Amanda Wilde (Host): Thyroid disease comes in many forms and can develop at any age. We'll talk through the types and treatments of thyroid disease with endocrinologist at the medical group at Montefiore St. Luke's Cornwall, Dr. Ashok Vaswani.

Welcome to Doc Talk, presented by Montefiore St. Luke's Cornwall. I'm Amanda Wilde. Welcome to the podcast, Dr. Vaswani.

Ashok Vaswani, MD: Thank you, Amanda.

Host: Well, as I mentioned, there are many forms of thyroid disease. Let's talk about what are the different types?

Ashok Vaswani, MD: Well, I mean, thyroid disease, as any other endocrine or any other hormonal system, will have underactivity, overactivity and some kind of cancers. So, those would be the general kind of topics that we would then discuss.

Host: And what are some of the underlying causes? I'm sure there are multiple possible causes of thyroid disease. Is there anything under our control?

Ashok Vaswani, MD: Well, I don't think you would have anything under your control, not even diet, because sometimes the diet can mess it up also. So, the typical under and overactivity of the thyroid, you can kind of lump it together as an autoimmune disease, which means your body is kind of reacting against the thyroid to destroy the thyroid and make it underactive or activate the thyroid to make it overactive. So, the overactivity would be considered or it's called Graves disease, named after a person named Graves, last name, rather than the deadly form. And of course, the underactive version is also by a name of another physician who made the discovery. It was Hashimoto. So, the typical version that you hear about for underactive is Hashimoto's, and for the overactive is Graves disease, and these are the autoimmune disorders.

Host: What are the causes of these autoimmune disorders?

Ashok Vaswani, MD: So, these are proteins that are made in the body as if your thyroid gland is producing something abnormal. And just like any other virus or whatever infection you can get, basically, the system just tries to react and protect itself. So, what it does is it then produces proteins or sort of a security team to attack the actual tissue. So in this case, it's a thyroid. So, they'll make antibodies against the thyroid or the specific parts of the thyroid cell.

Host: And isn't thyroid disease more common in women than men? Do we know why that is?

Ashok Vaswani, MD: Well, it is more common in women than men. And a simplistic reason would be that women tend to have more autoimmunity. Because when women do get pregnant, they have babies and that's a foreign body in a sense. So, you are more prone to producing your own antigens or antibody in that sense. That would be the most simplistic explanation. Other than that, men get it too. And sometimes, their disorders are much more severe.

Host: Oh, interesting. Can you talk about those symptoms? What are the symptoms of each thyroid disease?

Ashok Vaswani, MD: So, we can combine them together, and we'll talk about a specific organ system and then work our way through. So, an underactive thyroid and an overactive thyroid. So, let's put them together. Let's start with the basic stuff.

Fatigue, it's a common symptom for both. So, tiredness is equally present in the underactive and the overactive. But what happens is the underactive person is too tired to start work. They're tired to begin with, whereas the overactive person is already going, going, going, going, going constantly, and they can't stop, because they have that overactive impetus. So, that would be one. So, sleep is another thing. Underactive patients or people would complain of feeling sleepy while the overactive people would stay awake all night.

Then, there's temperature control. So, underactive would be colder than usual, and the overactive would be warmer than usual. And you can go on any of those symptoms you want. For example, the heart would be slow for the hypothyroid, fast for the hyperthyroid, and those are the symptoms that the patient would manifest. So, they might come with palpitations, diarrhea, inability to sleep, anxiety, then you would suspect them to have overactive.

Host: So when does someone know when to go to the doctor for these kind of symptoms? Because what you're describing may be severe, but what if they're milder than that? How do we uncover thyroid disease?

Ashok Vaswani, MD: Sure, sure. So, the milder disorders, people go to virtually many of the doctors before they finally wind up with the Endocrine, because some of the earlier symptoms would be just as we said, fatigue, "I'm tired." So, where do you go when you're tired? You go to your primary care maybe. Or you might say, "Oh, maybe I'm anemic." So, they'll say, "Okay, let's do a CBC and see if you're anemic. If it doesn't prove out to be anemia, you will say, "Okay, now what are the symptoms you have?" "Well, my joints hurt." "Okay, so go to the rheumatologist." So, maybe you'll go to the rheumatologist next.

And so, symptoms in the early stages, they're very hard to say where you would go and find your answers to the problem that you actually have. That's essentially what you would do. So in the end, somebody will put it together and say, "Oh, looks like you have joint pain. You're fatigued. Your heart was slow. Let's think about a thyroid problem." And then, they'll do the thyroid tests.

Host: And once one has been diagnosed, what are the treatments for the underactive and overactive thyroid conditions we've been talking about?

Ashok Vaswani, MD: So, here, I would want to put out another concept for you and your listeners. The thyroid gland puts out two types of hormones, which are thyroid-related and many, many more, but certainly the two we are interested in. One is called T4 and one is a T3. And the 4 and the 3 stand for the amount of iodine that the molecule is holding. So, there's a protein which holds onto iodine, so it becomes first, T1, then T2, then T3 and T4.

