Thyroid Disease Update | Angela Leung, MD - UCLA Health

you so I'm very happy to make this as informal and informative and interactive as possible and happy to take any questions comments etc and we'll actually have a dedicated time at the very end of the formal presentation before that about half an hour at the end but feel free to raise your hand if you have something that you think of as we're discussing these topics so what I thought I would cover in the next 45 minutes or so is just an entire breadth in range of thyroid health thyroid disease comes in many different forms as you can have different imagine and so what I thought we would cover is the spectrum of hypothyroidism which is defined as an underactive thyroid the thyroid is not making enough thyroid hormone then we'll move on to cover hyperthyroidism in which the thyroid is making excess thyroid hormone the opposite and then we'll move into thyroid nodules which are defined as lumps or bumps within the thyroid gland and then finally and with thyroid cancer so I hope that covers everything it would answer everybody's questions so let's very very broadly start off with even what is the thyroid gland right so let's try this pointer if you can see the thyroid gland is this butterfly-shaped gland right in the front of the neck here and in men is usually right below the Adam's apple so it's fairly easy to find in folks with a prominent Adam's apple and in large this is what it looks like here so it's a butterfly-shaped gland made up of sort of the right size lobe we call it a little bridge in the middle called the Isthmus and then the left-sided love it should be a symmetric hole looking gland and you know fairly small we say that it weighs about 15 to 20 grams or so and what does the thyroid do why do we need it what is its role in the body well the thyroid gland makes the thyroid hormones of which there are several them and thyroid hormones in themselves are needed for maintaining the tissues in the body things like the heart here the brain muscles many other parts of the body a sort of acts as the fuel of the body if you can perhaps think of it that way and so the thyroid hormones are critical for the functioning of the entire bodily health and so now let's focus in on hypothyroidism what happens when the thyroid is under active so again this is defined as when the thyroid is not making enough thyroid hormone and this is suggested when you go to your physician or your provider of a blood test something called the TSH this stands for thyroid stimulating hormone and that would be perhaps the first test in which your provider would order to check the response of the thyroid to see if it's making enough thyroid hormones and what are some of the common causes of why a person might have an underactive thyroid gland well by and large worldwide actually it turns out that hypothyroidism is due to something called Hashimoto's thyroiditis you might have heard of this term it's a little bit of a confusing terminology because sometimes it's referred to as Hashimoto's disease as well and it is an autoimmune disease we'll go through it in just a little bit in greater detail but it is by far and large the most common cause of hypothyroidism in the world an autoimmune disease secondly there could be prior thyroid surgery if you've actually had your thyroid surgically removed for a variety of reasons you have an underactive thyroid by definition there could also be prior treatment of and perhaps an overactive thyroid so hyperthyroidism with treatments including something called radioactive we'll go through in greater detail of what radioactive iodine is if a person had medications used to treat an overactive thyroid perhaps now that those medications are now producing the opposite end of the spectrum so it's hypothyroidism and then there are various medications and one of them might be something called lithium which is a medication used to treat mood disorders that's very common that in some cases can also be associated with hypothyroidism so we taught that Hashimoto we have a question here yes please very good question so this lady here had a question of what are the symptoms of hypothyroidism let me just address that I think it's in the next slide can you hold off on that thought for now so we talked a little bit of Hashimoto's thyroiditis which is an autoimmune disease I wanted just to talk very briefly of the difference between something called Hashimoto's thyroiditis and Hashimoto's hypothyroidism because you might sort of hear these terms being tossed around and sometimes it's a little bit confusing so I tried to define it very simply here Hashimoto's thyroiditis are positive thyroid antibodies something like TPO antibodies which might be floating around in their bloodstream very very common to actually have this those antibodies are present in about 15 to 20 percent of the general population so perhaps one in five people wasn't six people actually have these TPO antibodies giving you this disease called Hashimoto's thyroiditis and in most people this Hashimoto's thyroiditis the antibodies don't do anything they're just sitting around in your blood but in a minority of folks these antibodies can develop something called Hashimoto's hypothyroidism which is the antibodies giving rise to an underactive thyroid gland and then this in turn is called Hashimoto's hypothyroidism we have a question here good thank you TP o stands for thyroid peroxidase antibodies that's what it stands for it's one of the more common thyroid antibodies there are others as well but it is the most common so I hope that clarifies a little bit of the difference between Hashimoto's thyroiditis and Hashimoto's hypothyroidism one leads to the other in some folks okay in addition there could be some other even more rare causes of an underactive thyroid gland one of those would be congenital disease so the disease in which you are born with their inherited and so babies are sometimes born with hypothyroidism this would be a lifelong scenario pituitary disease is also possible the pituitary gland is a little gland right in the brain in the middle of the brain and it actually controls the production of the thyroid hormones coming from the thyroid gland in the neck so if this is wrong here in the brain perhaps there's no signaling to talk to the thyroid gland in the neck and in finally in certain parts of the world there