The Doctor Is In: Thyroid Disorders -- Brunilda Nazario, MD. -- Nov. 12, 2002.

Last Editorial Review: 10/23/2003

By Brunilda Nazario
WebMD Live Events Transcript

If you have concerns or questions about the diagnosis or treatment of thyroid problems and their affect on your weight, energy level, fertility, and more, read what WebMD's own thyroid disorders expert, Brunilda Nazario, MD, had to say during this live event.

The opinions expressed herein are the guest's 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.

Moderator: Welcome to WebMD Live. Today's guest is Brunilda Nazario, MD. She has joined us to talk about thyroid disorders. Let's get to our questions:

Member: I have just been diagnosed with hypothyroidism, and had a TSH (thyroid stimulating hormone) of 84. It is now down within range, but I still do not feel well. How long does it take before I feel better?

Nazario: A TSH of 84 tells me that for a long period of time you developed subtle symptoms of thyroid dysfunction and probably became very accustomed to a slow metabolism. With such high elevations of TSH and slow metabolism we tend not to over-correct the hypothyroid state.

From the start of medication to a change in the next dose it usually takes about six weeks for reassessment of a TSH. It's not unusual that patients continue to feel subtle symptoms of fatigue, despite what is a normal level of TSH. Most labs record a normal range TSH at 0.5 to 5.5. Although a more realistic goal for a TSH should be at around 2.

If after placing patients on appropriate thyroid replacement the patient continues to have abnormal levels of TSH, I ask questions about not only their timing of medications, but also potentially what else they take with their thyroid pills. Simple things like multivitamins that contain iron can cause your thyroid pill not to be absorbed completely. Commonly we see both men and women unaware of this fact. It's best to take thyroid hormone pills first thing in the morning, preferably on empty stomach, and always take them ALONE, without other pills.

The other common problem I frequently see is the combination of birth control pills and thyroid hormone. Interpretations of lab results from patients taking these two medications can be difficult. It's important that patients tell their physicians if they're taking both. In this case both a TSH level and a Free T4 should be ordered to appropriately assess the patient's thyroid status.

Member: Is there any food that one can take in excess or avoid to help in the regulation of the hormone?

Nazario: Good question. In individuals who have a susceptibility to thyroid disease because of genetics or predisposition of family history or underlying scarred thyroid for whatever reason, they can be susceptible to foods containing a high iodine content. These individuals can develop hypothyroidism from iodine-containing foods like kelp. Sushi does not apply here and seafood does not as well. You can't consume that much that you overload on those foods.

But excess supplementation of iodine like with health-food supplements can lead to an accelerated hypothyroid state. Although it is true that the thyroid uses iodine to make thyroid hormone, in excess amounts you will shut down and scar your thyroid gland. This character of iodine excess is used as treatment for hyperthyroidism. In a hyperthyroid patient, to quickly make them hypothyroid, excess iodine is frequently used. Is there anything that helps your thyroid as far as foods go? No.

Member: On the concern of iodine in excess amounts, I note that people consume salt heavily in the United States, and most of this salt is iodized. Good or bad idea?

Nazario: Excellent question. Years ago in the U.S. there was a deficiency and the government supplemented iodine in salt and in bread, but this is in miniscule amounts. Our bodies also do a very good job of recycling iodidne.

The reason for doing this (adding supplementation) is in the pregnant woman, her fetus depends on the mother's diet and appropriate supplement of iodine. Without iodine the fetus' thyroid would grow into a goiter or huge grapefruit-like gland. During the process of labor and delivery in such a case, asphyxiation of the fetus could happen as it travels through the birth canal since it brings its head close to its chest, and with a goiter the soft tissues in the neck would get crushed. That type of supplementation in bread and salt is adequate even in miniscule amounts. We don't see congenital goiters anymore in this country or in countries that supplement these amounts.

Member: I have an underactive thyroid. How does that affect me trying to conceive a baby?

Nazario: During the first six weeks of development the fetus depends on the maternal supply of thyroid hormone for development of the brain and nervous system. Only after six weeks is the fetus capable of supplying its own source of thyroid hormone. During pregnancy, a hypothyroid patient, one who has inappropriate levels of thyroid hormone, can have a few complications. A TSH should be checked during the first trimester and should be monitored every eight to 12 weeks.

The delivery of infants smaller than their gestational age can happen. There is also an increased risk of stillbirths. There is a possibility of impairment of brain development. And in the mother, other complications exist as well. These include:

  • A higher risk of pregnancy associated hypertension
  • Early rupture of the placenta
  • A severe type of hypertension associated with seizures and kidney problems
  • An increased risk of hemorrhage during the labor process

It is extremely important that your thyroid hormone levels be checked during pregnancy, and again multivitamin and iron supplements need to be taken at a different time than when taking the thyroid hormone.

