In this episode our guest is Dr. Martin Milner.  Today's interview features information on optimizing medication with slow-release compounded thyroid replacement.  

Can adding adjusting your medication from T4 to slow release with T3 really make you feel better?  The answer is, yes!  And, could also be the key to losing weight.

We also discuss the following topics, painful feet, dizziness, fatigue, hair loss, iron deficiency, chronic pain, fibromylagia, adrenal connection to to inflammation, sleep problems, muscle spasms, caution with your morning smoothies, and why you should stand up when taking T3.

Want to find a compounding pharmacy that will make your slow release T3 and T4?  Start here:  http://www.pccarx.com/     

Dr. Milner has published several articles on new treatment protocols for hypothyroidism. Most recently, ” Hypothyroidism: Optimizing Medication with Slow-Release Compounded Thyroid Replacement” was published in the peer review journal of compounding pharmacists, International Journal of Pharmaceutical Compounding (IJPC) Vol. 9 No. 4 July/August 2005. In 2006 and 2007 he lectured around the United States guiding physicians and compounding pharmacists in the management of hypothyroidism using his protocol of slow released compounded thyroid replacement. Also to his credit are “Wilson’s Syndrome and T3 therapy – A Clinical Guide to Safe and Effective Patient Management” IJPC Vol. 3 No. 5, Sept/Oct 1999, p. 344-349 and Assessment and Management of Thermoregulation, IJPC Vol. 3 No. 5, Sept/Oct 1999, p. 350-351. Reprints of many of these and other Dr. Milner articles are available at CNMWellness.com, the medical education website of the Center for Natural Medicine. Dr. Milner co-authored chapter 14 in An Alternative Medicine Definitive Guide to Cancer by J. Diamond and W.L. Cowden, the most definitive text on alternative cancer therapies. He also served as the primary consulting physician for Judith Sach’s book Natural Medicine for Heart Disease. The has authored many articles over the years in cardiology.

Dr. Milner is well published with texts, medical journal articles and studies in cardiology, endocrinology, pulmonology, oncology, and environmental medicine. Dr. Milner published in May 2005, Menopause Revolution: Smashing the HRT Myth- Alternatives to Manufactured Drug Therapy , Agora Health Books. He enjoys what he calls practicing “integrated endocrinology” balancing all the endocrine hormones using bio-identical hormone replacement and amino acid neurotransmitter precursors.

Dr. Douglas Van Nostrand, MD is the Director of Nuclear Medicine and the Program Director of the Nuclear Medicine Residency Program at Washington Hospital Center and Professor of Medicine, Georgetown University Hospital Center.

His specialty is nuclear medicine, and his primary area of interest and expertise is the nuclear medicine diagnosis and treatment of thyroid cancer. He has held numerous academic and medical society positions including Clinical Professor of Radiology and Nuclear Medicine, Uniformed Services University of Health Sciences; past President, Mid-Eastern Society of Nuclear Medicine, Director of Continuing Medical Education Department, and other elected positions of the Medical Staff of Good Samaritan Hospital. He has over 150 articles published and has been the co-editor of seven medical books including the medical textbook entitled Thyroid Cancer, A Comprehensive Guide to Clinical Management.

In this episode, get the critical questions to ask prior to committing to a surgeon.  And, other useful strategies to make sure a patient gets the best outcome possible.  

One-third of all thyroid nodule fine needle aspirations come back indeterminate. When surgery is performed on these cases, pathology of the thyroid reveals that many times the nodule is benign.  Through molecular profiling, patients with indeterminate thyroid nodules, can now avoid unnecessary surgery and get more accurate pathology results from the fine needle aspiration.

Are you a patient and your doctor has said your thyroid nodule is indeterminate and is recommending surgery as an option?  The key is, to confirm that molecular profiling was performed.   

Jennifer Kuo, MD is Director of the Thyroid Biopsy Program, Director of the Endocrine Surgery Research Program, and Instructor in Surgery, at the Columbia University Medical Center. Dr. Kuo received her medical degree from the College of Physicians and Surgeons at Columbia University and completed surgical training at the University of California, Davis Medical Center, in Sacramento.  Her new position follows completion of her clinical fellowship in the Department of Surgery, Division of Endocrine Surgery. Dr. Kuo has clinical expertise in minimally invasive endocrine surgery and fine-needle thyroid biopsy and is dedicated to the advancement of the field of endocrine surgery.

NOTES:

Dr. Jennifer Kuo

Afirma - Veracyte

RELATED DOCTOR THYROID EPISODES

23: You Have a Thyroid Nodule, What Happens Next? with Dr. Regina Castro from The Mayo Clinic

In this episode, we hear from Elle Russ, Author of The Paleo Thyroid Solution, and former hypothyroidism sufferer.  Elle discusses:

• Hypothyroidism symptoms — including physical, mental, and emotional.
• How to find the right health professional.
• Hypothyroidism treatment with T3.
• The importance of iron and ferritin. 
• The emotional toll of hypothyroidism. 
• Nutrition strategies. 
• Basal body temperature method for testing hypothyroidism.