could be a deficiency of a nutrient of micronutrient called iodine iodine is a common part of all of our foods you hear about iodized salt iodine is common part of you know certain breads and needs and dairy and etc and in some parts of the world in which there might be endemic iodine deficiency perhaps in more mountainous areas the iodine is not sufficient enough to make the thyroid hormones resulting in an underactive thyroid the thyroid tries to compensate by enlarging trying to work overtime and we call this an endemic border something like this but this would be very very pronounced obviously here in the United States we might have more mild or for of this okay question yes right right right so this is what I was talking about the pituitary gland is a little gland right in the brain it's right behind the eyes right centrally and it's a little gland that controls it puts out a hormone that controls the way that your thyroid makes the thyroid hormones but as I think that that's the only part of the central nervous system in which it is connected the which the pituitary gland or the beggary the thyroid again I don't know if you saw this first line it's a little gland right in the front of the neck here this is a good picture right here and enlarged this is what it looks like but it's very small right in the middle of the front of the neck sort of right underneath the chin it's connected right it's connected to the surrounding structures of course so around it would be the windpipe the esophagus in which you swallow food the blood vessels that supply blood to the brain and there's muscle and fat around that area as well thank you for the question so I think we're about to get to your question which is the symptoms of what happens when the thyroid is not making enough thyroid hormone and here we go so these are sir perhaps some common symptoms of hypothyroidism an underactive thyroid gland they're fairly nonspecific and if you ask people you know generally folks might have a little bit of fatigue or weakness low energy again you can think of thyroid hormone is the fuel of the body and you can imagine like a car when the car doesn't have enough gas then you're slow so you might also have some weight gain hair loss dry skin some forgetfulness constipation mood problems legs swelling and problems with cold so some people might feel that they're more cold than other people in the same room that you are so I'm fairly nonspecific symptoms and even without Sardis disease probably one of you already has you know a little bit of tiredness day to day and so we always have to check with the blood test to see if these symptoms correspond to the thyroid right okay and so how do we diagnose when you have one of these symptoms again we usually recommend a thyroid blood test something called a TSH to begin with a thyroid stimulating hormone and if the TSH is abnormal then your doctor may also confirm with or during subsequent tests things that might include the actual thyroid hormones t3 and t4 for some confirmation okay and if the initial blood test TSH is high that is suggestive of hypothyroidism so it's a little bit ironic when the thyroid hormones are low then the TSH is increased as a result and that's hypothyroidism and then the confirmatory tests are t3 and t4 which would be low okay and then remember that the most common cause of haja under active thyroid disease hypothyroidism in the world is Hashimoto's disease that autoimmune disease in which the antibodies are around in the bloodstream if that suspected we can actually check for those antibodies so your question here that tpo antibody oh sorry here in the blood so the tpo titer can be tracked and measured yes question the range is very wide okay and are we talking for the tests are we talking about the TSH oh okay yes so if they're in range we do call that and consider that normal there's a reason that the branch is defined as you know those parameters and they're different for every laboratory by the way but in that specific laboratory that you got your tests done if it's normal we do consider that normal even if it's borderline right the course the question is if you're yeah the question is if your tests are borderline but yet you have some of these symptoms of hypothyroidism which you benefit potentially from treatment from from thyroid hormone treatment the answer is generally no because even tests that are so borderline even borderline abnormal generally you probably wouldn't be feeling many symptoms that are attributed to the thyroid itself there might be other things usually the symptoms are if the blood tests are really abnormal to to be correlated did we have another question back here I thought yes sir yes so that's a very good question if you have one autoimmune disease for example rheumatoid arthritis it's a very common one or type 1 diabetes vitiligo celiac disease these are all sort of autoimmune diseases do you have an increased risk for developing the autoimmune form of hypothyroidism Hashimoto's and the answer is yes the autoimmune diseases like to travel together so even if you don't have an autoimmune disease in you yourself if you have that history of your family perhaps brothers sisters parents or so forth then you are still at slightly increased risk more than the average person but it's not dramatically increased it's just a slightly increased Gris so you should be looking out for that and I thought I saw one other hand here yes yes sure oh I see right right so it's actually um it it sort of depends on the doctor style I guess that you go to me as an endocrinologist if I happen to see a person who comes in with an underactive thyroid I'd like to give you an answer to figure out why you have that and so I generally do check that tpo antibody the treatment is still the same but it's more for just perhaps reassurance that it couldn't be really due to anything else and so common things being common the Hashimoto's is the most common cause of hypothyroidism I'd like to prove it in folks who come to see me it can be done yes it's very very commonly done as well okay so let's say that the person does have hypothyroidism they have the symptoms they get the blood tests that confirm that they are abnormal so when what that happens we do recommend treatment basically replacing low levels of thyroid hormone with thyroid hormone pills and so we have some examples of what