Thyroid Q & A

WebMD Live Events Transcript

Are you one of the more than 13 million Americans with thyroid problems? If you have questions about the diagnosis or treatment of thyroid problems and their affects on your weight, energy level, fertility, and more, check out our discussion with WebMD's in-house expert, Brunilda Nazario, MD. She joined us Sept. 1, 2004.

The opinions expressed herein are the guests' alone and have not been reviewed by a WebMD physician. If you have questions about your health, you should consult your personal physician. This event is meant for informational purposes only.

MEMBER QUESTION:
I have Hashimoto's disease and I am on Synthroid. Any suggestions for losing weight? I have about 80 pounds I need to lose.

NAZARIO:
It's not uncommon to have weight gain attributed to thyroid problems. It's an unfortunate reality that for the most part, excess weight is not attributed to a detectable thyroid abnormality. Having said that, I would make sure that your lab results that checks for adequate replacement is on the mark, meaning your TSH should be at least less than 3. Secondly, you really want to make sure that you take your thyroid hormone without any other medications, and try and take it the first thing in the morning.

My best advice, having done lots of work with patients that are overweight and obese, is actually quite simple. The first step should be cutting back on the amount of calories we take in. This cutting back should not be a drastic amount where you're left with hunger throughout the day. Simply cutting back about 500 calories a day should lead to about 1 to 2 pounds weight loss per week.

Secondly, increasing physical activity is key to maintaining that weight loss. That doesn't mean joining a gym and drastically changing, such as joining the next marathon, it simply means taking a few more steps a day. Eighty pounds is a lot of weight to lose. Weight loss is a difficult challenge for anyone and there are no magic pills. I would start there.

What we need to look at when we talk about excess weight is excess weight as a chronic condition. What that means is we need to make lifelong changes. So the decrease in calories and increase in physical activity is something you need to commit to, lifelong. That alone is guaranteed to take your weight off and keep it off. Surgery doesn't promise this, and medications do not promise this.

"All women over the age of 35 should at least have a TSH on their annual visit to their physician. This is because thyroid problems occur more frequently in women than in men."

MEMBER QUESTION:
I don't know if I have a thyroid problem, but I have been having lots of symptoms that make me think that I do have a problem. I am wondering what tests I should have done.

NAZARIO:
It sounds like this is a very simple issue that you're looking at. Simply stated, you need a blood test called a TSH, and another blood test called a T4, which is the actual level of thyroid hormone.

I would not be surprised if these blood tests come back normal, so prepare yourself. Unfortunately, many of the symptoms of a thyroid problem, especially hypothyroidism, are quite vague and shared by many other conditions.

So the typical person that says I may have a thyroid problem, says I've put on weight, I'm tired, I've got dry skin, are things that could be attributed to many, many conditions. It's unfortunate, but hypothyroidism does not have one specific symptom that points it to the thyroid. A simple test will determine that.

Hyperthyroidism, on the other hand, is accompanied by symptoms like:

  • An increase in your heart rate
  • Insomnia
  • Headaches
  • Sometimes an increase in appetite
  • Weight loss, even when you're not trying

These are a bit more specific. There are also many telltale signs on examination that help us pinpoint a thyroid problem with hyperthyroidism. But again, a blood test is needed.

All women over the age of 35 should at least have a TSH on their annual visit to their physician. This is because thyroid problems occur more frequently in women than in men. For men with thyroid problems, a health care provider or the doctor needs to be a little more suspicious that a problem is occurring. A symptom in men, like a decrease in their sex drive, or small increase in their cholesterol despite a good diet and medications, might signal a thyroid abnormality. So it really does take a good primary care doctor or health care provider to be a little suspicious that this may be something relating to the thyroid.

MEMBER QUESTION:
My son was diagnosed with a thyroid g----- cyst. I can't remember second word. He is 9 months old. It is at the base of his tongue. Can you give me info?

NAZARIO:
Thyroglossal cyst is a benign condition. What your son has is a problem that occurred during the development of his thyroid. It basically is a cyst that was left while he was developing as a baby within you while the thyroid gland was descending into the neck. These cysts can accumulate fluid. Sometimes they can become very enlarged and cause cosmetic problems, problems swallowing, even problems with the vocal chords if they compress the vocal chords.