Member: Can I get pregnant though?

Nazario: Of course you can. Is infertility affected if hypothyroid? Yes, it is, most definitely. And even if a hypothyroid individual becomes pregnant, there is a higher risk of spontaneous abortions (miscarriages). This doesn't apply to the person on thyroid hormone supplementation. It applies to the hypothyroid patient who is uncorrected by medication replacement or medication therapy.

Member: Is it true that hyperthyroidism will eventually "burn out" the thyroid? Also, what are the symptoms of hyperthyroidism besides weight loss?

Nazario: Hyperthyroidism in Graves disease can eventually burn itself out. It can take sometimes up to five or more years. Hyperthyroidism from Graves can lead to life-threatening consequences, including heart abnormalities (congestive failure) and extremely irregular heart beats. Muscle wasting and paralysis can also occur.

Weight loss is usually seen early in the disease. A few patients are not aware of the more devastating consequences of hyperthyroidism caused by Graves. Other more appropriate options for treatment include medical therapy, radioactive iodine, and even surgery to remove the thyroid.

Member: I take my prenatal vitamins at night around 11 p.m. and take my synthroid 50 mcg at 7 a.m. the following morning. Is that a sufficient gap for both to act?

Nazario: Perfect.

Member: I take birth control pills with estrogen (levelen 28). Does that interfere with synthroid? The gynecology clinic said that it shouldn't, but that it might interfere with following thyroid tests.

Nazario: Your doctor is right. Birth control pills do not interfere with the absorption of thyroid hormone, but they increase lots of proteins in the body. And when we interpret thyroid blood tests, many of these tests are analyses of proteins in the body. So in an individual taking birth control pills, the best thyroid test to analyze is a Free T4 as opposed to a T4, which has a protein component to it and is affected by birth control pills.

Member: What is a thyroid scan and what does it tell you?

Nazario: It is a functional test or picture of the thyroid. It contains a very inactive or minimally active radioactive iodine substance. The radioactivity basically glows on a scan, and your thyroid uses iodine to make thyroid hormone. So one having a thyroid scan would be given a pill containing radioactive iodine, then asked to return in six hours, and again in 24 hours after the ingestion of the tablet.

During that time the iodine is taken in by the thyroid in an attempt to make thyroid hormone at a normal rate. At six hours a picture of the thyroid is taken. A calculation is made depending on how much iodine is consumed and how much radiation is detected on the scan, and the pattern of glow that appears on the scan.

This allows one to determine various pieces of information: How fast or how slow the thyroid is in making thyroid hormone. Where it is making the thyroid hormone, like in a nodule or in all of the gland that is functioning. Or if there is a "cold nodule." The cold nodule is an area of deficit of the glow or area of the gland that is NOT functioning, which may be one of various characteristics that physicians look for when determining whether a mass is cancerous or not.

Member: How often should a thyroid scan be done?

Nazario: It depends on whether you have cancer or not.

Member: My sonogram indicated a water-filled cyst on the thyroid. What exactly does that mean?

Nazario: A fluid-filled cyst usually indicates a benign mass, as opposed to a rock-hard or solid or calcified mass. Again this is USUALLY one of the characteristics of a benign mass versus a cancerous mass. The only thing that can truly differentiate the two is a biopsy. A fine needle biopsy will go into this fluid-filled mass not attempt to drain the fluid from the mass, but attempt to scrape the wall of it to get cells. Those cells are later sent to pathology to evaluate for cancerous cells.

Member: How do you know if a man has a thyroid problem? Is sweating a sign?

Nazario: Both men and women and children can get thyroid abnormalities, but it's much more frequent in women with one in ten women with a thyroid problem. Symptoms in men mirror those seen in women, whether hyperthyroidism or hypothyroidism. Thyroid masses are unusual in men and warrant a higher level of suspicion. So when typically I see men in the office for a thyroid mass, I almost immediately recommend a biopsy be done after the history and the physical. So yes, thyroid problems can be seen in men but are not as common as we see in women.

Member: I am trying to make sure my 18-year-old son who is 200 miles away at college is properly treated. He developed symptoms beginning in early October and getting progressively worse. He is fatigued all the time, has tingling in both legs, feels weak, naps a lot, hair is brittle. TSH test shows 3.8. Doctors disagree as to whether to doT3/T4/free thyroid test. Should they? They are of course investigating lots of other things, as they should be. But the campus health service doesn't want to do anything more with the thyroid.