those medications might be and they are usually in the endocrine community we do recommend t4 replacement I remember earlier I have sort of summarized that the thyroid gland makes two different types of thyroid hormone t3 and t4 but we generally do not because we have a lot of evidence about the safety and the efficacy of this recommend replacing with just t4 and those examples it would be generically known as levothyroxine the brand name available in this country currently is synthroid and then there's also another brand called Tyra scent which is a dye free so it doesn't have any colors or artificial dyes in it in folks who might be allergic to fillers and that kind of thing some patients actually might prefer the combination hormone treatment so that's replacing with both t3 and t4 this is a little bit of a controversial topic some of you might have heard about or read about this but the potential danger is that replacing with t3 can give you too much of the active thyroid hormone all at once and when that happens there's potential damage to revving up the body too fast so wrapping up the heart and the bones especially so it's a little bit of a cost benefit decision that you would have to discuss with your physician of whether or not you would want this particular type of replacement in any scenario whether or not you take t3 and t4 or just t4 alone an eternal thyroid hormone when when administered should be taken only on an empty stomach only with water no coffee no juice no tea or anything like that and preferably 30 to 60 minutes before you eat food your first meal of the day perhaps breakfast vitamins or other medications and the reason for all of these recommendations is that the thyroid hormone pill tends to bind to food and medications and vitamins so that you're absorbing actually less than the prescribed amount so it is preferable to to follow these directions to maximize your absorption okay so that was an overview of hypothyroidism any questions regarding an underactive thyroid gland before we move to the opposite end of the spectrum what happens when the body makes too much question here well that's a very good question the question is do I alpha always have to take the thyroid Walmer replacement for the rest of my life in general yes when the thyroid gland is under active it generally doesn't sort of recover and make the amount that was that that is low and so you do rely for the benefit of health to replace what is not there so it generally it is a lifelong prescription yes question here okay okay so let's talk about natural medications are we talking about natural fiber and hormone or other sorts of other therapies other therapies not so much is there specific one you're wondering about that I could potentially directly address a vitamin or okay so some people might be thinking when I talked about iodine deficiency in the world iodine remember is that micronutrients a night I solved it's in different foods etc the thought is if we don't have enough of that micronutrient it's perhaps not making it's it's impairing the thyroids ability to make thyroid hormone because it is needed in that process so some folks might think well perhaps I can just take some iodine then to prevent potentially this problem of an underactive thyroid I can help us IRA make its supply of thyroid hormones in general we in the u.s. if we eat a sort of a normal routine well-balanced diet we are generally considered not to be Ivan the efficient in the majority of folks on average there are some folks that Mitch you know for example folks with some restricted diets or a very special diets they might be a little bit iodine deficient and in pregnant and lactating women those requirements are a little bit different because they are you know providing nutrition nutrition for their fetus as well but in general sort of regular adult healthy adults who are eating a well-balanced meal we probably are not iodine deficient such that if you go out and buy some iodine pills or think about taking kelp tablets which have a lot of eye in them or eat kelp as a food regularly you know in too much quantities the thyroid actually is confused and it actually shuts down thyroid hormone production as a result of excess thyroid excess iodine exposure or ingestion so for that reason it could be dangerous to take iodine pills and we would not recommend that unless it's part of a multivitamin and the amount that is generally recommended by the FDA which is 150 micrograms of iodine a day but if you go out and buy a dedicated kelp or Ida and tablets that's going to be much more than that dose I saw a hand here yes sir yes yes you can imagine this is a hint of what we're gonna address next if we are replacing your thyroid hormone you know not to just back to where it was before but over replacing with too high of a dose perhaps unintentionally then you run into the problem of hyperthyroidism which is the next topic excess fiber and hormone and there could be ramifications adverse health effects there as well we'll discuss that briefly yes question here right so the question is what if I wait the full hour that's recommended before I go ahead and eat or take other sort of supplements the the concern is lessened but I don't think it's ever been studied specifically for each of these things it's only been studied for different medications specifically calcium iron soy you know sort of more common things flaxseed it looks a little bit separate it's a smaller niche so that I don't think has been studied but the thought is they do interact with those other things such that we in general recommend some separation of time just in case it does interact an hour is probably adequate you know some folks they recommend and depending on your provider they might even recommend two hours practically speaking it's a little bit difficult I find to tell people to wake up so early before they you know are ready to eat breakfast some people even set an alarm clock and then go back to sleep which is I feel like you know so burdensome so I just saved one hour would be sufficient and if you do that consistently and there's some sort of interference with say your first meal then your blood test will reflect that and your provider can intentionally give you a little bit extra to overcome that so as long as you're consistent I think that is okay the problem is when you're doing different things every