Elle Russ is a writer, health/life coach, and host of the Primal Blueprint Podcast. She is becoming the leading voice of thyroid health in the burgeoning Evolutionary Health Movement (also referred to as Paleo, Primal, or Ancestral Health). Elle has a B.A in Philosophy from The University of California at Santa Cruz and is a certified Primal Health Coach. She sits on the advisory board of The Primal Health Coach Program created by Mark Sisson, bestselling author of The Primal Blueprint.  Exasperated and desperate, Elle took control of her own health and resolved two severe bouts of hypothyroidism on her own – including an acute Reverse T3 problem. Through a devoted paleo/primal lifestyle, intensive personal experimentation, and a radically modified approach to thyroid hormone replacement therapy…Elle went from fat, foggy, and fatigued – to fit, focused, and full of life!

NOTES:
Elle Russ web site

http://www.elleruss.com/

Primal Blueprint Podcast

http://blog.primalblueprint.com/

Yahoo Natural Thyroid Support Group

https://beta.groups.yahoo.com/neo/groups/NaturalThyroidHormones/info

Combination Therapy of T4 and T3 as a way to combat Hypothyroidism

Thyroidectomy often leads to hypothyroidism-like symptoms.  This includes brain fog, sluggishness, weight gain, unmotivated, and water accumulation. 

Dr. Bianco’s research has revealed the connection between thyroidectomy, hypothyroidism symptoms, and T4 only therapy.  Although T4 only therapy works for the majority, others report serious symptoms.  Listen to this segment to hear greater detail in regard to the following topics:

Combination therapy of adding T3 to T4

85% of patients on Synthroid feel fine.

Nearly 5% of the U.S. population takes T4, as revealed by the NHANE survey

Residual symptoms of thyroidectomy include depression, difficulty losing weight, poor motivation, sluggishness, and lack of motivation.  For some, there is no remedy to these symptoms. 

The importance of physical activity and its benefit in treating depression

If we normalize T3 does it get rid of hypothyroid symptoms?

Overlap between menopause and hypothyroidism symptoms

Dr. Antonio Bianco, Rush University Medical Center as professor of medicine, senior vice chair in the Department of Internal Medicine and division chief of endocrinology at Rush University Medical Center.  He has more than 30 years of experience in thyroid research.

Bianco’s research interests have been in the cellular and molecular physiology of the enzymes that control thyroid hormone action in which he contributed more than 200 papers, book chapters and review articles, and lectured extensively both nationally and internationally.

Recently, he has focused on the aspects of the deiodination pathway that interfere with treatment of hypothyroid patients, a disease that affects more than 10 million Americans. He is Director of Bianco Labs.

Notes:

Bianco Lab

http://deiodinase.org/

Bianco Lab on Facebook

https://www.facebook.com/biancolab/

NHANES Survey

The National Health and Nutrition Examination Survey (NHANES) is a program of studies designed to assess the health and nutritional status of adults and children in the United States. The survey is unique in that it combines interviews and physical examinations.

https://www.cdc.gov/nchs/nhanes/

You have been diagnosed with thyroid cancer, and choose no surgery.  Although thyroid cancer diagnosis has spiked around the world, a trend is to pass on surgery if the cancer is identified as low risk.  In doing so, mortality rate does not increase and it avoids unfavorable events sometimes related to surgery, such as vocal chord paralysis, hypothyroidsm, financial costs, and lifelong thyroid hormone treatment. 

In this episode, we visit with Dr. hypothyroidism, a pioneer in prescribing active surveillance in place of immediate surgery.    

Dr. Miyauchi is President and COO of Kuma Hospital, Center for Excellence in Thyroid Care, Kobe, Japan. He is an endocrine surgeon, especially interested in thyroid and parathyroid diseases. He earned his MD and PhD at Osaka University Medical School in 1970 and 1978, respectively. He was Associate Professor of Department of Surgery, Kagawa Medical University until he was appointed to Vice President of Kuma Hospital in 1998. Since 2001, he is at his present position. About 2,000 operations, including about 1,300 thyroid cancer cases, are done every year at Kuma Hospital. He is currently serving as Chairman of the Asian Association of Endocrine Surgeons. He also served as Council of the International Association of Endocrine Surgeons until August 2015.

Topics covered, include:

• Incidence versus mortality
• Worldwide trends related to thyroid cancer
• Papillary Microcarcinoma of the Thyroid (PMCT)
• Unfavorable events following immediate surgery
• Results of research which began in 1993
• The current trend in the incidence of thyroid cancer is expected to create an added cost of $3.5 billion by 2030, to the individual and as a society.

NOTES

Akira Miyauchi, MD, PhD (Kuma Hospital)

In this interview, items discussed include:

• the emotional burden of being diagnosed with cancer and the haste that sometimes follows
• the unnecessary damage of thyroid surgery, including the cutting of the laryngeal nerve resulting in vocal cord paralysis, low calcium levels and a need to supplement calcium and Vitamin D for life, and leaving residual disease behind
• knowing your risk factor and finding the right medical team to address it

Dr. Ralph P. Tufano is the Director of the Division of Head and Neck Endocrine Surgery at The Johns Hopkins School of Medicine, and conducts thyroid and parathyroid surgery with a focus on optimizing outcomes.  He is a recognized world authority on the management of thyroid cancer, thyroid nodules, benign thyroid diseases and parathyroid disease.  He has expertise in the management of thyroid cancer nodal metastases, advanced and invasive thyroid cancers as well as recurrent thyroid cancers.  His work in molecular markers, improving surgical outcomes, nerve monitoring and exploring novel treatment techniques for thyroid and parathyroid diseases has helped the medical field tailor and personalize treatment for patients with these conditions.  He is a Charles W. Cummings Professor, sits on the American Thyroid Association Board of Directors, is Director of the Division of Head and Neck Endocrine Surgery, and is a part of the Department of Otolaryngology-Head and Neck Surgery.  He conducts approximately 450 thyroid surgeries annually.  