They can be treated surgically. Many times they're left alone. If they accumulate lots of fluid, a simple drainage can be done and repeated if the fluid rebuilds within the cyst, which frequently happens. It's a developmental problem; it's benign; and it can be treated.


MEMBER QUESTION:
I am a 56-year-old female. I have hypothyroidism diagnosed two years ago. I was prescribed 75 micrograms of Levoxyl. I would like to know if severe sweating and flushing of the face, chills, heart palps, fatigue, and anemia symptoms should be this persistent, to the point that the sweating is very embarrassing and annoying. It has me changing my lifestyle by not wanting to go anywhere because I am embarrassed. Every time my doctor runs labs he tells me they are good. This is so confusing to me. He seems to dismiss my complaints of sweating, etc. Also what is Armour thyroid, and is it safe to take?

NAZARIO:
The first thing I would do is I would check the thyroid panel, and again, specifically looking at what the level of your TSH level is. That level would determine whether you have sufficient replacement, and more importantly, whether you are taking excess amounts. Excess amounts of thyroid hormone could lead to symptoms of hyperthyroidism. You could get fatigue and flushing and excess sweating.

I'm not quite sure what it is when you say the doctor says your hormone levels are normal. You want a TSH level that's less than 3, but you certainly don't want a TSH level that is close to undetectable.

You're on Levoxyl, which should be an adequate medication. Armour is also a thyroid hormone, but it is a combination of two different thyroid hormones, one called T4, which the thyroid makes, and one called T3, which comes after breaking down T4. T3 is particularly potent; so many endocrinologists tend to shy away from prescribing Armour because it can lead to hyperthyroid symptoms.

The symptoms that you describe, the fact you're a female, and that they started around the age of 54, leads me to suspect a potential drop or deficiency of female hormones, or estrogen. Many of the symptoms that you describe sound like the perimenopausal flush. Again, this is something that can easily be detected by having your doctor measure FSH, and a level of estrogen would help determine that.

If this is related to menopause, the answer may lie in putting you on female hormone replacement, but many other options also exist. If the problem is more relating to the flushing episodes and the chills, there are indeed many options for women aside from estrogen. A few of the seizure medications and even antidepressants can be used to treat hot flashes.

I would suggest opening a discussion with your physician about the possibility that this may be flushing relating to menopause. Typically, if it is, women can have these symptoms for a period of five years on average, although many women have this for less time, and there are women who have this even for more extended periods. So it's worthwhile having this investigated in particular, because it seems it is affecting the quality of your life.

"Excess amounts of thyroid hormone could lead to symptoms of hyperthyroidism. You could get fatigue and flushing and excess sweating."

MEMBER QUESTION:
I have been on Synthroid for four years. This year I turned 60 and have been having some problems with losing my hair and dry skin dermatitis. I asked the doctor if this was from my hypothyroid and if I need to have an adjustment with my meds. She said no, but I have never gone to a specialist for this. Should I, because of these events?

NAZARIO:
This is a question I get asked commonly. Certainly hypo or hyperthyroidism affects hair loss, so it's always a good idea to get your thyroid checked and adjusted if there is a problem.

Hair, as an organ, is a very complex system. There are totally asynchronous phases in hair, so while some hair follicles are totally dormant, some are growing, some are shedding, and it's asynchronous for a reason. If we all shed our hair at the same time we'd all become bald. It's not uncommon that there are periods or seasons where the shedding seems to be more exaggerated. Some of that may be linked to a small degree of vitamin D deficiency, although that does not usually occur in the summer when we're bathing in the sun; it's in the winter season. It still would be a good idea to have your vitamin D levels checked. From a hormonal standpoint those are two things I would check.

The third thing from a hormonal standpoint, when we talk about hair loss, is male hormone. When women go through the changes of life we typically lose female hormones without a loss of male hormones that we make. Male hormones, although they cause an increase in body hair, cause a loss of scalp hair, especially frontal balding (I'm assuming you're not talking about male type baldness; I assume what you're talking about is shedding throughout your scalp). An assessment of what your male hormone levels are should be done now.

Aside from those things, let's look at the damage we do to our hair. If you use hair color, if you highlight, take a look at the quality of those substances. Most of those are acidic substances that take away the natural lubricant on the hair follicle. What I see in our society is as we age and we become gray, like myself, we tend to try to cover that up. We tend to put in more highlights so we have a younger appearance. So look for salon-quality products, and try and limit the amount of treatments you do to your hair.