day and I saw another hand here very good question I love iodized salt and everyone should be using only that because it is part of that recommended dietary allowance the daily allowance of hundred and fifty micrograms a day if we're eating again a well-balanced diet that includes iodized salt as well as you know other things that you might be eating in smaller proportions eggs and bread and meat and dairy and all that sort of stuff it should about add up to that 150 micrograms so if a person was not cooking with an iodine salt and by the way kosher salt as well as some of these gourmet salts sea salt Himalayan salt etc they are actually not they do not contain in the iodine iodine has to be fortified and added iodine in order to be iodized does not come naturally and so over the long term you know day to day would be probably okay one day at a time but over the long term if you're not cooking with iodine salt you could potentially be at risk for low and that's been shown actually even here in this country I was on this either I think the question was you got it okay so actually that's a very good question glad you asked that can we measure the amount of iodine in our body to suggest are you you know cooking with enough iodine salt or taking enough foods that have enough iodine it's unfortunately not reliable to do this on an individual basis person-to-person and we can you know there are ways to measure it through the blood and the urine both but it's really not reliable in any one person because of the differences day to day of the foods that we eat that contain iodine so that if you measure your urine for example for iodine it will just be a reflection of what you ate yesterday so it would be an artificially low or high or normal result blood same thing blood is even worse so what we do in terms of sort of more research questions is we do measure across the board the general population the public we measure everybody's urine in everybody's blood not so much blood actually everybody's urine and on average we can say that this country is generally iodine sufficient and we can measure it obviously in different age groups and genders and ethnicities race is sort of identify who might be more susceptible to iodine deficiency but large surveys that have been done even in the last 40 years now have been long-standing across the country show that we are right on the border of being iodine sufficient we are okay as a group thank you for that question yes and so how often should we be having blood testing is this in a person who already being treated with thyroid hormone so okay this is a good question the dose of thyroid hormone whether or not it's levothyroxine or sin through it or Tyra sent is based on your body weight so you can imagine if your weight goes up and down a lot than your dose requirement would change as well if you're maint amina sort of generally seem an unchanged body weight then your dose shouldn't really change and your blood specimens left that as well so I would only probably recommend once a year at most unless there's some big body weight changes throughout that time or if you're suspecting malabsorption because of you know some stomach problems anything when you what you're suspecting that you're really not absorbing the full dose okay so let's question here no no this is a question that's near and dear to my heart I sty do this a lot um I adore sis and by the way the the majority of iodine exposure really is through the diet unless you're taking it through medications that are prescribed so you can't get it from other sorts of ways it's not made naturally in our body so we're thinking about dietary sources iodine salt is by far the most stable and guaranteed route of getting iodine nutrition enough iodine nutrition in us and this is a worldwide phenomenon there's something called universal salt iodization efforts made globally to decrease the risk of hypothyroidism worldwide this has been going on for many many decades but other foods if you know for example that are iron rich or and this is a result of the natural just coastal and glacial patterns of the earth iodine is more commonly found in more coastal water areas so you can imagine seafood see products in general have props a little bit more iodine so fish shellfish etc but otherwise it's just been added to dairy and bread products so those industries are now fortified with a little bit of iodine as well but in varying amounts oh ok so and I'm not actually advocating that you take extra salt because of obviously the the concerns of high blood pressure in this country and worldwide we don't advocate for people to use extra salt but I do recommend if you are going to use any salt or cook with it or add table salt to your food if you're going to do that anyways then at least use iodized salt but it's not a prescription or something extra that I would recommend taking you know in addition to what you normally do well so I was trying to answer this question earlier help is probably too variable to give you an answer of how much iodine it contains and this you can imagine is because kelp naturally contains iodine right it's in the sea just like fish and all this or the other seafood so each batch each each plant each kelp stem or you know leaf has different amounts of iodine leave to leave to leave to leave that's been proven Oh supplements okay so ground-up kelp into a little tablet how much do you take I wouldn't recommend that at all unless it's only 150 micrograms as I was saying which is the US Food and Drug Administration the FDA recommendations for normal health a day but I guarantee you the supplements that are ground-up kelp it into the little tablets contain much more than 150 micrograms they're on the order of maybe 10 20 30 fold higher than that so probably a little bit dangerous okay I'm going to move on to hyperthyroidism and we can come back to some of these questions if they come up later as well so hyperthyroidism is the opposite end of the spectrum what happens when your body is making too much thyroid hormone so again that's too much thyroid hormone is made is the definition of hyperthyroidism and in contrast to hypothyroidism we again always start with a blood test called TSH thyroid stimulating hormone and in the sort of opposite scenario this time that TSH blood test will be too low okay to suggest that the thyroid hormones are too high what