Nazario: Your son has a complicated problem. He's got a normal TSH but has a lot of symptoms which sound thyroid in origin. Your son should have a complete thyroid panel looked at, which includes a total T4 and TSH. The TSH is a blood test of something that drives your thyroid to function or a gland called the pituitary gland. His physicians should probably question whether his TSH is appropriate. One way to do that is to evaluate the rest of his pituitary gland or other hormones produced in the pituitary. So a prolactin hormone level, testosterone level, an AM Cortisol, a TSH and Total T4 should all be done in one sitting. This is what I recommend, and your physicians can take it from there.

Member: What is the difference between a TSH and T4 test?

Nazario: TSH comes from the driving force of thyroid or brain of all hormones -- from your pituitary, a little gland in your brain. Your T4 is produced by your thyroid gland, which is in your neck. They are two different things made by two different organs, connected to bring a balance to your metabolism.

Member: I am on synthroid 125 m and have not been successful in conceiving OR losing weight. My TSH is right at 4. Should I have my doctor adjust my medications more aggressively (he has been treating me for four years with no results, only increasing my meds by 5m each time)?

Nazario: It seems like an appropriate normal replacement dose for an average adult. Increases or decreases in doses should be done slowly, rechecking labs each six weeks. Your TSH at a level of 4 does not sound ideal. Typically the goal level for TSH should be between 2 to 3. Obtaining that goal does not necessarily mean you will achieve weight loss whatever that may be, or a successful pregnancy. Both weight loss management and infertility are very complex. Your TSH sounds like it should be adjusted to a more reasonable level. I agree your TSH should be regulated better than it is.

Member: Are there any indicators that a woman might be susceptible to hypothyroidism?

Nazario: Just being a woman and with a family history makes you more susceptible. If you have other autoimmune diseases, then you have already demonstrated that you have some unknown genetic susceptibility to thyroid abnormalities, whether hyperthyroidism or hypothyroidism.

Member: Is a person with hypothyroidism more likely to catch colds/flu?

Nazario: No.

Member: My TSH is 3.5, right in the middle of the scale, yet I have hypothyroid symptoms still. Should I pursue trying to get the doctor to lower it more? How would I do this, since they seem to be going off the range setup -- "after all if it's right in the middle that's the best we can be doing."

Nazario: I think it depends on the symptoms. If you have things like carpal tunnel or elevated cholesterol, your TSH could be reduced a bit more. If it's that you have symptoms of fatigue, it's such a vague symptom that you really can't pinpoint one disease process. Sometimes pushing the TSH lower can actually make fatigue worse. It really depends on symptoms. If you are young and without heart disease, making TSH lower might be worth it.

Member: Is there also a T3 test? Can it give more information than the TSH and T4?

Nazario: Yes, there is a T3 test. A T3 test is usually ordered in cases of an overactive gland. Otherwise it's usually not done routinely because it adds little information compared to the combo of a TSH, T4 and Free T4 that you get when you get a thyroid panel.

Member: What is your opinion of using herbal supplements instead of prescribed medications for hypo thyroid disorders?

Nazario: My opinion is that I generally would warn patients against supplementing with iodine and/or desiccated thyroid which are the two things patients frequently ask about. I have seen more patients harmed than benefited in my experience with supplemental iodine. In the case of desiccated thyroid, I have seen many physicians confused with interpretation of the results. It's best to stay away from those.

Member: I am currently taking thyroid medication for Graves, but the last week I have been so tired I can't get enough rest and am falling asleep at my desk and pretty close to it while I am driving. So I need to have my TSH and T4 levels checked again?

Nazario: Assuming that you are taking PTU or Tapezol, if your symptoms are worse, then you probably should have your thyroid hormone levels checked and your medications adjusted accordingly.

Moderator: Before we wrap up for today, do you have any final comments for us, Dr. Nazario?

Nazario: Thyroid abnormalities are hard to live with and can affect quality of life whether it's hyperthyroidism or hypothyroidism. There is a lot of information out there. Don't be uncomfortable with it. Go back to your physicians to have comfort with your decisions once you have all the information. These are issues you can deal with your entire life. Thank you for chatting with me today. Please visit me on the WebMD message board. It's a busy, busy site. Be patient. There is always someone available to answer your questions. Hopefully I can chat again with you soon. I had a great time.

Moderator: Thanks for joining us members, and thanks to Brunilda Nazario, MD, for being our guest. Be sure to visit her on the WebMD Message Board " Thyroid Disorders with Brunilda Nazario, MD."

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