As an endocrinologist, if you're looking at hair loss, it's important to look at your level of thyroid hormone, your level of vitamin D, and if the pattern is male hair loss, and then an evaluation for excess male hormones should be done.


MEMBER QUESTION:
If you have been diagnosed with hypothyroidism and leave it untreated, what will happen?

NAZARIO:
It's not a pretty picture. Left untreated, hypothyroidism will lead to a slowed metabolism.

  • Your hair would dry and fall
  • Your skin would dry
  • Your body temperature would drop
  • Your heart would slow
  • You'd become swollen
  • You'd become hoarse because of swelling of the vocal chords
  • Your heart would slow down and become a big blobby organ so you'd go into heart failure
  • Your lungs wouldn't function appropriately so you wouldn't be oxygenating well so your brain function would not be normal

Left alone, you could go into what's called a myxedema coma
MEMBER QUESTION:
Recently I was diagnosed with a pituitary adenoma. Can it affect the thyroid, whether or not it is a prolactin-producing tumor?

NAZARIO:
The issue is which came first, the thyroid problem or the high prolactin levels? Hypothyroidism slows down everything, including the clearance of other hormones, like prolactin. So in hypothyroidism you frequently see an elevation in prolactin that is misdiagnosed as a tumor of the pituitary. Treating the thyroid problem results in normalization of the prolactin.

If you have a prolactin-producing adenoma, and if it is large, it can certainly destroy other cells in the pituitary and cause numerous hormonal problems, including thyroid problems. Small prolactin-producing adenomas do not do this. In the first case scenario the treatment would be thyroid hormone to treat the hypothyroidism, and the second would be something like bromocriptine, to lower the prolactin level. It's important to really differentiate what's going on in your case.

"During pregnancy there's a greater need for more thyroid hormone, so immediately after you find the positive pregnancy test, speak to your doctor about upping your dose."

MEMBER QUESTION:
Hello, Dr. Nazario. In your experience, approximately what percentage of hypothyroid patients benefit from added synthetic T3 (brand name Cytomel)?

NAZARIO:
In my opinion, very few. T3 is so short-acting that a once-a-day dose doesn't work, so typically you need to take it two or three times. What happens is you get a boost from the T3 and then you bottom out, then you have to repeat your dose to get your boost, then you bottom out again. I don't really see a place for this medication in the treatment of hypothyroidism.

We do use it when we prepare patients for scanning their thyroid. In this particular case patients need to be hypothyroid for an extended period of time. It's just easier to give them T3, which is removed from their body quickly, as opposed to T4, which sometimes can take up to six weeks before they become hypothyroid enough to do a scan. That's my opinion.

MEMBER QUESTION:
I have hypothyroidism. I am 23 years old and I have had it for about two years. I am taking Levothyroid for it, and I was wondering if a person with hypothyroidism is able to have kids. I have been married for a year and I have never taken birth control, and I am still not pregnant yet. Is it common for women with hypothyroidism to not be able to conceive or to have trouble becoming pregnant? I don't know what causes me to have thyroid problems. I wasn't getting my period for about five months straight and that's why I went to the doctor, and they told me that I have hypothyroidism. My periods are not on time; can that also be a problem?

NAZARIO:
Yes, a woman who has hypothyroidism can become pregnant. There are many issues relating to hypothyroidism that can make conceiving a bit more difficult, but appropriate replacement therapy should overcome those barriers.

The second thing I want to tell you is if and when you do become pregnant it's important to increase your dose of thyroid hormone replacement, the reason being very early in pregnancy the baby does not have a thyroid and the baby depends on your medication, basically. During pregnancy there's a greater need for more thyroid hormone, so immediately after you find the positive pregnancy test, speak to your doctor about upping your dose.

Another issue is the fact that you have irregular menses, which usually means an ovulatory problem. Unless you're able to ovulate regularly, you won't have the egg to fertilize. So what's causing you to have irregular periods/no ovulation? That needs to be investigated.


MEMBER QUESTION:
I have both Hashimoto's and Graves' and am severely hyper right now. I also have Graves' eye disease. I am leaning towards surgery as a treatment -- complete removal of my thyroid. It is my understanding that, as I am only 26 years old and have been hypo in the past, if I go with radiation, my eyes can get worse, and I will continue to go back and forth between hypo and hyper. What is your opinion?

