Iodine Induced Graves' Disease Why Treat with Iodine?

48 Y/O Female with hypothyroidism was treated with iodine pills and T3 cytomel. While on high dose T3 and iodine, she developed double vision and pop eye on the right. MR= swollen eye muscles=Graves Eye Disease.The patient was hyperthyoid on examination. The thyroid was enlarged, firm, and Ultrasound showed Graves'firestorm blood flow. The iodine was stopped, as was the T3. She was started on beta blocker and a I/123 uptake was planned. No ultrasound was ever done.A real time ultrasound was positive. Several nodules were suspicious for cancer.A Biopsy was done, and it was negative for cancer.The patient was cooled off with beta blocker, and was treated with RAI/131.The eye disease stabilized and then a muscle relocation procedure cured the double vision.
What did we learn?
Always see an endocrinologist or thyroidologist if you are told by your primary MD, you have thyroid disease.
www.thyroidologists.com
www.aace.com
www.thyroid.org

Good luck,
Dr.G.

"My Physician found my TSH was high, and started me on thyroid hormone. Why am I worried about this ? Isn't there more investigation needed?"

The answer to this Ask the Doctor email is yes. The finding of an elevated TSH or even a slowly increasing TSH over a few years is a clue to the onset of hypothyroidism. The abnormal TSH should be the starting point to investigate the cause of the failing thyroid and to evaluate the structure of the gland. TSH elevation even in the upper normal range has been found to be a risk factor for thyroid cancer. All newly diagnosed patients with TSH 2.5-10 are in the risk pool for cancer. The primary physician may not even feel the patient's neck before starting therapy. The thyroid gland is almost always abnormal to physical examination by a clinical thyroidologist. Firm gland with cobble stone surface is usually missed by the primary physician. Before allowing the physician to treat you, you need a complete thyroid evaluation looking for nodules. The endocrine neck ultrasonographer thyroidologist will do a detailed study of the thyroid, lymph nodes and parathyroid areas. If a suspicious nodule or lymph node is found, an ultrasound guided FNA will be done. Modern thyroidology concepts include hands on ultrasound real time done by your thyroidologist or endocrinologist, not by a radiology tech, who prints out pictures for a radiologist to look at after the fact. The original evaluation when the abnormal TSH is found is the best time to see a clinical thyroidologist, notjust start thyroid hormone.

Surgery for Benign Thyroid Cystic Nodules? Not Anymore! There is a New Medical Treatment Using Injection of Alcohol call PEI

42 year old female with a large visible mass on the right thyroid lobe. She had local symptoms and did not like the looks of the mass, as it distorted her thin neck. Her thyroid tests were normal, but a complex cyst was seen in the right lobe on ultrasound.
An FNA and drainage of the cyst fluid was done. The free hand FNA done without ultrasound guidance, was negative for cancer, but the mass recurred in 4 weeks. The endocrinologist referred her to a surgeon to remove the mass. She was referred to me for a second opinion on the need for surgery. Of course she had searched the web for alternatives to surgery, and found my website.
She learned about my Ethanol Injection Method (PEI) for recurrent Cysts. The cyst was 11 ml in size and had a complex solid component. An ultrasound guided FNA aimed directly at the solid component to R/O cystic papillary thyroid cancer was negative. The injection of ethanol after draining the cyst was successful. She had slight burning sensation as the needle was removed, but othewise there was no other side effects. She returned in a month to see the effects of the ethanol on the cyst. When she walked int the examining room, she said, "The thing is gone". The large visible mass was not seen on inspection, or was it felt on palpation. The mass was still there but was markedly reduced. From the original 11 ml to 0.6 ml. That was a >90%
reduction in size. The average reduction noted in the literature is 80%. She did not need surgery, because the reasons for surgery did not exist anymore.They are fear of cancer, obstruction,and removing an ugly mass for cosmetic reasons.

Get a second opinion before having thyroid surgery for a cyst.

Good Lck,Dr.G.

Thyroid.About.Com, the Source for Dangerous Thyroid Information has Done it Again. Now You Don't Need an Endocrinologist at All!