NOTES:

American Thyroid Association

Dr. Ralph P. Tufano

Doctor Thyroid past episodes

In this interview, the following topics are discussed:

• Better treatment options for thyroid disease
• Better testing for thyroid disease
• Mental challenges
• Juggling career and Hashimoto's
• The word insignificant
• The role of T3 and biological connections
• Diagnosed at twelve years old
• Disappearing eyebrows
• You can’t have thyroid disease because you’re not overweight
• Always cold
• Depression and anxiety
• Integrative medicine
• High TSH levels
• The myth of fork to mouth disease
• Armour Thyroid
• Cold intolerance
• Saliva testing and cortisol levels
• Lyme disease
• The problem of testing TSH levels only

NOTES

Thyroid Change Resources

Website:  www.ThyroidChange.org
Facebook:  www.facebook.com/ThyroidChange
Twitter:   www.twitter.com/ThyroidChange

This episode details the medical approach to thyroid nodules.  Topics include:

• 60% of the U.S. population has thyroid nodules

• Discovered when evaluating other neck issues such as an unrelated pain

• What happens when you are told you have a thyroid nodule?

• How to know if your thyroid nodule is cancerous?

• When is surgery done despite the nodule being benign?

• Decreasing patient anxiety with quick biopsy results

• The American Thyroid Association as a resource for patients and physicians

• A word of caution about sourcing medical information from online resources

Dr. M Regina Castro is an endocrinologist in Rochester, Minnesota and is affiliated with Mayo Clinic. She received her medical degree from Central University of Venezuela and has been in practice for more than 20 years. Dr. Castro accepts several types of health insurance, listed below. She is one of 78 doctors at Mayo Clinic who specialize in Endocrinology, Diabetes & Metabolism. She also speaks multiple languages, including Spanish and French.

NOTES:

M. Regina Castro, M.D.

THYROID NODULES —  Thyroid nodule size larger than 4 cm does not increase the risk of false negative biopsy results or the risk of cancer

American Thyroid Association 

Dr. Wartofsky is Professor of Medicine, Georgetown University School of Medicine and Chairman Emeritus, Department of Medicine, MedStar Washington Hospital Center.  He trained in internal medicine at Barnes Hospital, Washington University and in endocrinology with Dr. Sidney Ingbar, Harvard University Service, Thorndike Memorial Laboratory, Boston.   Dr. Wartofsky is past President of both the American Thyroid Association and The Endocrine Society.  He is the editor of books on thyroid cancer for both physicians and for patients, and thyroid cancer is his primary clinical focus.   He is the author or coauthor of over 350 articles and book chapters in the medical literature, is recent past Editor-in-Chief of the Journal of Clinical Endocrinology & Metabolism, and is the current Editor-in-Chief of Endocrine Reviews.

In this episode, Dr. Wartofsky discusses the following:

• Hypothyroidism causes
• When is replacement thyroid hormone necessary?
• The history of replacement thyroid hormone going back to 1891
• The early treatment included a chopped up sheep thyroid and served as a ‘tartar’, often resulting in vomiting
• Myxedema coma
• The danger of taking generic T4; are cheaper, larger profit margin, but the content varies.
• Synthroid versus generic
• Manufacturing plants in Italy, India, Puerto Rico are known to produce generics
• Content versus absorption when taking generic T4
• An explanation of TSH
• 1.39 is a healthy TSH level for women in the U.S.
• Symptoms of hypothyroidism, such as a slow mind, poor memory, dry skin, brittle hair, slow heart rate, problems with pregnancy, miscarriage, and hypertension.
• Screening TSH levels if contemplating pregnancy
• T4 is the most prescribed drug in the U.S.
• Hypothyroidism is common when there is a family history
• Auto-immune disease is often associated with hypothyroidism
• An explanation of T3
• An explanation of desiccated thyroid
• The T3 ‘buzz’
• Muhammed Ali’s overdose of T3
• Dangers of too much T3
• When to take T4 medication, and caution toward taking mediations that interfere with absorption
• Coffee and thyroid hormone absorption
• Losing muscle and bone by taking too much thyroid hormone
• Taking ownership of your disease

Related episodes:

37: Adding T3 to T4 Will Make You Feel Better? For Some the Answer is ‘Yes’ with Dr. Antonio Bianco from Rush University

NOTES

Leonard Wartofsky

American Thyroid Association

Andrew J. Bauer, MD is an Associate Professor of Pediatrics at the Perelman School of Medicine, University of Pennsylvania and serves as the Director of the Thyroid Center in the Division of Endocrinology and Diabetes at The Children’s Hospital of Philadelphia. Dr. Bauer maintains active membership as a fellow in the American Academy of Pediatrics (FAAP), the Endocrine Society, the Pediatric Endocrine Society, and the American Thyroid Association. He also volunteers as a consultant for the Thyroid Cancer Survivors Association and the Graves’ Disease and Thyroid Foundation. In the American Thyroid Association Dr. Bauer has recently served as a member of the pre-operative staging committee, the thyroid hormone replacement committee, and as a co-chair for the task force charged to author guidelines on the evaluation and treatment of pediatric thyroid nodules and differentiated thyroid cancer. His clinical and research areas of interest are focused on the study of pediatric thyroid disease, to include hyperthyroidism, thyroid nodular disease, thyroid cancer, and inherited syndromes associated with an increased risk of developing thyroid nodules and thyroid cancer.

