Transcription:

Melanie Cole (Host): Welcome to UAB Med Cast. I'm Melanie Cole. And today we're discussing thyroid disease. Joining me is Dr. Richard Rosenthal. He's an Endocrinologist at UAB Medicine. Dr. Rosenthal, I'm so glad to have you with us today. This is a pretty prevalent situation we're seeing now. Can you tell us a little bit about thyroid disease and what are the different types that you see most commonly?

Richard Rosenthal, MD (Guest): Well good morning. Thank you for having me speak on this very important topic. Thyroid disease is very common. In the general practice population, we get lots of patients who come see us for various thyroid disorders, whether it be hypothyroidism or hyperthyroidism. With the advent of increased imaging over the years, we also see a lot of people who develop nodules in the thyroid gland that need to be addressed.

Host: So, what are some common conditions and factors? Can you speak a little bit about the etiology and any risk factors that you can identify for us? Is there a genetic component? Tell us a little bit about this.

Dr. Rosenthal: Well, thyroid disease tends to be a little bit more prevalent in certain populations. Patients who have other autoimmune disorders, patients who have a family history of thyroid disease. It's also very common in patients in the postpartum period. A lot of women who are pregnant or have just delivered baby may also develop some thyroid dysfunction.

And we also see patients who present with a condition called Graves disease, where their thyroid is hyperfunctioning or overactive, and they need therapy for that condition.

Host: Well, then how does it present Dr. Rosenthal? Is it found incidentally? Are there some symptoms and signs? Are people supposed to see their primary care provider, if they've gained weight or have fatigue? Tell us a little bit about the presentation and really diagnosis for us.

Dr. Rosenthal: Well, a lot of patients who present to a primary care office may have various signs or symptoms. They may have fatigue or weight gain, dry skin, constipation. And these are very common presenting signs of hypothyroidism, which is an underactive thyroid condition. A very common word that we see used for this is Hashimoto's thyroiditis, which is an inflammatory condition of the thyroid. You develop white blood cells that infiltrate the thyroid and cause it to not function as properly. Women account for about 95% of the cases of an underactive thyroid, when it's related to this autoimmune condition. And patients may also be asymptomatic. They may just have a slightly enlarged thyroid gland. And where we get involved as an Endocrinologist, is the primary care provider checks a blood test called a TSH level or a serum thyrotropin level. And that level is sometimes elevated. And an internist may either start that patient on therapy or refer them to us as an Endocrinologist to complete the evaluation and work up.

Host: And what's involved in that evaluation and work up? And you can speak about any imaging or radiologic technology that's really advanced and augmented your abilities for detection and therapy.

Dr. Rosenthal: Well in hypothyroidism, the TSH value is elevated. And that's the first thing you need to do to, to check someone's thyroid condition. Because if it's elevated, you want to go ahead and feel their thyroid gland. And a lot of times we think of a thyroid gland as being about 20 grams and we make an assessment of the size of the gland. Sometimes we need to go ahead and order a thyroid ultrasound. The patient may have a nodule that we detect on our physical examination. They may also present with signs and symptoms of compression of the thyroid gland into other organs, mainly the esophagus or trachea. So, if patients are having problems swallowing, we call that dysphasia. Or they're having problems with hoarseness where the gland may be affecting their trachea, that also leads to additional imaging, most commonly the ultrasound, but sometimes we do need to do a CAT scan of the neck to see if there's any impingement of those organs. The other tests we also order are called antithyroid antibodies. They're present in a high titer in about 70 to 80% of these patients.

Host: So, then speak about first-line treatment. Now you've mainly been mentioning hypothyroidism, but what about hyperthyroidism? Speak a little bit about first-line treatments that you would try in either situation with a patient, Dr. Rosenthal.

Dr. Rosenthal: For hypothyroidism, the first thing is to place them on thyroid hormone supplementation. We give them a hormone called thyroxin or serum T4, that is commonly a generic form of that medication is levothyroxin sodium and we follow their thyroid levels and we repeat their thyroid levels in six to eight weeks. That's the amount of time it takes for the pituitary thyroid access to normalize, to see if we need to make further adjustments. On the flip side of things, patients with hyperthyroidism also present with tremulousness, heart racing, weight loss, fatigue, irregular menstrual cycles. And just like we check a serum thyrotropin level for hypothyroidism, we also check it for hyperthyroidism. And in that situation, the TSH value is low or suppressed. When we see a suppressed TSH, the test we like to order in that situation is a nuclear thyroid scan and uptake. The reason we order a thyroid scan and uptake is it helps us differentiate for the cause of hyperthyroidism. Is it an inflammatory problem with the thyroid? Or is it an endogenous problem with the thyroid where antibodies may be causing the thyroid gland to work harder than it needs to?

Host: When is surgical intervention necessary?