The about.thyroid.com website, for alternative medical information has reached a new low. Patients with thyroid disease should NOT see an endocrinologist or thyroidologist. The post claims that "thyroid friendly" alternative types will listen to the patient and give them therapy based on symptoms, rather than hard thyroid hormone blood studies. The patients with cancer or needing radiation for Graves' disease are the exception, and need to see a thyroidologist. This is a very way out idea. Here is why. First, hypothyroid patients need to see a specialist at the first sign of disease. The careful examination of the neck by an expert will be able to feel a firm nodular surface of an early Hashimoto's thyroiditis. That will trigger an ultrasound. The ultrasound done real time by the endocrinologist could reveal a cancer nodule, goiter,or nodular goiter years before it can be troublesome to the patient. Waiting until the patient has cancer,or nodules that can result in a surgery is a poor concept,and is the major reason not to consider anyone other than an endocrinologist. Every patient with subclinical hypothyroidism with TSH >3.0 and slowly climbing yearly needs to see an endocrinologist,or thyroidologist PERIOD. Hashimoto's thyroiditis with progressively increasing TSH from 2.5 to 10 over 10-20 years, or has positive antibodies needs a complete endocrine/thyroid evaluation. TSH is a risk factor for thyroid cancer in patients with Hashimoto's thyroiditis.
Also TSH causes nodules to grow that are not cancer but look bad on a thyroid biopsy, and can result is surgery.Early detection of Hashimoto's can save surgeries and find cancer when it is small and curable. Also, in 35 years of practice,I have seen goiters melt away, and the antibodies disappear on T4 therapy. The disease will destroy the thyroid if you prevent the regrowth due to TSH. Failure to visit an endocrinologist to get an early diagnosis of possible troubles is a major mistake that will happen to some of those who read the posts on thyroid.about.com. Finally, that leaves only the few percent of all thyroid patients who are still complaining about symptoms when their T4, and TSH are normal, to seek those physicians, that prey on the patients ignorance and give them Armour, T3, Combo T4/T3, and compounded products, to treat symptoms totally unrelated to the thyroid disease. The impossible dream is that just treating thyroid problems will correct all the symptoms the patient have. That is not only a dream, but a pipe dream. They may feel better for a while due to the effect of T3 on the brain, but will suffer in the long run.

I challenge the website managers to allow comments, without deleting those that have a contrary opinion to it's alternative views. My comments given here in my last few blogs were sent as comments to the website. They were clearly received, but disappeared by the next day. The only comments that were allowed to appear were the "yes, I agree" type. The alternative thyroid audience will not like what I have to say, but there will be a few among them that will rethink their position.
Good Luck,
Dr.G.

A German Story of a Failed Treatment Plan for a Radiation Exposured Patient With a Toxic Nodule, and the Negative Long Term Effect on HER.

A 45 Y/O female presented to my center with a thyroid nodule. The history was positive for radiation therapy for a skin problem as a child in Germany. At age 30 she had symptoms of hyperthyroidism, and was diagnosed with a single toxic nodule by thyroid uptake and scan. The endocrinologist in Berlin referred her to a surgeon, who did a lobectomy removing only the lobe with the toxic nodule. 15 years later is when she arrived at my doorstep after a CT scan, done for another unrelated problem revealed a mass in the thyroid. A large scar over the left side of her neck was secondary to the childhood irradiation. A palpable mass was noted in the right lobe. The scar from the surgery was located over the other lobe area that was removed in Berlin. Her thyroid blood tests were normal, but the high frequency ultrasound was abnormal. There was a large nodule in the right lobe, but there were 10 nodules in all ranging in size from 3-10 mm. The left lobe was also enlarged and had nodules as well. Did the surgeon do a nodule removal only or was this regrowth? The ultrasound guided FNA of all nodules > 5 mm were benign. The patients problems began when the Berlin endocrinologist and the surgeon failed to factor in the radiation history in the surgery plan for the toxic nodule. The radiation history should have been the reason to do a total thyroidectomy to remove at risk thyroid tissue along with the toxic nodule. This would have removed the risk of cancer in the future, and would have prevented the progression of her goiter to the point that now she will need careful ultrasound and blood monitoring for the rest of her life. Any one of the nodules that were not biopsied could be a cancer, and if they grow another round of biopsies will be needed. The endocrinologists should have known that patients in their area have a high incidence of iodine deficient goiters. That toxic nodules arise out of those glands. Also that needed to remember that radiation therapy for benign conditions of the head and neck causes goiters, nodules, benign and malignant tumors. Her life would have been simple if they did a total as recommended, and simple thyroid blood T4, and TSH, would have been the only followup needed. Instead she will need yearly ultrasounds to follow the massive number of nodules that are present,or go in for another surgery now.
I wish her luck in the future,

Dr.G.

Mary Shomon, and the Medical Review Board of about.thyroid.com, on their Opinion on the Top Thyroid Websites: Pros and Cons