And so, the T4, it is more like a carrier protein. It just circulates. But the T3 is the more active one. So as far as treatment goes, most of the drugs that are available are in the T4 format. So, they'd be the standard Synthroid, Unithroid, those are the brand names, for example, or the generic is called levothyroxine. So, that's your T4. The T3s are more specific and we don't necessarily jump to them right away, but we keep them reserved for a few kind of selected patients. And then, again, there are groups of drugs available, for example, like Armour thyroid, which is a mixture of T4 and T3, and it's more like an animal-based protein that's taken from thyroid of the animals.

Host: So, those are medications to up your thyroid. What if you need to suppress your thyroid?

Ashok Vaswani, MD: So if you suppress the thyroid, you have other groups of drugs which will actually block the synthesis of the thyroid hormone. So, what those drugs would do is they would block the uptake of the iodine from the circulation into the thyroid so that no new thyroid hormone is formed. So, let's suppose a person has Graves disease. They've already made so much hormone in the thyroid gland that the gland gets big and large, swollen, and very vascular. So, that particular hormone that's already made is going to have to be put out somewhere, and that's being released by the thyroid gland.

But what you could do with the drugs called methimazole, tapazole and so on, those drugs would block the uptake of new iodine from coming in. And eventually, with time, the amount of thyroid hormone production would slow down. So right away, in the beginning, you're not really cutting off the production. You're just cutting off the actual availability for new hormone. So, you would need to treat them with other symptomatic treatment like palpitations, you would slow down with a beta-blocker, like a propanolol or an Inderal. So, that's a combination of therapies you would use for the people who are overactive.

Host: And with these therapies, how effective are they?

Ashok Vaswani, MD: The effectiveness is dependent on several factors for mostly the overactive ones, and we'll come back to that in a minute. Let's go to the underactive one.

So for the underactive patients, we would start on a slow, comfortable dose based on the patient's TSH, which is the thyroid-stimulating hormone, that is a sensor in the pituitary gland. So once that happens, we just take a look at the TSH value and decide empirically what the dose you might start off with. So, we'll start with a certain dose, let's say 50 micrograms. And then, we work our way up gradually. And when the TSH comes down into a comfortable range, which we would say is acceptable, and the patient feels better, then we would stop at that point, at that dose. So, that's the underactive. It's relatively simple.

The overactive is a little tricky. If the overactive has been induced by antibodies for the Graves disease, for example, then they become more or less a sort of a marker for us to see if they do go down fast enough, then we would assume that the treatment would work quickly. If they don't come down fast enough, then you are almost expecting a relapse very quickly.

Host: Are these conditions chronic?

Ashok Vaswani, MD: No, they're fixable. So if you've detected an underactive thyroid and you know it is related to autoantibodies related to, say Hashimoto's, and you just replace the thyroid hormone with T4 or Synthroid or whatever, you're normal, then you're basically normalizing that person and there's no more problem with the disorder because you haven't done anything to the disorder. You're simply replacing the hormone that's not being made, as simple as that. In that sense, it is chronic because once you take off the thyroid hormone, they'll just fall back and become underactive again.

On the overactive side, there's a potential for remaining really normal. Because if you get the right dose of this medication to slow you down and the antibodies behave themselves, you could remain without thyroid hormone eternally or forever. On the other hand, if you've got antibodies, then the up and down movements will continue for a while until everything calms down. So in that sense, they're chronic.

Host: And I was wondering, do they change over time? So, you may start with an underactive or overactive thyroid, you're taking medication. Does that ever change on its own where you might need less of that medication or an underactive becomes overactive or the other way around?

Ashok Vaswani, MD: Sure. Now, you brought up another concept, which is very popular and common, and that is what happens is some patients actually produce both kinds of antibodies, the underactive and the overactive. So at some time, they'll with the first kind, overactive, for example. And then, the next time, they might show up as an underactive. So for example, the typical stress reactions in our normal world could precipitate overactivity much faster.

So, let's say somebody starts overactive, and they made those antibodies to produce as if the person has Graves disease. You treat the Graves disease, or the doctors will treat the Graves disease. It calms down, it stays calm for a while. Eventually, it slows down. And by then, maybe the underactive antibodies are activated and they will worsen the hypothyroidism and then you have to treat them with Synthroid. So from going to producing a huge amount of thyroid to requiring treatment, that kind of a situation, we kind of consider people who have both antibodies-- we call them hashitoxicosis because it's a mixture of both hyperthyroidism and hypothyroidism.

Host: So, you always have to monitor for symptoms and for T3 and T4 levels.

Ashok Vaswani, MD: Exactly. Measure the T3, measure the T4, measure the TSH. And at the moment they manifest overactivity, you should measure the antibodies again.

Host: Dr. Vaswani, thank you for this information. You've been a great resource for understanding thyroid disease and treatments.

Ashok Vaswani, MD: You're welcome.

Host: Dr. Ashok Vaswani is endocrinologist at the Medical Group at Montefiore St. Luke's Cornwall. To learn more about our Endocrinology services as well as other primary and specialty services, please visit slcmedgroup.com. Thanks for listening to Doc Talk, presented by Montefiore St. Luke's Cornwall. For more information, visit montefioreslc.org. That's montefioreslc.org. Please remember to subscribe and rate and review this podcast and all other Montefiore St. Luke's Cornwall podcasts.