: I’ve heard and read that the generic Synthroid is not as effective as the brand?

Dr__Joyce_Shin: The generic form is good, but the dosage of the actual hormone may change because it’s from different manufacturers. Because Synthroid is from one manufacturer, it has a consistent dosage of the hormone in every pill.

KMS: I had my thyroid removed in October, and now take daily levothyroxine. But I travel a lot, and have forgotten to take my medicine with me once already (I went to a local drugstore and got a refill.) What is the longest I can go without taking this pill?

Dr__Joyce_Shin: Thyroid hormone lasts in your body for a few weeks, so although we wouldn’t recommend it, you probably can go without it for two weeks or so.

Tranquil: Are there any natural alternatives to Synthroid that I can take?

Dr__Christian_Nasr: Tranquil Thank you. “Natural” is attractive to people. There is nothing natural anymore. Levothyroxine (Synthroid, Levoxyl, Unithroid, Levothroid or generic levothyroxine) preparations are purified and go through a very meticulous process. Armour Thyroid is “natural” because it comes from an animal source. Some patients feel better on it compared to the synthetic T4 hormones.

Svetlana_1: I have had low TSH for a number of years (0.16, 027, etc.). My T3 and T4 all the time are normal. I do not take Synthroid. I had tests in 2005 and 2007, both were negative. Do I need any medication to change TSH to normal range? Thank you.

Dr__Christian_Nasr: Svetlana_1 Thank you. It looks like you have subclinical hyperthyroidism. As long as your TSH is not lower than 0.1 and you do not have high T4 or T3, and you do not have symptoms of hyperthyroidism, then you could continue to have the TSH monitored every six months. No intervention is needed.

GV1: I am a 40-year-old male who has been on .137mg of Synthroid since I was 22 years old. I was told not to use generic medications by my initial endocrinologist, but have used them in the last 10 years and my levels have remained consistent. I would like to get off of Synthroid and wondered if there was a specific type of doctor I should look for that would specialize in that. What are the risks of getting off of Synthroid, and would you recommend it?

Dr__Christian_Nasr: Thank you Gary. It is not a good idea to quit taking Synthroid. It is difficult to make this decision 10 years later. If your initial TSH was very high (more than 10 mIU/L), then I would recommend against stopping the medicine. The right doctor to do that is an endocrinologist. We would be happy to see you, look at your initial lab results, and advise you on the right action.

Thyroid Disorders and Weight

PamelaHarrim: Obviously, hypothyroidism makes losing weight extremely difficult. Any tips that would help or supplements that you would recommend?

Dr__Joyce_Shin: If you are hypothyroid on laboratory studies, then you need to be on medication (Synthroid). If you are truly getting enough of the medication (lab values have normalized) and you’re still gaining weight, then unfortunately, there isn’t a supplementation to help lose weight. Just make sure that your thyroid labs have become normal (euthyroid).

kdlower: I am 46 years old. I have hypothyroidism and take Levoxyl 100mcg. I am 165 pounds and 5′ 4″, I wonder what kind of diet should I be on/foods should I be eating. I exercise three to five days per week, but can’t lose the weight. My cholesterol is high (285-300), and I am post-menopausal for four years (due to having early oophorectomies for cysts at 13 and 19 years.) I also have mitral valve prolapse – though not severe. Are there any specific foods I shouldn’t be eating? What can I do to lose weight and get back to my pre-condition figure/weight of 135 pounds? Thank you.

Dr__Christian_Nasr: Thank you for the question. Let us start with the weight issue. You will need to work on that regardless of what is happening with the thyroid. If the thyroid is off, that can be fixed, but then you will have to work on the weight. Regarding the diet, you do not have to be on a special diet; however, try to avoid eating a lot of foods containing soy because those could increase your requirement for thyroid hormone. There is no issue with the mitral valve prolapse. Hypothyroidism can be associated with high cholesterol, but once the hypothyroidism is fixed, the cholesterol should go back to your baseline.

The most important thing to do is to make sure you’re on the right dosage of thyroid hormone medication. This means you need to have your thyroid function test repeated after you’ve been on your medication. If you truly are euthyroid (normal TSH), then the weight gain is not due to the thyroid gland.

jegriffin: I have benign nodules and a TSH that fluctuates WNL (so no medication), but I still can’t lose weight (even tried Weight Watchers). I have gained 35 pounds in eighteen months. I work night shift as an ICU RN so my sleep schedule is screwed up anyway, but I cannot focus or stay energized. Do you have any advice on any supplements to take to help my thyroid function? Thank you very much for your time.

Dr__Joyce_Shin: If your thyroid function test is normal, then unfortunately, your weight gain is not from the thyroid gland. Lack of sleep can definitely contribute to weight gain!