are some of the causes of hyperthyroidism it's also an autoimmune disease is the answer here so this time it's something called Graves disease which accounts for about 70% of all causes of hyperthyroidism and overactive thyroid gland this is just here in the United States sorry worldwide and it is overproduction of thyroid hormone by the entire thyroid plan so again here's a picture perhaps of what the thyroid gland looks like in the front of the neck this disease is an autoimmune disease in which those antibodies in the blood are attacking the entire thyroid gland to make extra thyroid hormone and in reference to this person's question previously just like any other autoimmune disease having Graves disease puts you at slightly increased risk for developing other you mean autoimmune diseases either in yourself or your immediate family members so examples are type 1 diabetes vitiligo celiac disease pretentious anemia rheumatoid arthritis a bunch of other autoimmune diseases other causes of hyperthyroidism you can actually have a situation of what we call toxic thyroid nodules these are also known as hots nodules or autonomous thyroid nodules and what it is is remember when I told you previously like Graves disease was stimulation of the entire thyroid gland to make the extra thyroid hormone this is a situation in which you have a one or more lumps for example this one here in the thyroid gland that it itself alone is making the extra thyroid hormone the surrounding area is normal and you can have more than one thyroid or one toxic or hot or autonomous thyroid nodule as well you can have multiple of them doing all the same thing and the treatments are a little bit different between Graves disease and these toxic thyroid nodules other causes sometimes the thyroid might be temporarily inflamed from a variety of reasons perhaps a virus or other things and so the amount of thyroid hormone that is already in the it leaks out as a result of this inflammation and you have a situation of temporarily high thyroid hormones in the blood right this is something called a thyroiditis this thyroid inflammation sometimes it could be permanent but most often times it is transient and it will self resolve now we talked a lot about iodine for hypothyroidism just like hypothyroid adjusting contrast to hypothyroidism having excess iodine exposure either through the diet or other methods might predispose and increase your risk of developing hyperthyroidism again it's a nutrient required for the thyroid hormone production so sources of excess or extra iodine might be cat scans or radiology procedures because in order for them to do the cat scan you know for other reasons for house you know a cat scan of the stomach or something they do need to inject dye usually in the bloodstream through the arm that dye happens to have a lot of iodine in it so that's just a needed procedure but it is one source of too much iodine and even if it happens once that can potentially give rise to some problems cardiac catheterizations are another type of seizure where when the dye that they use to do that cardiac catherization even a one-time exposure exposes the body to a lot of iodine at once and we talked a lot about kelp and iodine supplements the brands that are commercially available out there generally contain way too much iodine it's not that 150 micrograms a day that is recommended so in generally we consider them probably unsafe okay symptoms of hyperthyroidism it's as if the body has too much energy too much gas in the body so everything is in overdrive everything is happening too fast too rapidly so too much energy you might be anxious you might have a lot of weight loss because you're just running around too much fast heart rate you're feeling more warm than other people and same room lose stool diarrhea as possible' shakiness tremors you know people that sometimes I see with a fine tremor of their outstretched hands and trouble sleeping so these are just some of the common symptoms of hyperthyroidism okay we talked a little bit about Graves disease again it's the most common cause of hyperthyroidism is that autoimmune disease where the antibodies in the blood are attacking the thyroid gland to make the extra thyroid hormone specific to Graves disease there is some symptoms that we can potentially look out for pay more attention to the first is also an enlarged thyroid something called a goiter and this is because the thyroid is making excess thyroid hormone there's a lot of action going on right here in the neck temporarily while the thigh pro thyroidism is not treated under untreated yet you can have thyroid enlargement like this or even in milder forms secondly those same antibodies are floating around in your blood attacking the thyroid gland to make the Graves disease can also attack the back of the eye interestingly so just in this form of hyperthyroidism Graves disease some folks might have thyroid eye disease and this can be manifest I think I'll show you a couple more examples next slide is that folks might have some itchiness of the eye irritation redness bulging of the eyes there just appear bigger than perhaps when you didn't have the grave disease tearing people often talk about this feeling of grittiness in the eye like there's sand that you just can't give out that feeling in the eyes those are examples and then just like other autoimmune diseases there could be other autoimmune disease it's either in yourself or the family member okay this is a little bit about Graves eye disease just in a little bit more detail it is only specific to this form of hyperthyroidism and these are some of the symptoms I loo did - previously the Bulge the itchiness etc these are some examples of photos of more extreme cases of grapes eye disease interestingly if you have this it is worse than made worse by cigarette smoking so in folks that I do see with graves eye disease I try to counsel them to at least stop or decrease smoking significantly to make the eye disease better and in severe cases or even in more milder forms I would probably recommend referral and I work directly with a few folks at UCLA in the jule styne eye institute who'd specialize specifically in thyroid eye disease and it can be treated in various ways okay what are the risks if we keep hyperthyroidism untreated what is the risk of having too much thyroid hormone I think I talked about this previously