Dr Bob Underwood (Host): While many people associate thyroid issues primarily with weight changes and energy levels, they may not realize the broader effects and symptoms, like mood changes, cognition, or even heart health. Some thyroid conditions are relatively common, while other conditions are more rare and may need help from a specialist.

This is Expert Insights with the Carle Foundation Hospital. And I'm your host, Dr. Bob Underwood, and we're going to dive into the world of thyroid awareness and research with Carle Health endocrinologist, Dr. Lakshmi Das.

Today's Expert Insights episode will shed some light on the common symptoms, evaluation methods, treatment options, and when patients should seek specialized care. Dr. Das, it is so good to have you with us today to talk about this important medical topic. Thanks for being here.

Dr. Lakshmi Das: Hi. Thank you. Thank you for having me.

Host: Yeah. So, you know, thyroid issues are really relatively common in the world today. So, can you tell us about some of the common symptoms that might indicate that there's a thyroid issue going on?

Dr. Lakshmi Das: Absolutely, yes. Like you rightly said, Bob, it's very common and basically some people don't even know where their thyroid exists. It is typically in the bottom of your neck. It's a strawberry-sized gland, butterfly-shaped, about 15 grams. And basically, thyroid disorders, when we think about them, things could be wrong in the anatomy versus the functioning. And when we go to anatomy, we are mainly talking about thyroid nodules, which typically on a clinician's exam may get picked up or an imaging study that was done for another reason, and this incidentally pops up and we have to evaluate this further.

When coming to the functioning part, it could be an underactive thyroid where your thyroid is not working hard enough to make the thyroid hormone, or it's working too hard and making too much thyroid hormone and causing issues. So again, coming to the symptoms, typically, underactive thyroid or low thyroid hormone production typically comes with nonspecific symptoms like fatigue, weight gain, dry skin, constipation, symptoms that anyone could have at some point in their life. And hyperthyroid symptoms or overactive thyroid symptoms are a little more dramatic. Patients come in with weight loss despite having a good appetite or menstrual issues in a female patient, having increased frequency of bowel movements or anxiety attacks, raised heart rate. And sometimes even in hyperthyroidism, your eyes could have some symptoms like redness, Itching, watering, or there may be some bulging of the eyeball. So, those are some of the common symptoms that typically patients present with.

Host: So, how important is it that they recognize these symptoms early on in the process?

Dr. Lakshmi Das: So like any disease diagnosis, the earlier we do it, the better we can evaluate, the sooner we treat the patients and get them symptom-free. That's what we want to help the patients with. And then, depending on whether it's an underactive thyroid and an overactive thyroid, for example, especially in our reproductive age group women, we want to make sure that they are euthyroid, which means their thyroid hormones are normal before they try to conceive a baby, because the developing baby does not have a functioning thyroid until the first three months of conception. So, we want to make sure that the earlier we find, the better we treat and prevent cardiovascular mortality. Same thing with overactive thyroid. We want to ensure that we diagnose, we treat, and provide appropriate treatment, so that we are preventing heart issues, osteoporosis, which comes with uncontrolled hyperthyroidism.

Host: Absolutely. And, you know, we said it's kind of common. And so, if a patient is being diagnosed with some level of a thyroid disorder, how should they monitor their symptoms and when do they need to seek further medical advice?

Dr. Lakshmi Das: Any symptom under the sun could be related to the thyroid, because your thyroid hormone deals with your metabolism and then it can affect your body temperature, your weight, it can affect your heart. So, any change in your normal health should be monitored closely by patients. And if it's something that's ongoing for a long time, it should be brought to the attention of their closest health provider and the health provider can run a specific test to kind of see is it truly their thyroid or something else going on? Because like I said, the symptoms can be very non-specific.

Host: It really is very broad in terms of how that symptom might show up. So, explain to us a little bit, since we already started talking about it, about what are those evaluation methods that could be used by healthcare providers to diagnose thyroid disorders?