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Jerome: After four years diagnosed with Hashimoto’s disease taking T4 and TSH is within range (approximately 2.0), but I keep slowing adding weight without a change in my diet, and I still have all my presenting symptoms. What can I do?

Dr__Joyce_Shin: If you truly are euthyroid (normal TSH/free T4), then – unfortunately – it’s not the thyroid that is causing weight gain. Make sure you truly are euthyroid.

Thyroid Surgery

meganmc18: I have a 4cm nodule on my right lobe, as well as a few cysts. On my left lobe, I have a 1cm nodule, as well as a cyst. Would you suggest a total thyroidectomy or partial?

Dr__Joyce_Shin: It depends on if the nodules have been biopsied. If the 4cm nodule is benign on the biopsy, and the other side only has subcentimeter nodules, then you can have the one side removed. However, if the 4cm nodule is cancer, then you will need to have the whole thing removed. Where is the 1cm nodule? Any nodule greater than 1cm needs a biopsy.

meganmc18: My biopsy results came back non-cancerous but suspicious, and my thyroid blood test came back normal.

Dr__Joyce_Shin: Most people with thyroid nodules have normal thyroid function tests (lab values). What was it suspicious for? Was it suspicious for papillary thyroid cancer? If so, then you need further evaluation with a surgeon. If suspicious for follicular neoplasm, you still need a surgeon.

HyperT: 1) I have hyperthyroidism (Graves’) and find it nearly impossible to lose weight. Do you have any suggestions? 2) My endocrinologists have been urging me to undergo irradiation of my thyroid, but I have heard of too many people becoming hypothyroid after this procedure and then struggling to find their right level of thyroid medication for the rest of their lives. I don’t want to just trade one problem for the other problem. Why can’t they just surgically remove part of my (enlarged x3) thyroid to control the amount of thyroid hormone being secreted?

Dr__Joyce_Shin: If you have Graves’ disease, your entire thyroid gland is affected. Therefore, removing only part of the thyroid will not make your euthyroid (normal thyroid function). You will most likely remain hyperthyroid. The surgical treatment for Graves’ disease is a total thyroidectomy. If you truly are hyperthyroid and you’re gaining weight, it’s not from the thyroid gland.

weezy81: What is the benefit of having your thyroid removed by an endocrine surgeon versus a general surgeon? Both do these procedures. Does it really matter who you go to?

Dr__Joyce_Shin: An endocrine surgeon is a board-certified general surgeon who performs surgery on four of the main endocrine organs (thyroid, parathyroid, adrenal gland, and pancreas). Therefore, they are more likely to have a higher volume of thyroid/parathyroid cases than a general surgeon and more experience operating on these specific organs. General surgeons are trained to perform thyroid/parathyroid surgery also; however, they may only do these cases on a monthly/yearly basis. Endocrine surgeons undergo further training in this field, and learn special techniques to improve outcomes and reduce complications.

meganmc18: How do I select a surgeon? I live in a small town in Georgia? Do I look to bigger cities for a surgeon for a total thyroidectomy?

Dr__Joyce_Shin: Try to find a surgeon who has done a high number of thyroid surgeries. An endocrine surgeon is a great option, if you can find one. They are trained to operate on four organs, including the thyroid gland, so they usually have more experience compared to a general surgeon who may only do a couple of thyroid surgeries a year.

Thyroid Function and Other Disorders

Becky: Is there a connection between celiac sprue disease and thyroid problems?

Dr__Christian_Nasr: Thank you. Yes. They are both autoimmune disorders. They can be associated namely with Hashimoto’s disease and Graves’ disease.

JSBNews: Is there a connection between thyroid disease and infertility in men?

Dr__Christian_Nasr: Thank you. Yes, hypothyroidism and hyperthyroidism could be associated with infertility, but they have to be severe, and correcting the thyroid condition could correct the infertility problem.

ConnieWoods: I have an 18-year-old daughter who was diagnosed with Turner syndrome (TS) shortly after birth.  By age 15 our endocrinologist strongly suggested my daughter try HGH shots. Her bone scan revealed her bone plate only measured at age 12. She started out at a height of 4″6. Within a year she started having complications. She remained on HGH for another four months. She did grow approximately 1”3/4 inches. With TS, I was aware there is a risk for kidney or heart defects. My daughter was always monitored with complete cardio and renal workups. I was quite upset when it was discovered about three months after she stopped taking HGH that she has a bicuspid valve leakage and an aortic aneurysm measuring 5.2 cm. My first question is: is it possible that this defect occurred due to her being on the HGH? My second question is: since this defect was discovered, are there endocrine issues that she needs to be followed for now or treated for sooner rather than later? What issues are the greatest concerns for me to address in conjunction with her heart issues? I realize she is at risk for diabetes and obesity. Please let me know anything I need to be concerned about and keep monitored. Thank you.