when we were talking about levothyroxine and synthroid but when a person has too much excess that were at home when in their body there's almost you know a situation of too much gas your your body is revved up and specifically it would potentially have bad effects in the heart it makes the heart go faster stresses it out more as well as it depletes the bone because the thyroid hormone wants to suck out the calcium from the bone making it weak over time potentially this can happen more acutely in the short term or over the long term depending on how long the extra thyroid hormone has been around and so these are just some examples of irregular heart rhythms and that osteoporosis weak bones which might occur as a result of hyperthyroidism that's untreated okay so how do we diagnose we always again begin with a serum TSH a siren stimulating hormone blood test if that is abnormal then your physician might confirm with measurement of the actual thyroid hormones themselves of the t3 and the t4 everything is by blood tests and in some instances in contrast to hypothyroidism for hyperthyroidism we actually might pursue some image and this can be either by an ultrasound which is a little movie of the thyroid gland on the outside or a nuclear scan that I'll show a little greater detail in the next few slides so TSH is the first test again but know that there are some caveats if if your physician tests you for that TSH and it is low suggestive of some sort of hyperthyroidism excess thyroid hormone just know that there could be other things that actually lower the TSH that is not hyperthyroidism so sort of important to do a little bit more investigative work in the situation so recent illness if you had a big cold or virus or some sort of acute illness that can temporarily lower your TSH blood tests which would resolve when the cold is over or certain medications specifically prednisone hydrocortisone all these are steroids which are very common for inflammation or asthma or arthritis your person might be on prednisone for a long time and that can temporarily decrease the TSH blood tests as well without having this type of hyperthyroidism as but that's a real problem so we would probably recommend conformation with those t3 and t4 actual blood tests to figure out a little bit more what the scenario might be about and then just like Hashimoto's for hypothyroidism for this hyperthyroidism when the an autoimmune phenomenon is suggested like Graves disease we can also check those same antibodies so we not only check in this scenario the TPU thyroid peroxidase antibodies but specifically for Graves disease we can to check before those antibodies are directly attacking the thyroid gland and those are called TS eyes or thyroid stimulating immunoglobulins and this is a picture this is an example of that first type of picture I was talking about the thyroid ultrasound we might do this as a way just to see what is going on you know we talked about Graves disease as the entire thyroid gland being stimulated to make excess thyroid hormone sometimes there's a little lump a thyroid nodule that toxic thyroid nodule death making of the thyroid hormones we'd like to structurally see if that little moment potentially was there so this is one way to do it very quickly non-invasively painlessly it is just a little probe but just like this person has on the left side taking a little movie on the outside of the neck we do it just at the same time in our office at UCLA and this is an example of what that picture shows here is a very normal thyroid gland this is the right side of it the little bridge and then extending here into the left side so give us a lot of information very very quickly and sometimes when piecing together the blood tests and the thyroid ultrasound we still can't figure out what is the reason for the hyperthyroidism your physician might recommend something called a thyroid nuclear skin in or uptake what this is it's a separate test done by appointment in usually a radiology department the person takes a small tracer radioactive iodine pill comes back for and 24 hours later after taking the pill and this technologist here has the person sit here and is able to take another picture from the outside to see how much of that radioactive iodine is incorporated into the thyroid gland and what sort of pattern so it's also very very helpful tests sometimes in the setting of hyperthyroidism the treatment okay so now oh yes question so this is just that excuse me this is just the radio radioactive iodine test just just for the just for this then I've taken scan for diagnosis is that correct yes it's very very small so for this test itself it's on the order of one or two or three million Curie's of radioactive iodine it's essentially called a tracer dose because it's very small it goes right in and it comes out in the next one or two days the treatment the what testified the dye oh it's a different sort of dye it's not the same guy as an MRI or a cat scan this is just for the thyroid oh well for an MRI or cat scan they the person wouldn't be taking a radioactive iodine pill it's a different dye altogether is what I'm trying to say for a cat scan or an MRI this rate of divide I'm pill even it's different altogether it's it's a different substance yes question yes very good question is there any danger or side effects or symptoms from taking this test this diagnostic test the answer is no unless you are pregnant or breastfeeding because we don't want to expose the baby to even any small small doses of radiation in that setting but for the normal person taking this test taking that radiation pill it will go out of your body in the next one or two days or even a few hours and it is really beneficial in order to see what's going on in the body so we generally do recommend it when we can't figure it out from the complication the blood tests and the ultrasound without any real harm long-term harm okay let's move on to treatment so in this setting we have excess thyroid hormone but there's three options to remove that excess thyroid hormone first we can give you medications to actually slow down the thyroid to actually have the thyroid itself emit less thyroid hormone second would be surgery we can actually remove directly by resection the entire thyroid gland get rid of the whole problem immediately or radioactive iodine we talked a little bit about radioactive