The last newsletter from Mary Shomon has her company's opinion on the top thyroid websites. I am honored to be listed alongside the Endocrine Society, and the American Thyroid Association. She has cleverly added a medical review board, since her last top websites list, probably paid by her corporation, which has 12 physicians, who are evaluating the top sites. It should be noted that not a single endocrinologists is on the panel. The way Mary Shomon and her bosses treat top level endocrinologists, as bag men and women for the drug companies, there is no wonder why she can not get a real qualified expert clinical endocrinologist to be on the panel. Headed by an internist, and without a single physician board certification in endocrinology among them, they are asked to judge the top thyroid websites. The last "top" site they reviewed was her own site, about.thyroid.com. That shows the panel's level of objectivity. The panel appears to be just a rubber stamp for all the slanted views presented on their website. What was the review panel doing allowing Mary to blow her own horn, calling it a a top site. Not only did she include about.thyroid.com on the list of top sites, but plugged her book, Living Well with Hypothyroidism, and even worse plugged another of her books on an unrelated subject. The panel mentioned the slanted, and biased qualities of the other top sites toward evidenced based conventional medicine, because of corporate money funding the sites, but failed to mention that Mary's site was extremely outside the range of objective thyroid medical opinion. There was no mention that this approach was considered by the vast majority of physicians and patients to be beyond any reasonable credible concepts of thyroid patient care. The problem with The American Thyroid Association website, was according to the panel that it was in the pocket of drug companies, that is why they only mentioned mainstream medicine, and did not cater to alternative medicine. Similar knocks on other top thyroid sites, such as the Endocrine Society, were made by the panel. Finally, let me look at the comments made about my site, Thyroid.com, which was founded by me personally in 1997. This was the first private thyroid website, and except for a short partnering deal with Amazon, we have never accepted ads. Most endocrinologists and clinical thyroidologists will not waste their breath to respond to things listed on her website as it is considered a "way out" site. Let me take a moment to respond to the inaccurate comments made about my site.
1. The concept of virtual second opinions on the web did not start with me. Her site stated that I charge excessive fees for those opinions. The Cleveland Clinic had one before me and charged more than I do. A fee of $400-500 to review all the records, actual thyroid scans, ultrasounds, pathology materials and give the patient valuable advice is not excessive. 2. The few complaints they said they received are out of thousands of thyroid patients I have treated in 35 years. The patients who are unhappy with me are the ones who are told they are properly treated and need to look elsewhere for the cause of their symptoms. I am not an internist, or even an endocrinologist, but a clinical thyroidologist. I refer them to others but many insist, after reading the slanted stories on about.thyroid.com, that it is the thyroid causing the symptoms and I, as a mainstream physician, am not treating the symptoms only the numbers. 3. My Blog, www.thyroid.blogspot.com, is my personal diary about my experiences in 35 years practicing in the thyroid field. I do not have a paid corporate spell checker or any Grey Flannel Suits with lawyers packed inside them to correct my grammar or tell me not to write things that could hurt the image of the corporation, decrease the ad revenue from the Grapefruit therapy for Graves' disease suppliers and other alternative types. I do not want anyone telling me how to inform by readers. 4. As for bedside manner, I have plenty of that. Name five other endocrine physicians in the country that see thyroid patients 5 days a week, giving me a following of 3-5,000 patients from around the world. 5. As a test, please look at thyroid.com and then look at about.thyroid.com. I think you will see who is full of corporate cash from ads on the site. Why should patients be worried about the educational grants that keep excellent thyroid websites, such as the Endocrine Society, working, but do not also question the funding of about.thyroid.com which takes all comers as long as they have ad dollars to spend. Every page is clean of ads, and no money changes hands to support my website. I have turned down all ad revenue, and refuse to be a paid hack fishing for ads to pay the bills and make a profit for myself. I have turned down 5 figure offers to buy thyroid.com by corporations eager to take it and ruin it. I have refused to sell out to drug companies.

Thank you, and keep looking for excellent endocrinologists, with good records, to care for you.
Good Luck,
Dr.G.

The Brits are Half Right, and Mary Shomon is as Usual All Wrong

The national health service NHS, of the United Kingdom, has banned the use of Armour thyroid, compounded combination thyroid preparations, Cytomel, and other products with anything but LT4 in them for treatment of hypothyroidism for all patients treated by the NHS. This is a good step by the NHS to get rid of these second tier drugs that cause more harm than good. The recent story by Ms. Shomon on about.thyroid.com was off base as usual, and aimed again at the fringe patients who feel they are not "doing well" on T4 alone, even though all the proven tests of T4, and TSH are completely normal. They are not hypothyroid, but are truly not feeling well, but for other reasons, not thyroid. As an expert in thyroid disease for 35 years, I am glad that we are finally seeing the beginning of the end of these drugs. To all the thyroid patients in the NHS, and the USA, do not pay any attention to doomsayers like Ms. Shomon, as she is not a physician, and as a hired gun for a large corporation, has an interest in appealing to the patients who are unhappy with the results of their thyroid therapy, even though it is properly treated with thyroid hormone of the T4 type. However, there are problems with the other part of the NHS guidelines. Although a TSH less than 10 is rarely associated with symptoms, as they correctly state,therefore, therapy for pure hypothyroidism is rarely needed when a TSH is less than 10. However, the problem is more complicated than that. TSH values between 2.5-10 are abnormal,and are associated with other problems than symptomatic hypothyroidism. As the TSH rises there is a increased risk of cancer of the thyroid, nodules, and goiter formation. If the NHS mandates ultrasounds for all patients with elevations of TSH above 2.5 and there is no goiter, or nodules, then follow up without thyroid therapy is reasonable. Also if the patient does not have heart disease or lipid abnormalities, then the use of TSH > 10 is a reasonable choice for symptomatic hypothyroidism for therapy. Remember, by the time the TSH rises it may be already the cause of significant nodule formation,and increased risk of thyroid cancer.
DR.G.