In this episode Dr. Bauer shares the complexities of managing children with thyroid nodules, and differentiated thyroid cancer.  This is a must listen interview for parents whose child has a thyroid nodule or thyroid cancer diagnosis. 

There are a several important differences in how pediatric thyroid nodules and differentiated thyroid cancer (DTC) present and respond to therapy. Kids are less frequently diagnosed with a thyroid nodule; however, the risk for malignancy is four- to fivefold higher compared with an adult thyroid nodule. For DTC (specifically papillary thyroid cancer), more than 50% of pediatric-aged patients will have metastases to cervical lymph nodes at the time of diagnosis, but because the tumors typically retain the ability to absorb iodine (retain differentiation), disease-specific mortality is very low, with > 95% of pediatric patients surviving from the disease. This is true even for children with pulmonary metastases, which occur in approximately 15% of patients who present with lateral neck disease.

With the high risk for malignancy and the invasive potential of the cancer, there has been a stronger tendency to take kids with thyroid nodules to the operating room (OR) and to administer RAI to those found to have DTC. With a greater realization of the increased risk for surgical complications as well as the short- and long-term complications of RAI treatment, the guidelines emphasize the need for appropriate preoperative assessment of nodules, and the approach to surgical resection, and they provide a stratification system and guidance for surveillance to identify which patients may benefit from RAI. The stratification system, called the "ATA pediatric risk classification," is not designed to identify patients at risk of dying of disease; it is designed to identify patients at increased likelihood of having persistent disease.

We have known about these differences for years, but the approach to evaluation and care has never been summarized into a pediatric-specific guideline. The adult guidelines aren't organized to address the differences in presentation, and the adult staging systems are targeted to identify patients at increased risk for disease-specific mortality. So, the adult guidelines are not transferable to the pediatric population.

NOTES:

Dr. Andrew Bauer

American Thyroid Association

Not all thyroid cancer patients who receive a thyroidectomy require radioactive iodine, but for those whose cancer maybe more aggressive and spread beyond the thyroid area, often radioactive iodine (RAI) is protocol. 

RAI treatment may vary depending on the hospital.   For example, in this interview you hear protocol for RAI at Cedars Sinai. 

In this interviews, Dr. Alan Waxman explains what occurs leading up to, during, and after RAI.   Topics discussed include:

• If staying at the hospital after taking RAI, how long is the stay required?
• Should you go home after RAI?
• What is the benefit of staying overnight at the hospital when receiving RAI?
• Worldwide trends toward prescribing lower doses of RAI.
• Is there risk in RAI causing leukemia?
• The importance of ultrasound prior to administering RAI of done.
• The need to stimulate TSH prior to administering RAI.
• Withdrawal versus injections in raising TSH levels.
• Damage to salivary glands. 

Alan D. Waxman, MD is Director of Nuclear Medicine at the S. Mark Taper Foundation Imaging Center at Cedars Sinai. He is also a member of the Saul and Joyce Brandman Breast Center – A Project of Women’s Guild and the Thyroid Cancer Center at Cedars-Sinai Medical Center. He is a clinical professor of radiology at Los Angeles County + University of Southern California (USC) Medical Center. Dr. Waxman’s participation in research has led to the development of many new imaging techniques and equipment adaptations. A leading expert in nuclear medicine imaging, Dr. Waxman has directed efforts to develop innovations in whole-body tumor imaging using new and existing radiolable compounds. Dr. Waxman is an active member and officer of the Society of Nuclear Medicine. He has authored numerous publications and lectured extensively throughout the world. Dr. Waxman is a graduate of the USC Medical School, where he completed his postgraduate training. He also completed a clinical research fellowship at the National Institutes of Health.

NOTES:

Dr. Alan Waxman

Salivary gland toxicity after radioiodine therapy for thyroid cancer.

Blog by Philip James

American Thyroid Association

RELATED EPISODES

34: What Happens When Thyroid Cancer Travels to the Lungs? with Dr. Fabian Pitoia from the Hospital of University of Buenos Aires

30: Thyroid Cancer and Children with Dr. Andrew Bauer from the Perelman School of Medicine, U of Pennsylvania

Dr. Aime Franco is professor at the University of Arkansas.  She leads a research group investigating the role of thyroid hormones in tumorigenesis.  She is also actively involved, both locally and nationally, advocating for the importance of biomedical research and the importance of engaging patients and survivors in cancer research.

After, completing her Ph.D. in Cancer Biology, she became a thyroid cancer research fellow at Memorial Sloan-Kettering Cancer Center in the Human Oncology and Pathogenesis Program.

Dr. Franco is a survivor of thyroid cancer, and balances her research as a mom and competitive triathlete. 

in this interview we explore the following:

Does thyroid cancer have a good prognosis compared to other cancers because its different or because we are aggressive with surgery and radiation therapy?

What were some personal insecurities when facing thyroid cancer surgery?

What are the questions in regard to TSH that the medical community is overlooking?
Which prescription medication works best?

How often and when should thyroid blood markers be tested?