iodine for the scan this is a much larger dose in which the radiation is permanently able to get rid of the thyroid gland so it's a different order of dosage altogether okay so let's go through each of these the pills first so medications the effect is really just to slow down thyroid hormone production examples of these medications here in the United States is myth simha's all brand name is tatis all or purple Thyer your açelya it is often commonly abbreviated PTU and we sometimes see remission in folks that take these medications remission is defined as the ability for the thyroid to not require any more treatment because the set point of too much thyroid hormone is now normalized back to reference levels so that's achievable with medications about 20 to 30 and over one or two years it does usually take one or two years for potential treatments to be realized and that is the maximum amount of time that we would probably recommend mytha missile or puerperal failure or so because there's some associated side effects with these medications those include rash the rash is usually not dangerous not life-threatening but in more severe forms it would prevent the person from continuing to take the medication we'd have to think about one of these other treatment forms also there could be liver damage this is usually more rare and mild and it really outweighs the cost of unless it's very very severe of these treatments there could be a scenario of low white blood cell count this is very very rare with these medications but when it happens and this is defined as a weakened immune system no white blood cells is prevents you from having an intact immune system it's on the order about 0.4% of people who take these medications but you can imagine that this is a potentially very very serious side effects and so whenever I prescribe these medications I tell patients if you suspect that you have a low white blood cell count by having a really high fever or the worst sore throat of your life stop the medication and call me immediately so that I can actually measure the white blood cell count for you again very very rare but because it does potentially happen we don't advise patients to take this more than 18 to 24 months before now considering to considering another type of therapy so what might that be we can also consider something called reactive iodine as we talked about before it is a radiation pill something called i-131 and it's job is to destroy thyroid cells potentially just the overactive cells but also normal thyroid cells as well slowly over the course of taking and after you know several months or so six seven eight nine months sometimes each even is possible it is a single pill that you would take it looks like this here you wouldn't have to usually require weekly treatment unless the dose is not enough which would be very rare because it is radiation and you know everyone has some concerns of what radiation might do there are some safety precautions that are recommended sort of in the first few days even up to a week following the ingestion of this radioactive iodine pill most of the radiation is immediately eliminated through the body through the bodily fluids so the sweat the saliva the tears the urine etc so all of it oh not only most of it is rapidly eliminated and the remaining amounts are then just sitting in the thyroid for several months to get rid of that excess thyroid hormone but because it is excreted through a lot of these bodily fluids we we do want to limit exposure to you know folks that might be living with you especially pregnant women or little children and who's the thyroids might be still developing we want to limit exposure to those folks for at least a few days or even weeks potential long-term side effects so if the treatment gives is it's sort of too strong and too much of even normal thyroid tissue is destroyed you can imagine then you will end up in a situation of what we talked about initially the underactive or hypothyroidism and that can be permanent in some cases and may require thyroid hormone replacement just like in those initial scenarios and then some folks often are concerned about the effect of radiation on developing other cancers the chance of this is quite small especially in doses that we would use to treat hyperthyroidism they're much smaller than thyroid cancer doses and so that generally this is not thought to be a large issue but in general if one was really interested there is a perhaps a slightly increased chance of developing a second cancer from the radiation not a second cancer cancer from the radiation and the most common one if we had to pick one would be something like a blood cancer a leukemia very very rare for that to happen and then thirdly the third mechanism is thyroid surgery we can actually get rid of the thyroid by resection to get rid of the source of the extra thyroid hormone we can consider this if a person is maybe allergic or can't take the medications for some reason or they just don't prefer that radioactive iodine treatment route it's best performed by a surgeon with a high volume of experience and a center that does that frequently at UCLA we do I work with plenty of wonderful thyroid surgeons who do this very very often but there is potential damage to the parathyroid glands which are not related to the thyroid at all they just happen to have a little bit of the same name but the parathyroid glands are for little glands - on the right side and two on the left side and they control the way our body uses calcium so if one of or more of the parathyroid glands might be temporarily irritated because the surgery got too close to it or accidentally removed then your body might have a hard time controlling calcium for the rest of your life potentially sometimes it is temporarily and also the vocal cords are sort of in that area right next to the thyroid gland so that thyroid surgery if it gets too close to those vocal cords also might impair voice giving you hoarseness that might be temporarily there or permanent but these complications done in a very high volume good center should be really less than 1% of all the thyroid surgeries so done very very safely um question Oh how has surgery done no no surgery is literally surgery surgery is using a make an incision with a knife usually about one or one and a half inches right at the area of a siren so in the front part