Frequently Asked Questions
• thyroid diseases
• metabolic disorders
• over- or underproduction of hormones
• cholesterol (lipid) disorders
• lack of growth (short stature)
• cancers of the endocrine glands
Endocrinologists also conduct basic research to learn the way glands work, and clinical research to learn the best methods to treat patients with a hormone imbalance. Through research, endocrinologists develop new drugs and treatments for hormone problems.
Do not stop your thyroid hormone without discussing this with your physician. Most thyroid problems are permanent, and therefore most patients require thyroid hormone for life. If you miss a dose of thyroid hormone, it is usually best to take the missed dose as soon as you remember. It is also safe to take two pills the next day; one in the morning and one in the evening. It is very important that your thyroid hormone and TSH levels are checked periodically, even if you are feeling fine, so that your dose of thyroid hormone can be adjusted if needed.
Desiccated (dried and powdered) animal thyroid (Armour), now mainly obtained from pigs (also cows in the past), was the most common form of thyroid therapy before the individual active thyroid hormones were discovered. People can still buy it over the Internet—legally if it’s sold as a food supplement, but illegally if it’s sold as a medicine. It is also available still as a prescription. Since pills made from animal thyroid are not purified, they contain hormones and proteins that never exist in the body outside of the thyroid gland. The human thyroid produces primarily T4. While most actions of thyroid hormone are most likely due to T3, most T3 in the body comes from the conversion of T4. While desiccated thyroid contains both T4 and T3, the balance of T4 and T3 in animals is not the same as in humans, so the hormones in animal thyroid pills aren’t necessarily “natural” for the human body. Further, the amounts of both T4 and T3 can vary in every batch of desiccated thyroid, making it harder to keep blood levels right. Finally, even desiccated thyroid pills have chemicals (binders) in them to hold the pill together, so they are not completely “natural”.
According to the American Association of Clinical Endocrinologists and American Thyroid Association guidelines for the management of hypothyroidism published in 2012 a PubMed computer search of the literature in January 2012 yielded 35 prospective randomized clinical trials (PRCTs) involving synthetic L-thyroxine published in 2007-2011, compared with no PRCTs involving desiccated thyroid extract for all years in the database. Thus, there are no controlled trials support¬ing the preferred use of desiccated thyroid hormone over synthetic L-thyroxine in the treatment of hypothyroidism or any other thyroid disease.
This “natural” approach is primarily advocated by holistic, integrative medicine, and chiropractic providers. In the greater Tampa Bay area alone there are at least 5-10 high volume practices pushing these replacement modalities not to mention the countless advocates nationwide. This has become a huge industry often tied in to sales of products from where financial benefits are either directly or indirectly derived by the prescriber. I have seen many patients who have been on these agents for many years with labs consistently showing over-replacement and as a result of it very symptomatic, with significant loss in bone mineral density and cardiac arrhythmias. In some instances the same so called experts that prescribe these products have great difficulty interpreting the lab tests and adjusting the dose of the same medications they prescribe.
Although our approach is not to prescribe these agents as first, second, or third line agents we have seen patients that have experienced significant side effects to multiple synthetic preparations and when placed on “natural” agents experienced improvement in symptoms and overall well-being. We do not claim to know the best approach and we always listen to our patients, so for these selected patients if convinced there is no other suitable alternative after evaluating bone status and documenting no other adverse effect to “natural” thyroid replacement as long as labs are within expected range we would ensure that there is no disruption in therapy.
Reverse T3 should not be routinely sampled and is of no clinical value not to mention that the levels can be quite variable even in conditions known to cause elevations. This is contrary to the recommendations by holistic and integrative medicine providers who advocate routine measurement. Conditions that lead to the activation of the enzyme that produces reverse T3 include prolonged starvation, severe illness (sick euthyroid syndrome or non-thyroidal illness syndrome) for which hospitalization is required and some tumors that when studied in rats were found to have increased expression. These are hardly the patients we deal with in routine clinical practice.
9. Do you only prescribe generic synthetic medication (levothyroxine) or brand (synthroid, tirosint)?
The other important reason for having your biopsy performed at our facility is the quality of the relationships we have forged with our lab partners. Every cytopathologist that interprets our specimens is board certified and reports the findings using the Bethesda Tier Classification (the gold standard for reporting thyroid cytopathology). I review many reports constantly of biopsies performed at some local labs where this gold standard classification is not used by the interpreting cytopathologist unfortunately putting the clinician in a very difficult situation. The last reason for using our office for your biopsy is our cytology adequacy assessment protocol (see next question). When we assess for adequacy we not only ensure the collection of sufficient specimen but when we see abnormal features under the microscope right there and then we go ahead and take additional specimen that may be required at a later time preventing the need to re-biopsy.
19. Do you have the ability to perform molecular testing on thyroid biopsies and if so when is it indicated?
With the advent of the human genome project and our knowledge of the genes that are involved in the development of thyroid cancer we are now able to do molecular testing on biopsy specimens to create a better genetic risk profile to help decide with more accuracy who are the patients who would best benefit from undergoing surgery. As with any new technology there are some controversies associated with molecular testing ranging from which of the commercially available tests are best to use, the proper clinical setting in which to use them, or if to use them at all. We are well versed at our practice in the subject of molecular testing and are one of a few practices in the area with significant experience using these tests since these breakthroughs came to light a few years back.