You may find Dr. Franco here, http://physiology.uams.edu/faculty/aime-franco/

In this interview, some of the key points include:

• Self-discovered thyroid nodule
• Diagnosed thyroid nodule
• FNA and biopsy
• 5 cm nodule
• Juice cleanse and no more red meat
• 3 hour surgery
• Regret about a Friday afternoon surgery
• Outpatient surgery
• Vocal cord paralysis
• Impact of vocal cord paralysis
• RAI six weeks post surgery - 176 mc
• RAI diet
• A positive and optimistic approach to the disease
• Surgeon did not present consequences of thyroid surgery
• Ran cross-country in high school

Jody Gelb is a Broadway singer and actress.   Six months ago she was diagnosed with papillary thyroid cancer, during a doctor's visit for an unrelated issue.  This news sparked immediate research and discovering an alternate path that does not include surgery.

In this episode, the following topics are discussed:

• Broadway musical and tour
• Voice used during work as a performer, singing and acting
• Diagnosed with thyroid cancer while going to the doctor for a minor back strain
• MRI on back lead to discovery of thyroid nodules
• A scare, at one point being told cancer could be medullary
• BETHESDA scale
• Book by Dr. Gilbert Welch
• Incidental findings
• Watch and wait or active surveillance as an option to removing your thyroid
• Conflicting and inconsistent information from healthcare professionals to the patient
• Maximilaist or minimalist
• Cultivating a wherewithal to ask questions, even when being told something by a healthcare professional
• Dr. Atul Gawande
• Dr. Henry Marsh
• Choosing active surveillance and then feeling isolated or alienated
• Sharing selectively
• The importance of Google and Twitter and searching ‘papillary thyroid cancer’

NOTES

Regarding Thyroid Cancer, Are You a Minimalist or a Maximalist? with Dr. Michael Tuttle from Sloan Kettering

Diagnosed with Thyroid Cancer and You Say No to Surgery with Dr. Louise Davies

Avoiding Thyroid Cancer Surgery, Depending on the Size with Dr. Miyauchi from Kuma Hospital in Kobe, Japan

1 in 3 People Die With Thyroid Cancer — Not From with Dr. Seth Landefeld from UAB

Rethinking Thyroid Cancer – When Saying No to Surgery Maybe Best for You with Dr. Allen Ho from Cedars-Sinai in Los Angeles

American Thyroid Association

Overdiagnosed: Making People Sick in the Pursuit of Health

Best Time of Day to Take Your Thyroid Medication and Other Questions for the Endocrinologist with Wendy Sacks, M.D. from Cedars Sinai

Jody Gelb

blog

Twitter

Dr. Alan Farwell is an endocrinologist, Director of the Endocrine Clinics at Boston Medical Center, and Associate Professor of Medicine at Boston University School of Medicine, in Massachusetts.

In addition to his extensive academic and clinical activities, Dr. Farwell has been extremely active and served in multiple capacities in the ATA, including as Chair of the Education Committee and the Patient Education and Advocacy Committee, and as a member of the Program Committee and the Website Task Force Publications Committee. He has served two terms on the ATA Board of Directors, is the founding and current Chair of the ATA Alliance for Patient Education. 

Dr. Farwell has been an Associate Editor and member of the Editorial Board of Thyroid, and since 2009 has been Editor-in-Chief of Clinical Thyroidology for the Public.

In this interview, we discuss the following topics:

• Thyroid surgery and RAI sometimes results in hypothyroidism
• Most common cause is Hashimoto’s disease
• Explanation of overactive and underactive thyroid
• Weight gain, dry skin, constipation
• Very few symptoms unique to hypothyroidism
• Sleep apnea and being tired all of the time and weight gain.
• Brain fog and difficulty concentrating
• Blood tests diagnose hypothyroidism based on TSH levels, when elevated means it is not working too well.
• Explaining TSH in laymen’s terms
• Normal TSH in the U.S. is .3 to 3.5
• Treating for feel rather than a number
• People with elevated TSH have many of the hypothyroid symptoms, but people with normal TSH levels may also have hypothyroid symptoms
• Sleep disturbances such as apnea and anemia can be disguised as hypothyroidism
• Historical explanation of hypothyroidism treatment
• About 10% of patients do not respond to Levothyroxin
• Explanation of desiccated thyroid, including pig and cow
• Dr. Jacqueline Jonklaas, PCORI Grant will look at a study, head to head, Levothyroxin versus desiccated
• Adding T3 to T4 treatment
• Discussing Dr. Bianco’s research and deiodinases enzyme
• A discussion of celiac disease and gluten
• Explanation of auto-immune disorders, where the thyroid is attacked by the bodies own antibodies
• Physical symptoms of hypothyroidism are goiters, sluggishness, fatigue, dry skin, lateral eyebrows to disappear, the tongue can get thick, puffiness, swelling in legs, face, and around eyes.  With proper treatment, these are reversible.

NOTES

Dr. Antonio Bianco

Dr. Jacqueline Jonklaas

American Thyroid Association

Dr. Bridget Brady is Austin’s first fellowship trained endocrine surgeon. She has a passion for and expertise in disease of the thyroid, parathyroid, and adrenal glands. Since completing her endocrine surgery fellowship in 2006 under Matthias Rothmund, MD, an internationally acclaimed endocrine surgeon, she has performed thousands of thyroidectomies and parathyroidectomies here in Austin. Dr. Brady focuses on a variety of minimally invasive techniques to optimize patients’ medical and cosmetic outcomes. Her fellowship training in Germany and experience in Austin have enabled her to specialize in patients with recurrent or persistent disease of the thyroid and parathyroid, including thyroid cancer. She offers complete diagnostic workups including in-office ultrasounds and FNA biopsies of thyroid nodules and lymph nodes.