Dr. Lakshmi Das: Again, we can broadly divide this into anatomy disorders like the nodules. Typically, we would have to get an ultrasound to look at the character of the nodules to determine if they fall into a certain criteria, which warrants fine needle aspiration to rule out malignancy and take it from there versus most of the nodules are typically benign and can be monitored over time. Whereas the functioning part, when it comes to either hypothyroidism or hyperthyroidism, it is a biochemical diagnosis. Although you might have an array of symptoms, but we heavily rely on lab tests when diagnosing functional disorders of the thyroid.

So, the best test that we do is the TSH, because it kind of is the assay that is very reliable and it might give us an idea that the thyroid hormones are not behaving right way before there is overt disease. So, TSH is the most reliable test that we typically ask patients to get first and then if your TSH is elevated, TSH is the hormone that your pituitary is gland makes, if the TSH is elevated and your peripheral hormones, which is your T4 and T3, if they are low, then we call that as overt hypothyroidism. Sometimes the peripheral hormones are still normal, but the TSH is elevated and then we call that subclinical hypothyroidism. And the opposite, if the TSH is low or undetectable with normal peripheral hormones, then subclinical hypothyroidism versus if the peripheral hormones are elevated, then we call that as overt hyperthyroidism.

Host: Like we said, thyroid issues, relatively common. And uncomplicated disease processes like hypothyroidism, typically, that's managed by a primary care physician. So, at what point do primary care physicians need to refer their patients to a specialist like you?

Dr. Lakshmi Das: A lot of the primary care physicians are comfortable treating the basics of thyroid disorders. When it comes to the anatomy, when they find a nodule that was picked up, they typically send them to the specialist to see if it warrants an FNA or a fine needle aspiration. And if it turns out to be cancer, then further treatment of cancer is typically taken over by specialists. And when it comes to hypothyroidism, again, a lot of primary care providers are very comfortable managing that and a patient may never see a specialist for that, unless the primary care provider is trying to adjust the doses of medication and still not reaching the goal on blood work or a patient is not feeling symptomatically better.

And also, I think the pregnant patients and the older patients may need a specialist's help because things change with regards to the amount of thyroid hormone that's needed during pregnancy, as well as there is a change in the reference range in geriatric population. Also, some providers may be hesitant in starting thyroid hormone in those who have cardiovascular disease. So, that may be the time when they may want to seek the help of a specialist to help them out.

Host: Can you highlight the role of that collaboration between the primary care provider and someone like you?

Dr. Lakshmi Das: Yeah, absolutely. First thing again, prompt referral or prompt evaluation to see if the symptoms actually match thyroid labs. Is there a thyroid lab that is substantiating the symptoms that the patient presents either underactive or overactive? And of course, starting treatment when possible or prompt referral to try and get the patient in if the patient is really symptomatic and the primary care provider is unable to start treatment appropriately, again if patients have cardiovascular disease, so maybe a quick phone call, even though we can't see the patients immediately, at least a quick phone call to see what can be done while the patient is waiting to see you. What can we start? Is there a dose you would recommend?

And of course, once we kind of manage the acute issues and patients are pretty stable symptom-wise and biochemical-wise, then we may even discharge the patient back to the primary care provider and then see them as needed if anything changes in the patient's clinical condition. And then, of course, we want to collaborate more with pregnant women, with the primary care providers and the obstetricians, because patients, when they're pregnant, may be seeing their obstetricians more often than they might be seeing an endocrinologist. So, those are the situations that we would want to collaborate to make sure that nothing falls through the crack and patients are given adequate care.

Host: I think that's really important for us to keep that in mind, both as primary care providers and for the patients as well. We talked about a broad range of symptoms, right? And so, those aren't always, though, going to be thyroid conditions. So, what else might be in the differential diagnosis?

