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Frequently Asked Questions

2. What Is An Endocrinologist And What Does An Endocrinologist Treat?

An endocrinologist is a specially trained doctor. Endocrinologists diagnose diseases that affect your endocrine glands. They know how to treat conditions that are often complex and involve many systems within your body. Endocrinologists are trained to diagnose and treat hormone imbalances and problems by helping to restore the normal balance of hormones in your system. They take care of many conditions including:

• diabetes
• thyroid diseases
• metabolic disorders
• over- or underproduction of hormones
• menopause
• osteoporosis
• hypertension
• cholesterol (lipid) disorders
• infertility
• 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.

3. What Is The Training Required To Become An Endocrinologist?

Endocrinologists finish four years of medical school and then spend three or four years in an internship and residency program. These specialty programs cover internal medicine, pediatrics, or obstetrics and gynecology. They then spend two or three more years learning how to diagnose and treat hormone conditions. Overall, an endocrinologist’s training will take more than 10 years.

5. How Do I Take Thyroid Hormone?

Thyroid hormone is easy to take. Because it stays in your system for a long time, it can be taken just once a day, and this results in very stable levels of thyroid hormone in the blood stream. When thyroid hormone is used to treat hypothyroidism, the goal of treatment is to keep thyroid function within the same range as people without thyroid problems. Keeping the TSH level in the normal range does this. The best time to take thyroid hormone is probably first thing in the morning on an empty stomach. This is because food in the stomach can affect the absorption of thyroid hormone. However, the most important thing is to be consistent, and take your thyroid hormone at the same time, and in the same way, every day. If you are taking several other medications, you should discuss the timing of your thyroid hormone dose with your physician. Sometimes taking your thyroid hormone at night can make it simpler to prevent your thyroid hormone from interacting with food or other medications.

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.

6. Does Thyroid Hormone Interact With Any Other Medication?

Taking other medications can sometimes cause people to need a higher or lower dose of thyroid hormone. Medications that can potentially cause people to need a different dose of thyroid hormone include birth control pills, estrogen, testosterone, some anti-seizure medications (for example Dilantin and Tegretol), and some medications for depression. Yet other products can prevent the absorption of the full dose of thyroid hormone. These include iron, calcium, soy, certain antacids and some cholesterol-lowering medications. For all these reasons, it is important for people taking thyroid hormone to keep their physician up to date with any changes in the medications or supplements they are taking.

7. Do You Prescribe “Natural” Thyroid Hormones?

The use of “natural” thyroid replacement has been fueled by some patients dissatisfaction with synthetic thyroid replacement (L-thyroxine (T4)) aided by clever marketing strategies starting with the notion that “natural” hormone replacement is a suitable equivalent alternative to synthetic thyroid replacement and that it is specifically customized to satisfy individual requirements. The most commonly use agent is Armour thyroid.

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.

8. Do you check free t4, free t3, and reverse t3?

Free T4 and Free T3 are routinely checked as part of the workup for the causes of hyper and hypothyroidism. Checking these levels for patients who are on replacement therapy could lead to confusion when not interpreted correctly by a trained physician. For example, T3 has a very short life and when sampled 5-8 hours after ingestion could lead to values drastically different that when sample within 1-2 hours after ingestion. Generally speaking it is not necessary to sample Free T4 and Free T3 levels in the setting of replacement therapy. The main lab to assess adequacy of replacement is the TSH, for which the assays are generally very sensitive.

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)?

There is a push by insurance companies and pharmacists to prescribe generic levothyroxine and in most cases, for most patients this is acceptable. However, due to the intrinsic variability that may be part of the manufacturing process and quality controls in terms of concentration of active ingredients by the different companies that manufacture levothyroxine there are some situations where brand product may be preferred. For example, patients following removal of the thyroid for thyroid cancer would benefit from more predictable and consistent levels from refill to refill rather than slight fluctuating concentrations of active ingredients that may be part of generic formulations which may result in the need to adjust the dose. Many thyroidologists prefer to prescribe only brand product for patients being followed for thyroid cancer. The binders that are part of different generic formulations may be different than the ones found on brand products. If this is the source of inability to tolerate medication a switch to brand product may be considered.

10. What about t4 and t3 treatment?

Combination T4/T3 preparations contain much more T3 than is usually produced naturally within the body. Because of this, they can have the same side effects as T3 given by itself (short acting effect). It is also given once a day, ignoring the short life span of T3 in the body. There has been interest in whether a combination of T4 and T3, with a lower amount of T3 given more than once a day, might result in better treatment of hypothyroidism, especially in those patients that do not feel completely normal on T4 alone. In these cases, T3 is taken in addition to T4. A trial period of 3 – 6 months is reasonable to determine if combination T4 and T3 therapy will help.

11. Will thyroid hormone help me if i have hypothyroid symptoms but normal thyroid hormone levels?

Some people with normal thyroid blood tests have symptoms that are similar to symptoms of hypothyroidism. Several scientific studies have looked at whether T4 therapy would be of benefit to patients with symptoms that overlap with hypothyroid symptoms and normal thyroid function. In all cases, there was no difference between T4 and a placebo (sugar pill) in improving symptoms or well-being.