Dr. Brady was named director of endocrine surgery for the new medical school in Austin. She was also recently chosen to teach general surgeons seeking additional training in endocrine surgery. Dr. Brady instructs these endocrine surgeons from the Baylor Scott and White fellowship program.

In this episode the following topics are discussed:

• Austin Thyroid Surgeons sees 30 patients per week with thyroid nodules
• Up to 80% of US population could have a thyroid nodule(s)
• less than 5% of Dr Brady's thyroid nodule patients test positive for cancer
• How relevant is what I don’t know won’t hurt me in thyroid cancer and biopsies of nodules?
• BETHESDA system or the middle category, also known as indeterminate
• For thyroid nodules that are indeterminate, historically a surgery would be performed 
• With molecular testing, surgery can be decreased by up to 50%
• Afirma molecular testing uses messenger RNA
• If Afirma comes back suspicious it does NOT necessarily mean it is cancer
• Insurance covers molecular testing
• Nest steps for a doctor who would like to incorporate molecular testing
• Suspicious results with molecular testing can still be benign on final pathology
• How do you calmly tell a patient they have cancer?

NOTES

Dr. Bridget Brady

Veracyte

American Thyroid Association

Dr. Angela M. Leung is an Assistant Professor of Medicine at the UCLA David Geffen School of Medicine and an endocrinologist at both UCLA and the VA Greater Los Angeles Healthcare System.

After pursuing her undergraduate studies at Occidental College, Dr. Leung completed her internal medicine residency and endocrinology fellowship training at Boston University School of Medicine. She also studied at the Boston University School of Public Health and obtained a master's degree in Epidemiology.

Dr. Leung has particular clinical and research interests in thyroid disorders, and she also sees patients regarding parathyroid and adrenal disorders.  She has published widely and lectures frequently on thyroid disease, including hyperthyroidism, hypothyroidism, thyroid nodules, thyroid cancer, and thyroid disease during pregnancy.

In this episode, the following topics are explained:

• Optimizing thyroid health prior to conception
• Thyroid issues that affect pregnancy
• Hypothyroid as result of surgery or Hashimotos
• Hyperthyroidism and pregnancy
• Adjusting current thyroid treatment, meaning optimizing thyroid levels by adjusting dosage of thyroid medication
• TSH levels in light of pregnancy
• Planned pregnancy usually means a dose increase
• What happens if someone does not get treatment during pregnancy?
• Hypothyroidism and the fetus
• Brain development for the fetus
• Lower IQ scores and hypothyroid in pregnancy
• CATS study from UK and Italy
• Iodine and pregnancy
• Iodine intake prior to pregnancy
• Armour thyroid and pregnancy
• Concerns regarding animal derived thyroid replacement
  TSH levels

NOTES

Dr. Angela Leung

CATS study

American Thyroid Association

49: Thyroid and Pregnancy⎥Why It Matters, with Dr. Elizabeth Pearce from Boston University

Dr. Amanda Laird, MD is an endocrine surgeon and Chief of Endocrine Surgery at the Rutgers Cancer Institute of New Jersey in New Brunswick, New Jersey. She is currently licensed to practice medicine in New Jersey and New York. She is affiliated with Rutgers Cancer Institute of New Jersey and Rutgers Robert Wood Johnson Hospital.

In this interview, Dr. Laird reflects on a decade of treating papillary thyroid cancer patients and reports none have died.  In this interview we also explore these questions:

1. Prognosis and what will happen in the long run and quality of life.
2. Surgery complications.
3. Levothyroxine side-effects, including weight gain. 
4. Life after surgery and RAI.
5. What causes thyroid cancer.
6. What time of day to take thyroid replacement medication.
7. What blood tests should be ordered and is fasting necessary prior to thyroid lab work.

NOTES

Amanda Laird, MD

American Thyroid Association 

Dr. Danielle Ofri is a doctor at Bellevue Hospital in New York City. She is one of the foremost voices in the medical world today, shining an unflinching light on the realities of healthcare and speaking passionately about the doctor-patient relationship. Her newest book is "When We Do Harm: A Doctor Confronts Medical Error."
Ofri is a regular contributor to the New York Times and is also the editor-in-chief of the Bellevue Literary Review. She lives in New York City and is determined to get through the Bach cello suites before she kicks the bucket.

In this episode:

• Medical error is the third leading cause of death?
  After heart disease and cancer.
• Intended audience for the book? A general audience; lay-public and medical professionals.
• It is difficult to define a medial error. Starting medication at wrong dose? What errors cause death? This can be vague.
• Hospitalized patients are different than the general public
• All sorts of patient harm should be brought to light — shift the medical field to “more safe” should be our goal.
• Once you are in the patient chair, one loses their strength and power.
• System flaws: more common error is a qualified professional who is burdened by design flaws — including false alarms.
• Collaboration and intellectual humility — recognizing we don’t know.
• Patients are sicker and more chronic conditions, mean collaboration helps reduce error.
• Denmark as an example to error response: acknowledge and apologize.
• The U.S. malpractice system as part of the problem.
• Qualifiers of malpractice: harm occurred, doctor was the cause, and consequence was big enough to make the case worthwhile.
• Who is making the laws about malpractice? Could be an underlining agenda.
• Recourse for patients: 1. Talk with doctor or nurse. 2. The hospital’s patient advocate. 3. Insurance patient advocates. 4. Local Board of Health. 5. Keep notes, and have a paper trail.
• The system is not designed to get information easy — take advantage of CARES Act.
• When transparency backfires; if a doctor is treating high risk patients, then their error will be higher.
• Doctors penalized for spending more time with a patient.
• The need for silence or time to think.
• The problem with the “reimbursement” model.
• Medical error, adverse events, and unintended consequences.
• Over-treating and over-diagnosis in regard to prostate or thyroid.
• Statute of limitations.
• Errors that don’t cause harm.
• Wash your hands and stop and think.