NAZARIO:
You're absolutely right; radiation therapy tends to worsen Graves' eye disease. Usually that's in smokers, but the eye disease in Graves' can fluctuate, it can be worse, improve slightly, and worsen in time.

Killing your thyroid off with I 131, which is radiation, does not remove what your immune system is attacking. It's my opinion, since Graves' is an autoimmune disease, that removing your thyroid in a case like yours would be more beneficial than receiving I 131. Leaving the gland in will continue to promote antibodies that gear up Graves' and presumably gears up the eye disease. Again, that's my opinion.

MEMBER QUESTION:
I am currently taking thyroid medication, but it seems to be what is causing my stomach discomfort. I read that if this happens to take it on a full stomach. I've tried that, but it doesn't help. I saw something about a new form of thyroid medicine that dissolves in your mouth. Is this available at this time?

NAZARIO:
To be honest with you, I've never had a patient tell me that thyroid hormone has led them to have stomach discomfort. The only association I can think of is if you take your medication on an empty stomach and then wait hours before you eat. If so, it's not the medication, it's the fact that you're waiting so long. I may be incorrect, but stomach discomfort is not a side effect of Synthroid or whatever type of replacement hormone you're taking.

I really don't know anything about the sublingual (dissolves in the mouth), but I would discuss the stomach discomfort with your doctor. It may be something else you're taking.

"Synthroid is not a weight loss pill. The only way you'll lose weight is to change your diet and increase physical activity. "

MEMBER QUESTION:
Can Synthroid cause weight gain? I was told I would lose weight.

NAZARIO:
Synthroid is not a weight loss pill. The only way you'll lose weight is to change your diet and increase physical activity. Synthroid does not make people lose weight. Taken in excess, it can. But it can also lead to other negative effects, such as aging of the heart and osteoporosis and muscle paralysis.

MEMBER QUESTION:
I had a craniopharyngioma removed back in 1989. Without an active thyroid is there anyway to speed up my metabolism to help with the extra weight?

NAZARIO:
Again, this is another issue of weight loss relating to hypothyroidism. In your case, specifically, the fact you had the craniopharyngioma makes it a little more difficult. Typically the area of the brain and the area you find craniopharyngiomas affects appetite, how much food you take in, energy, and metabolism. So in your case, be aware that despite doing everything right, you may still have difficulty losing weight. It does not mean or translate into "give up." It means:
  • Make sure the thyroid levels are normal.
  • See a nutritionist to help you cut back on calories and learn about nutrition.
  • See someone or participate in an organized gym so you can exercise.
  • Know where you want your heart rate or metabolism to be so you're burning fat and building muscle (by working muscles you increase your metabolism and that helps burn more fat).

Unfortunately, in your case it is going to be difficult because of the location of where the craniopharangioma was.

MEMBER:
I had most of the pituitary removed!

NAZARIO:
They are not found in the pituitary; they are found in a place above the pituitary called the hypothalamus, and typically these are very large tumors. The hypothalamus controls appetite, energy, and metabolism.

MEMBER QUESTION:
My thyroid was tested and my T4 was 2.53. What can I do to bring it down?

NAZARIO:
The assumption is this is a free T4. So you have hyperthyroidism. First you need to find out what the cause of hyperthyroidism is. If it's an inflammation of the thyroid that will typically resolve itself. If it is just one mass in the thyroid, like an adenoma, that will need specific treatment directed toward that area of the thyroid.

If it's Graves', many more treatment options are available:

  • First off, there are medications that block the production of thyroid hormone and the release of thyroid hormone from the thyroid gland.
  • There's also surgery to remove a part of the gland that is producing excess hormones, or the whole gland if it's something like Graves' disease.
  • Thirdly, there's radiation, which is not external beam radiation. This is, instead, a capsule that contains iodine, which the thyroid usually uses to make thyroid hormone. In this procedure we fool the thyroid into thinking it's taking in more iodine to make more hormone. It takes in the iodine, but because it's radioactive, the radioactive iodine kills off the area of the thyroid producing excess thyroid hormone.

MODERATOR:
Our thanks to Brunilda Nazario, MD, for joining us.




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