12. What is your ideal tsh level?

There is no one size-fits-all when it comes to TSH level. In the case of pregnant women on replacement therapy the recommended levels are different (usually trimester specific). For the very elderly recent literature suggests that levels above the upper range (normal range 0.4-4.5) may actually be protective. Young individuals without other serious medical problems may actually benefit and feel better when their TSH is close to 1. If you are a thyroid cancer patient your TSH target for the first three years after surgery may be different than when you are ten years removed from diagnosis. The point here is that every situation is different emphasizing the need for evaluation by a trained specialist and as such it calls for individualized target based on clinical scenario.

13. Do you recommend any dietary supplements or a special diet in hypothyroidism?

The majority of dietary supplements (DS) fail to meet a level of scientific substantiation deemed necessary for the treatment of disease. In the case of hypothyroid¬ism, this is the case for over-the-counter products marketed for “thyroid support” or as a “thyroid supplement” or to promote “thyroid health,” among others. We do not recommend the use of these or any unproven therapies. DS are generally thought of as various vitamins, miner¬als, and other “natural” substances, such as proteins, herbs, and botanicals. We also do not accept the premise of “sensitivities” to certain foods as the cause of autoimmune thyroid disease, or underlying gut infections requiring “detoxification”. “Functional nutritional support” is also an approach that is not accepted in the mainstream thyroidology practicing community.

16. Why should i have my thyroid ultrasound done at your office?

The alternative is going to a dedicated imaging center or local hospital where in addition to doing thyroid ultrasounds they also do MRIs, CT scans, and multiple other imaging procedures but do not specialize in any of them. When doing a thyroid ultrasound you are the mercy of the ultrasound technician operator, the experience he may have. The small parts curriculum (the ultrasound category that thyroid falls under) varies at the different training programs from as little as two weeks training to a couple of months. Further, it makes a significant difference whether the interpreting physicians looks at the images in real-time (manipulating the angles of the probe, changing positions, adjusting settings to maximize visualization of critical elements) versus looking at static images saved by the ultrasound technician. At our practice we are solely dedicated to thyroid imaging. Our ultrasound technicians are very experienced, they have been well trained and know exactly what to look for. The physicians render their interpretation based on real-time evaluation of the thyroid images. On average half of the ultrasound reports I review that are brought to us from outside centers contain some kind of inaccuracy. These include mistaking the side where the findings are present, failure to provide three measurements for thyroid nodules, and not accurately distinguishing cysts from solid nodules which have huge clinical implications (the management of a cyst is entirely different than that of a solid nodule). There are often also errors of omission with regards to interpretation of the ultrasound characteristics of thyroid nodules which are very important in determining whether a biopsy is required. If you intend to come to see you PLEASE do not get your ultrasound done at another facility even if suggested by your primary care doctor or your referring physician.

17. Why should i have my thyroid biopsy done at your office?

We have performed over a thousand of these procedures and employ the latest techniques and technology. We used ultrasound guidance (some places do not) for every biopsy which enables us to see exactly where we are putting the needle. This is very important as without this visualization the nodule of interest may not be the one directly biopsied or as commonly happens the area of the nodule that is biopsied is not the solid portion, rather the cystic content which inevitably will lead to an insufficient diagnosis (not enough thyroid cells for the cytopathologist to render a diagnosis). Our insufficient rate is less than 2%. At some other facilities it may be as high as 15-20%. This will ultimately lead to having to come back for another procedure. We track every biopsy we do and are constantly improving our protocols to ensure optimal collection.

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.

18. What is cytology adequacy assessment and how is it beneficial to me?

Cytology adequacy assessment is the practice of evaluating every specimen we collect before sending it to the lab to make sure we are obtaining sufficient material for the cytopathologist to make a diagnosis and to ensure that the patient will not have to return for re-biopsy on the grounds that sufficient material was not obtained at the time of original biopsy. We perform this evaluation using our microscope. Endocrinologists, Radiologists, or Surgeons (doctors who routinely perform these procedures) are not routinely trained to do this. We have sought out this additional training to make sure we offer patients optimal care. In the process of assessing for adequacy we are able to identify abnormal cellular features for which our protocols then call to obtain additional material at the time of the original biopsy in the event additional testing (see next question) is required in deciding if to proceed for surgery.

19. Do you have the ability to perform molecular testing on thyroid biopsies and if so when is it indicated?

When a thyroid biopsy of a nodule is performed one of four diagnoses is usually given. The first category is benign for which ultrasound surveillance is generally recommended over a period of time. The second category is malignant for which the patient is sent for surgery. The third category is insufficient which as explained above at our practice we placed a great deal of emphasis in minimizing and our current rate is less than 2%. The fourth category is a gray zone category usually called indeterminate. This category has normal and abnormal features but not enough of either one to call it benign or malignant. In the old days (actually as recently as 2010) the standard of care was to refer these patients for surgery at which time a definitive diagnosis of benign or malignant would be rendered. Unfortunately this practice resulted in many unnecessary surgeries as the vast majority of patients turned out to have benign nodules. Some unfortunate individuals experienced complications from surgery including damage to the recurrent laryngeal nerve which innervates the vocal cords and permanent damage to the parathyroid glands which control the calcium metabolism for which lifelong calcium supplementation is required. Those that had their whole thyroid removed were destined to lifelong replacement therapy.

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.

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