Dr. Ofri’s Links:

Bellevue Literary Review

www.danielleofri.com

“When We Do Harm: A Doctor Confronts Medical Error”

New Yorker Covid Diary

Recent events - Dr. Ofri:

tinyurl.com/BLRViral  Covid Writing Goes Viral: How Literary and Social Media Writing Became a Lifeline during the Pandemic

tinyurl.com/ReadingTheBody Reading the Body: Poetry, Dance & Disability

Notes

CARES Act

Hardeep Singh, M.D., M.P.H.

Doctor Thyroid Facebook

Doctor Thyroid with Philip James

Twitter

philipjames@docthyroid.com

In this episode, topics include:

• Hypothyroidism and hyperthyroidism during pregnancy
• Pregnant and without a thyroid
• Avoiding T3 during pregnancy, including concerns with desiccated thyroid
• If being treated for hypothyroidism already, the importance of upping dose while pregnant
• Pregnant with auto-immunity
• Pregnant with Graves’ disease
• The dangers of pregnancy and overt hypothyroidism or hyperthyroidism
• Three-percent of pregnancies are affected
• The importance of iodine during pregnancy

Dr. Pearce received her undergraduate and medical degrees from Harvard and a masters’ degree in epidemiology from the Boston University School of Public Health. She completed her residency in internal medicine at Beth Israel Deaconess Medical Center, and her fellowship in endocrinology at the Boston University Medical Center. She is currently an Associate Professor of Medicine at Boston University School of Medicine. She has served as a member of the board of directors of the American Thyroid Association and is currently on the management council of the Iodine Global Network.  She recently co-chaired the ATA’s Thyroid in Pregnancy Guidelines Task Force. She was the 2011 recipient of the ATA’s Van Meter Award for outstanding contributions to research on the thyroid gland.

NOTES

Elizabeth Pearce

American Thyroid Association

Dr. Shaha specializes in head and neck surgery, with a particular interest in thyroid and parathyroid surgery. He uses an algorithm of selective thyroid tumor criteria (the size, location, stage and type of cancer, along with the patient’s age), to tailor therapy to each individual’s circumstances. This can help thyroid cancer patients avoid unnecessary and potentially damaging over-treatment, while still providing the best option for control of their cancer and better quality of life after treatment. Dr. Shaha works very closely with Memorial Sloan Ketterings’ endocrinologists to monitor the careful post-treatment hormone balancing necessary for thyroid cancer patients. Many academic hospitals and medical societies worldwide have invited Dr. Shaha to speak on the principles of targeted thyroid surgery and to share his expertise in the treatment of head and neck cancers.

In this interview, topics include:

• The first question a surgeon should ask and why.
• When talking active surveillance or observation, changing the language to deferred intervention,  ‘we are going to defer’.
• Understanding the biology of the cancer
• The biology of thyroid cancer is a friendly cancer.
• Anxiety when diagnosed with cancer.
• Medical legalities — spend a lot of time with patient — and empower patient.
• Let the treatment not be worse than the disease.
• Large tumors, more than 4 cm,  bulky nodes,  voice hoarseness,  vocal cord is paralyzed.  All circumstances where surgery maybe advocated.
• If a tumor is benign but there is presence of compressive goiters, or deviation of trachea or swallowing difficulty.
• Considering the condition of the patient, age, cardiac issues.
• When voice is critical to the patients livelihood, such as teachers, politicians, and singers.
• Main three complications of surgery include bleeding, change of voice, calcium problems.
• Non-academic surgeons.
• Cancer treatment requires a team: surgeons, anesthesiologist, pre-op, radiologist, pathologist, endocrinologists, oncologists.
• When wind pipe is involved with tumor.
• When in surgical business a long time, you become humble no matter how good you are.
• Family present during consultation.
• God gave you an organ — you took it away — now you are on a pill — since the surgery its ’just’ not the same.
• When treatment is out of the box — many will not agree with you.
• How to develop a scale to measure quality of life.
• To avoid scarring, surgery maybe conducted through the armpit in Korea and Japan.
• Fibrosis
• Progress in understanding biology of thyroid cancer only cancer, that there is 98% survival.