Dr. Rosenthal: There's different forms of therapy for hyperthyroidism, when it's endogenous. The most common thing we consider is putting patients on antithyroid medications. They may also need I-131 therapy. And as you mentioned, surgery is also an option. We tend to reserve surgery for patients that have a large gland, patients whose hyperthyroid signs and symptoms are uncontrollable with medication or those that have compressive symptoms from their thyroid condition, that may cause trouble swallowing or hoarseness. We also consider surgery for patients who have thyroid eye disease and in some of our younger patients.

Host: That's really interesting. So, Dr. Rosenthal, what about nodules? You mentioned it just briefly before. Tell us a little bit about the difference with how those might be treated. Do you see these vert often?

Dr. Rosenthal: Nodules are very commonly seen because primary care providers tend to order imaging of the thyroid gland. And when you image a thyroid gland, lots of little nodules can be found. Our job as an Endocrinologist it's to make a determination of which nodules need to be biopsied and which nodules can be followed. In general about 95% of these nodules end up being benign. So, we feel pretty good when we see nodules. However, sometimes when we do a fine needle aspiration biopsy of one of these nodules, we will detect thyroid cancer, which needs additional treatment. That treatment includes referring to a surgeon to either removing one of the thyroid lobes or both of the thyroid lobes, and then there's additional treatment that may need to be considered mainly in the form of I-131 therapy to ablate any kind of remaining thyroid tissue.

Host: Well, you mentioned now surgery and primary care providers. Is a multidisciplinary approach really important for these patients? What types of providers are involved in sometimes what could be considered complex situations?

Dr. Rosenthal: As an Endocrinologist, we feel pretty comfortable seeing these patients ourselves and making the determination of whether they need to see a surgeon or not. There are multidisciplinary clinics using surgeons as well as Endocrinologists. However, that's not a necessity in all situations. These patients can initially be managed just by the Endocrinologist and if they feel a biopsy is concerning and they need surgery, a direct referral to a thyroid surgeon is quite appropriate.

Host: So Dr. Rosenthal, do you see anything exciting? What's exciting in this field for thyroid disorders? Is there exciting medications on the horizon? Any research that you'd like to share with other providers?

Dr. Rosenthal: One of the things that's exciting about the management of thyroid diseases from a hypothyroidism perspective is there's various treatment options. Mainly in the forms of thyroid medications. We tend to use generic thyroid medications, however, in the last five years or so, we've seen different versions of thyroid medication, name brand versions that may be a little more pure, a little bit more tolerable for patients. However, in general, hypothyroidism is pretty standard in the treatment of the disease. The most exciting thing we've seen in the management of thyroid disease is more on the thyroid eye disease. There's been a new treatment out to manage these patients.

It's mainly prescribed by ophthalmologists. However, patients don't have to have surgery as much for their thyroid eye disease. The most important thing to manage the hyperthyroid is to treat the underlying condition, which is either getting them on thyroid medications, giving them I-131 therapy or surgery to see if the thyroid eye disease resolves.

Otherwise, they may need additional treatment from the ophthalmologist or with one of these newer infusion therapies for thyroid eye disease. As far as the thyroid nodules, the most exciting thing about that disease is most people live normal lives with thyroid cancer. If they are noted to have thyroid cancer on a thyroid biopsy, they need a surgery in the form of either a lobectomy or a thyroidectomy, and then the radioactive iodine is also a potential treatment option.

Host: So, do you have any final thoughts about referral to the specialists at UAB Medicine and when you feel it's important that they look to you and send their patients onto you for further treatment?

Dr. Rosenthal: Well, I believe that treating thyroid disease is something that is very standard. One of the things we like to do is if you detect a thyroid issue, go ahead and make the referral, after you order blood work. I tend to encourage patients not to do too many imaging studies that are unnecessary in the management of thyroid disease.

And one of the rules of thumb that I've always considered is that if you feel a thyroid gland that's abnormal, the first thing you need to do is just order a TSH. And if that TSH's value is normal, you feel pretty comfortable that the only additional tests they would need at that time would be a thyroid ultrasound.

On the flip side, if the TSH value is suppressed or elevated, that's when you want to consider referring on to an Endocrinologist to determine the next step in the process of the management of this disease. The other thing I would leave you with is also thinking about thyroid disease and pregnancy. It's very common to see thyroid abnormalities. You want to make sure that your pregnant patients are properly replaced because the treatment options are a little bit different. They need a little bit more medication as they progress through pregnancy. They also may develop thyroid abnormalities in the postpartum period.

And lastly, we've seen a little bit more inflammation of the thyroid. A A condition we call subacute thyroiditis with all kinds of viruses, including the recent COVID virus or Coronavirus that we've seen during the pandemic.

Host: Thank you so much, Dr. Rosenthal. Excellent summary and a very important, very informative podcast. Thank you so much for joining us today. A physician can refer a patient to UAB Medicine by calling the mist line at 1-800-UAB-MIST, or you can always visit our website at UABmedicine.org/physicians. That concludes this episode of UAB Med Cast.

Please always remember to subscribe, rate and review this podcast and all the other UAB Medicine podcasts. I'm Melanie Cole.