Dr. Lakshmi Das: Sometimes with the thyroid symptoms, the tricky part is even if we achieve biochemical euthyroidism or normal thyroid level sometimes the symptoms lag behind the lab work. So, we probably have to give it a little time to finally conclude that, Okay, this is not your thyroid. Maybe something else is going on." So, most patients feel better about two months to maybe a maximum of six months before we can kind of say, "Okay, maybe this is not your thyroid. We are probably needing to look at something else going on." Especially with the symptoms like fatigue, you want to make sure their sleeping pattern is good. Are they getting adequate sleep? With constipation, are they having enough hydration? Are they having enough fiber in their diet? And are they deconditioned? Are they exercising? Is their nutrition good? Do they have any vitamin deficiencies or anemia? Are those something that we are missing and blaming it on the thyroid? So, those would be some of the things that we probably need to figure out if getting labs under control and patients are still needing symptom control.

Host: Absolutely. So, we talked a lot about various kinds of thyroid issues. Let's talk about some treatment options, you know, what's out there for various thyroid disorders.

Dr. Lakshmi Das: There is hope. Of course, with nodules, like I said, patients may need a fine needle aspiration and then monitoring if it's benign. But if it ends up to be cancer, thyroid cancer is considered to be less complicated than our typical cancers out there. Treatment may involve either partial removal of the thyroid gland or a total thyroidectomy and then may or may not need radioactive iodine treatment. Whereas coming to hypothyroidism and hyperthyroidism, when it's hypothyroidism, it's simple, right? Your thyroid is not making the hormone, so we give it to you in the form of a pill. So, that's synthetic thyroid hormone, which the common one is levothyroxine. And typically, if your thyroid is still making some hormone, you don't need a full replacement. But if you've had your thyroid removed for any reason, then you need a total replacement, which typically we follow the 1.6 microgram per kilogram body weight rule. And it takes about six weeks after starting treatment for the levels to steady. So, we wait six weeks to check the TSH again. Whereas in hyperthyroidism, depending on the cause, it could be either autoimmune hyperthyroidism, commonly called as Graves disease, or it could be a toxic adenoma, which is one of the nodules just autonomously making more thyroid hormone.

So, there are three modalities for hyperthyroidism. Antithyroid medications, so these are medications which you give to decrease the production of the thyroid hormone. Number two and three are definitive therapies. So, radioactive iodine, ablation, versus total thyroidectomy. Depending on the etiology or the cause of hyperthyroidism, we can choose from these options. For example, if it's a toxic adenoma, we initially want to treat with antithyroid medications to ease the symptoms and get the thyroid labs under control. But then, eventually, they may need definitive therapy either with radioactive iodine ablation or even a lobectomy to take the nodule out.

But all said and done, the options should be laid in front of the patient and depending on the scenario, like for example, for pregnant women, if they opt for radioactive iodine ablation, they should be warned that they shouldn't get pregnant within six to 12 months after having that treatment. Some other caveats when we check thyroid labs is there are some interfering antibodies, which may give us false results. So, one must be aware about those. These are called heterophile antibodies.

Also, the latest that's scaring us doctors is the use of biotin, because biotin has been shown to cause a lot of interference with the thyroid hormone testing. So, biotin can falsely cause a low TSH with elevated peripheral thyroid hormones, falsely indicating that the patient may be overproducing thyroid hormones. So, we have been asking our patients to stop biotin for 48 hours prior to testing, that's the washout period, so that we get more reliable test results.

Host: Wow. I was unaware of that. So, that's phenomenal. Anything else you'd like to say, as we kind of come to an end today?

Dr. Lakshmi Das: Thyroid disorders are common, and they are pretty easily detectable either with imaging or blood work. Never hesitate to go to the doctor to present your symptom. It may not be the thyroid, but at least we can evaluate further to see what else could be going on.

Host: Thanks so much for being with us today. I know I learned a lot.

Dr. Lakshmi Das: Thank you. The pleasure is all mine.

Host: And for our listeners, if you'd like more information or to get connected with one of our providers, visit carle.org. That's carle.org. Also, for a listing of Carle providers and to view Carle-sponsored educational activities, head on over to our website at carleconnect.com. And that wraps up this episode of Expert Insights with the Carle Foundation Hospital. I'm your host, Dr. Bob Underwood.