Intro: Duly Noted, a Health and Care podcast, is the official podcast series of Duly Health and Care. Each podcast features physicians or team members discussing groundbreaking topics and innovations that help listeners reimagine and better understand an extraordinary health and care experience.

Cheryl Martin (Host): Being diagnosed with any new illness or condition can be overwhelming. One illness that is exceedingly common is thyroid disease. Our guest this episode is Dr. Bency Kurian, a Duly Internal Medicine physician. She will walk us through how to navigate this diagnosis and speak to some of the treatment options available.

This is Duly Noted, a health and care podcast. I'm Cheryl Martin. Dr. Kurian, according to the American Thyroid Association, the lifetime incidence of thyroid disease in the US is around 12%. How do you define hyper and hypothyroidism for your patients?

Bency Kurian, MD: Sure. Thyroid disease is common, and that kind of encompasses all of thyroid disease. So, there's nodules, there's cancers, there's hypo and hyperthyroidism, there's subclinical thyroid disease. So as far as like hypo and hyperthyroid, which is what we are going to focus on, we do have a thyroid gland, which is just on the base of your neck. And hypothyroidism is when the thyroid gland is not active enough, so it does not make enough thyroid hormone. And when it doesn't make enough thyroid hormone, that controls how your body uses energy and that can cause a cascade of effects. Hyperthyroidism, on the other hand, is when your thyroid gland is too active. So, it makes too much of the thyroid hormone and this speeds up your body's metabolism.

Host: So, what can patients expect the diagnosis process to look like to determine if they have either thyroid condition?

Bency Kurian, MD: So, that's a little bit controversial in the sense that if you have no symptoms, there really is no clear consensus as to whether you should have screening for thyroid disease. However, if you do have symptoms, then definitely you should be screened for a thyroid condition. And symptoms vary depending on if it's either overactive or underactive. But what we do is we look at your physical exam. So when you come in and you have symptoms, we know what is the heart rate like, what are your reflexes, where's your blood pressure. We obviously palpate the thyroid gland itself. We look to see if there's any eye changes and what symptoms are you having. Is there any swelling? Is there any shortness of breath?

And then, we go on to blood work. And blood work looks at your TSH level. That is the gold standard for screening for thyroid diseases. And the reason why we look at your TSH level is because that is kind of the monitoring parameter or hormone for your thyroid hormone itself. And depending on what that tells us is if it's high or low, then we may check the actual thyroid hormones, which is your T4, your T3. We may check also antibodies. We may do a thyroid ultrasound or an uptake scan as well.

Host: Doctor, you mentioned some of the symptoms. Just to clarify, can you just give us an idea if someone is possibly hypo? Give us a list of what those symptoms would be and then hyper, what some of those symptoms could possibly be.

Bency Kurian, MD: Sure. So for hypothyroidism, again, because your thyroid gland is not active, it's not producing the thyroid hormone, this slows everything down. So if you think about it like that, you'll have more fatigue, decreased energy, you'll have constipation, you'll have dry skin, you'll have cold intolerance. So, those are the main symptoms of hypothyroidism. And then hyperthyroidism, again, is when your thyroid gland is too active. You'll have things that will speed up your metabolism. So, those symptoms are more like anxiety, tremors, palpitations, increased sweating, weight loss, heat intolerance. So, those are the more common symptoms of hyperthyroidism.

Host: Great. Now, what treatment options are available to manage these conditions? And can hyper or hypothyroidism have an adverse effect on other aspects of your health?

Bency Kurian, MD: So, treatment really depends on the cause of either the hypo or hyperthyroidism. The main cause of either one is typically autoimmune conditions. So, autoimmune conditions means that your immune system is kind of attacking itself and it makes antibodies against your thyroid gland. So if you're talking about hypothyroidism, that tends to be Hashimoto's. And if you're talking about hyperthyroidism, that tends to be Graves disease.

So for hypothyroidism, typically, we would have to give lifelong replacement of a thyroid hormone, such as levothyroxine. There are other medications such as desiccated thyroid hormone, which is also T4, but also a little bit of T3. But typically, we would start off with levothyroxine, which is replacing your T4. And again, we start you off on a low dose and then we would titrate that up depending on your levels every four to six weeks. And then once you're at a steady state level, you would be on that medication typically for the rest of your life. Versus hyperthyroidism, we would use antithyroid medications such as methimazole or PTU. And these are medications to ease the symptoms of the hyperthyroidism by preventing the thyroid from making too much hormone. Other options for hyperthyroidism is radioactive iodine, surgery, or sometimes no treatment because sometimes hyperthyroidism can be something that can resolve on its own.

And there are definitely adverse effects that can happen if the diagnosis of thyroid disease is not found and if it's not treated appropriately. It can cause heart problems like arrhythmias such as atrial fibrillation. It can cause neuropathy, so that's numbness, tingling in your hands or your feet. It can cause infertility and birth defects if it's not diagnosed properly. It can cause vision issues, skin issues. It can cause brittle bones or osteoporosis. And it can cause also some mood issues, depression and anxiety.

Host: I'm glad you brought that up because I was going to ask you that very thing that it can be overwhelming, I assume, when someone finds out they are diagnosed. So, what should be the first step? What do you recommend for patients when they receive this diagnosis? What's the first thing? What's the first step?

Bency Kurian, MD: Sure. I think with any type of chronic disease, which is what a thyroid disease is, it's something that you will need to manage lifelong, is to just take a minute and acknowledge those feelings, because it's a rollercoaster of emotions. You could feel overwhelmed. You could have grief, you could have anger, you could have guilt. There's really no right or wrong way to respond. But just know having a thyroid disease, having that diagnosis, you can still live a very long and fulfilling life. And I always tell people, just try to face the diagnosis head on. You know, you don't want to ignore the situation. Develop a plan of action, write down questions, find a support system and just work on, you know, reducing your stress, exercise, having relaxation techniques as well.

Host: Now, after an initial diagnosis of either hyper or hypothyroidism, when would a primary care physician refer to a specialist to manage this condition?

Bency Kurian, MD: Yeah, I think this varies from primary doc to primary doc. I would say that most primary doctors are very comfortable treating hypothyroidism and also the initial management of hyperthyroidism. With hypothyroidism, we start medications. We have it rechecked, like I said, every four to six weeks until you're in that therapeutic dose. If symptoms improve and the levels balance each other out, then you just need blood work every single year.

But if for some reason we can't get that thyroid level to where it needs to be, or if the patient's symptoms don't improve, then we may refer to a specialist. With hyperthyroidism, usually, we're able to start the anti-thyroid medications, and then we would probably refer to a specialist to talk about the different options of radioactive iodine, surgery, or the different scans that would be needed.

Host: Now, have you found there to be a group of patients that seem to have or experience thyroid issues more than others?

Bency Kurian, MD: Thyroid disease usually typically is five times more likely in females than men. So, it's more common in women and it tends to be higher frequency in older women, so over the age of 60, 65. Now, this can still affect women in the age between 20 and 40, and also pregnant women as well. So, there is a wide range where we can see this, but definitely typically more in females more than men.

Host: Dr. Bency Kurian, thanks so much for sharing your expertise on this important topic. Thanks for being with us.

Bency Kurian, MD: Oh, sure. No problem. Thank you.

Host: If you'd like to learn more, visit dulyhealthandcare.com. That's dulyhealthandcare.com. If you found this podcast helpful, please share it on your social channels and check out the full podcast library for other topics of interest to you. This is Duly Noted, a podcast from Duly Health and Care. Thanks for listening.