Dr__Christian_Nasr: Thank you for the question. It is known that TS can be associated with bicuspid and aortic valve disorders. It is not related to the HGH treatment. It is also known that TS patients are at higher risk of developing type-2 diabetes, as you stated, and also hypothyroidism from Hashimoto’s thyroiditis. It is recommended that they be screened on a yearly basis for those conditions.

Gr8fulBeing: Is there any relationship between hypothyroidism and Raynaud’s?

Dr__Christian_Nasr: Definitely. Hashimoto’s and Raynaud’s can be seen in the same patient. Treating one does not correct the other, however.

Katelynn: Is there any research that supports a relationship among problems with the parathyroid glands, kidney stones, and breast cancer?

Dr__Christian_Nasr:  I am not aware of any relationship between these three components. Hyperparathyroidism and kidney stones can definitely be related. When we see one, we look for the other. Again, I am not aware of any relationship between breast cancer and the other two.

General Questions

nattie: I am curious If Cleveland Clinic offers endocrine surgery services anywhere else in northeastern Ohio, other than at the main hospital?

Dr__Joyce_Shin: Patients are now able to be seen by an endocrinologist and receive advanced ultrasound-guided diagnostics, as well as endocrine surgical care, at Cleveland Clinic Family Health Centers located in Independence, Solon, and Willoughby Hills. The goal of expanding these specialty services is to increase availability closer to patients’ homes for added convenience and less travel time. It also benefits patients because some endocrine conditions could require multiple appointments for diagnostic testing, pre- and post-op surgical visits, and general maintenance. The actual surgery is still done at Cleveland Clinic’s main hospital campus.

Katelynn: Will the standard thyroid blood tests given as part of a wellness examination also detect problems with the parathyroid glands?

Dr__Joyce_Shin: Thyroid and parathyroid laboratory studies are completely different. Many primary care physicians check thyroid function tests (include TSH, free T4, free T3, etc.). The test for parathyroid disease includes calcium (part of the usual laboratory exam) and PTH (parathyroid hormone). If your calcium is high and your doctor suspects parathyroid disease, then the PTH is sent.

Cali: My hair is dry and brittle. I’ve heard this is a result of my hypothyroid condition. What can I do?

Dr__Christian_Nasr: Dry and brittle hair can be a result of hypothyroidism, but it can be the result of many other conditions. If you have proven hypothyroidism by blood tests, then you should be put on thyroid hormone medication (Synthroid), which may help with the symptoms.

pattayo: Why is it so difficult to get adequate treatment for thyroid problems, as most doctors seem to know very little about treating the condition, or the newer lab values? Thank you.

Dr__Christian_Nasr: Thank you. It is not that difficult. Most patients do very well when they are seen once a year. Some patients have difficulty getting their doses adjusted. There are no newer lab values. You have to be careful what you read.

betterdaysahead: Why do my labs say I am fine when I don’t feel fine?

Dr__Christian_Nasr: Thank you. Maybe your labs are in the normal range but not where they are supposed to be. If your labs are where they are supposed to be and you are still not feeling fine, you should look at other possible causes of your symptoms.

caseed: I have lost my health insurance. How much does it cost to have your thyroid burned out radioactively?

Dr__Christian_Nasr: I am sorry to hear that. The cost of the radioactive material depends on the dose. We typically treat patients with doses of 8 to 25 millicuries of I-131. The typical cost is about 200 to 300 USD. There is also the cost of having the uptake and scan prior to the treatment, the cost of the nuclear medicine facility, and the fees of the treating physician. So you are looking at a couple of grand.

SThirlwall: Do you support the use of Nature Thyroid NT-1 (65 mg) and Pregnenolone CRT to improve thyroid and adrenal function?

Dr__Christian_Nasr: Thank you. No. I do not support prescribing Nature Thyroid for that purpose. Pregnenolone CRT does not do anything to adrenal function. Besides Nature Thyroid does not do anything to “thyroid function.” It only provides replacement in patients who do not make thyroid hormones.

scubadiva: Is the biopsy sent to a lab?

Dr__Joyce_Shin: The biopsy is most often sent to the cytopathology lab. There are physicians there who read the cells on the slides.

Mombutterfly: What if thyroid results come up normal, but symptoms of low thyroid still exist?

Dr__Christian_Nasr: If the thyroid results came back normal, but there are still symptoms, then look for other causes for those symptoms because they can be seen with other disorders.


Cleveland_Clinic_Host: I’m sorry to say that our time with Drs. Christian Nasr and Joyce Shin is now over. Thank you again, doctors, for taking the time to answer our questions about Thyroid Disease.

Dr__Christian_Nasr: Thank you very much.

Dr__Joyce_Shin: This was a great forum. Thank you for your questions.

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