NOTES:

Dr. Ashok R. Shaha

RELATED EPISODES:

50: Regarding Thyroid Cancer, Are You a Minimalist or a Maximalist? with Dr. Michael Tuttle from Sloan Kettering

40: New Research Reveals Thyroid Surgery Errors 5x More Frequent Than Reported with Dr. Maria Papaleontiou from Michigan Medicine

42: Flame Retardants Connected to Thyroid Cancer, with Dr. Julie Ann Sosa from Duke University

35: Rethinking Thyroid Cancer – When Saying No to Surgery Maybe Best for You with Dr. Allen Ho from Cedars-Sinai in Los Angeles

21: Diagnosed with Thyroid Cancer and You Say No to Surgery with Dr. Louise Davies

09: Thyroid Cancer Patients Experience Quality of Life Downgrade with Dr. Raymon Grogan and Dr. Briseis Aschebrook from the University of Chicago Medicine

36: 1 in 3 People Die With Thyroid Cancer — Not From with Dr. Seth Landefeld from UAB

American Thyroid Association

During this interview, Dr. Tuttle discusses the following points:

• Challenges of managing thyroid cancer as outlined by the guidelines
• Scaling back care for insurance-challenged patients, and adopting a plan that gets the same result without needing the expensive tests
• Desired outcome is survival and no recurrence, a third is for no harm that would be caused by an unnecessary surgery
• Unwanted side affects of thyroid cancer include nerve damage, parathyroid damage, and infections
• RAI sometimes has unwanted side affects
• With technology, ultrasounds and biopsies, we know some cancers do not need to be treated, as they are now being found very early
• Change in ATA guidelines, low risk cancers can be considered for observation
• Two different kinds of patient profiles: Minimalist and Maximalist
• 1cm or 1.5cm?
• Patient characteristic, ultra sound characteristics, and the medical team characteristics weighs who is the most appropriate for observation
• 400 active surveillance patients currently at MSKCC
• Certain parts of the world are harder to offer observation as a treatment due to practicality, examples include Latina America where multi-nodular goiters are common, and Germany still is iodine deficient

About Dr. Tuttle, in his words:

I am a board-certified endocrinologist who specializes in caring for patients with advanced thyroid cancer. I work as part of a multidisciplinary team including surgeons, pathologists, radiologists, nuclear medicine specialists, and radiation oncologists that provides individualized care to patients treated at Memorial Sloan Kettering for thyroid cancer.

In addition to treating patients I am also actively researching new treatments for advanced thyroid cancer. I am a professor of medicine at the Joan and Sanford I. Weill Medical College of Cornell University and travel extensively both in the US and abroad, lecturing on the difficult issues that sometimes arise in the management of patients with thyroid cancer. My research projects in radiation-induced thyroid cancer have taken me from Kwajalein Atoll in the Marshall Islands to the Hanford Nuclear power-plant in Washington State to regions in Russia that were exposed to fallout from the Chernobyl accident.

I am an active member of the American Thyroid Association (ATA) and the Endocrine Society. In addition to serving on the ATA committee that produced the current guidelines for the management of benign and malignant nodules, I am also a Chairman of the National Comprehensive Cancer Network Thyroid Cancer Panel, a consultant to the Endocrinologic and Metabolic Drugs Advisory Committee of the FDA, and a consultant to the Chernobyl Tissue Bank.

NOTES

Listen to Doctor Thyroid

American Thyroid Association

Dr. Michael Tuttle

RELATED EPISODES

35: Rethinking Thyroid Cancer – When Saying No to Surgery Maybe Best for You with Dr. Allen Ho from Cedars-Sinai in Los Angeles

22: Avoiding Thyroid Cancer Surgery, Depending on the Size with Dr. Miyauchi from Kuma Hospital in Kobe, Japan

21: Diagnosed with Thyroid Cancer and You Say No to Surgery with Dr. Louise Davies

The USPSTF upholds its 1996 recommendation against screening for thyroid cancer among asymptomatic adults.

The USPSTF commissioned the systematic review due to the rising incidence of thyroid cancers against a background of stable mortality, which is suggestive of over-treatment. And in view of the results, the task force concluded with “moderate certainty” that the harms outweigh the benefits of screening.

The USPSTF emphasizes, however, that this recommendation pertains only to the general asymptomatic adult population, and not to individuals who present with throat symptoms, lumps or swelling, or those at high risk for thyroid cancer.

A global problem

The over-diagnosis of thyroid cancer is worldwide.  

South Korean doctors treated these newly diagnosed thyroid cancers by completely removing the thyroid—a thyroidectomy. People who undergo these surgeries require thyroid replacement hormones for the rest of their lives. And adjusting the dose can be difficult. Patients suffer from too much thyroid replacement hormone (sweating, heart palpitations, and weight loss) or too little (sleepiness, depression, constipation, and weight gain). Worse, because of nerves that travel close to the thyroid, some patients suffer vocal-cord paralysis, which affects speech.

Over-diagnosis and over-treatment of thyroid cancer hasn’t been limited to South Korea. In France, Italy, Croatia, Israel, China, Australia, Canada, and the Czech Republic, the rates of thyroid cancer have more than doubled. In the United States, they’ve tripled. In all of these countries, as had been the case in South Korea, the incidence of death from thyroid cancer has remained the same.

1 in 3 people die with thyroid cancer, not of.

NOTES

As heard on NPR

Dr. Seth Landefeld

American Thyroid Association

RELATED DOCTOR THYROID INTERVIEWS

35: Rethinking Thyroid Cancer – When Saying No to Surgery Maybe Best for You with Dr. Allen Ho from Cedars-Sinai in Los Angeles

22: Avoiding Thyroid Cancer Surgery, Depending on the Size with Dr. Miyauchi from Kuma Hospital in Kobe, Japan

21: Diagnosed with Thyroid Cancer and You Say No to Surgery with Dr. Louise Davies

www.docthyroid.com