of the neck and out comes the thyroid gland it's the surgery that takes about an hour or two with it usually associate with an overnight stay but no no lasers it's a true surgery so it's less risky if the hyperthyroidism the excess thyroid hormone is somehow controlled in a way before going into the operating room because we don't want the body to be stressed with this extra thyroid hormone so generally I do try to give you a little bit of that anti-thyroid of medication the methimazole or the pro profile yourself before surgery even if surgery is their route that we decide to take to calm the body down and because you will have no if I were gland remaining after it's taken out you will most definitely have permanent hypothyroidism the need to replace what thyroid hormone for the rest of your life okay okay and then so we talked about three different treatments for hyperthyroidism the medications the radioactive iodine and the thyroid surgery what type of treatment sort of depends really on a discussion between you and your endocrinologist and it might depend on several factors things like your age the cause of the hyperthyroidism itself the severity of the disease other medical conditions which might be at play and then perhaps your personal preference and then so you should really discuss the pros and cons of each of these treatments with your endocrinologist just by way of interesting fact hyperthyroidism or excess thyroid hormone is the most common endocrine and thyroid condition in cats so if you have any kitties who are taking with them as all not uncommon I thought I'd just throw that two-bit in there okay so any questions about Cooper thyroid them before we move on to thyroid nodules yes yes okay so what what the question is what if you have mild or borderline hyperthyroidism is that the scenario oh so all the symptoms and are the blood tests confirmatory that are the blood tests showing oh okay so for both hypo and hyper thyroidism the blood test really has to match your symptoms the symptoms can be from so many other things besides thyroid disease so the symptoms are a clue that you might have thyroid dysfunction you really do have to confirm with the blood test to show that it is the reason for the symptoms so if you have a lot of symptoms they could be from something else altogether before getting sick what is there so I'm if I'm understanding correctly you're developing more more symptoms suggestive hyperthyroidism a oh the blood tests are getting worse I see I see so irrespective of the symptoms what if the blood tests are trending toward hyperthyroidism so this would be have to be an individual discussion with you and your physician it sort of depends on your overall health and other conditions in which you want to actually prevent the setting of true hyperthyroidism so perhaps you might treat earlier than waiting until that point because of perhaps stress to your heart or your bones that you want to avoid yeah it would be an individual discussion with your with your physician let's talk now very differently on a different topic about thyroid nodules we're not going to talk about thyroid hormones anymore so a thyroid nodule happen is defined as a lump in the thyroid gland and it's perhaps shown here you can perhaps feel it either in you or your physician can palpate it if it is large enough the thyroid function is usually normal in this situation so unlike the previous scenarios of an underactive or an overactive thyroid gland this is usually just a little lump that sitting in there and not doing anything to the production of the thyroid hormones it just happens to be literally a mass a little ball sitting in the thyroid gland very rarely you can have a situation remember how I talked about toxic thyroid nodules or hot nodules or autonomous thyroid nodules that little lump can be making excess thyroid hormone as one scenario but usually it's not doing anything usually it's just sitting there not making extra thyroid hormone and it's definitely not making the thyroid under act okay so the best test to see this little lump this little thyroid nodule is usually a thyroid ultrasound that same test that we looked at previously for hyperthyroidism again it's non-invasive there's no radiation involved this is frequently done here exactly at the same time you come in and do it exactly in the same office visit even this is a picture of what a thyroid ultrasound machine looks like and again it's just a little movie taking a picture of a thyroid from the outside okay by Royd nodules if that nozzle or that lump becomes large enough or is large enough to warrant some sort of suspicion for thyroid cancer then we would probably recommend putting the little needle into that lump or nodule to confirm if it is or is not thyroid cancer so that's called a thyroid nodule biopsy and if the biopsy comes back the results show that is or at least is even suggestive of thyroid cancer then thyroid surgery is recommended question it depends on the endocrinologist you go to search and endocrinologists do the biopsy right then in their office along with the ultrasound at the same time and I'm one of those folks here at the endocrine Center at UCLA everything is all one-stop shopping so one visit will help hopefully take care of everything but in some offices it might be referred to a radiologist which would be a separate appointment probably on a different day okay also if the biopsy results come back even not cancer totally normal meaning it's a benign non cancerous lump in the thyroid if the lump or thyroid nodule is big enough surgery still might be recommended because it could be interfering by its physical presence with your swallowing or breathing you're talking other sorts of things that might be there and if it is small enough we biopsy it and it's not a cancer we would just follow it with an ultrasound every so often probably every year or two to make sure that its size has stayed the same okay so this is what a biopsy is just in a little greater detail we usually recommend biopsies or putting a little needle into the thyroid nodule when it is reaching a size of at least one or one and a half centimeters sort of like a little small mini grape or so depending on the level of suspicion from the picture itself we can also use the picture to see how suspicious it is it's not just the pure size we are measuring but we can look at its color blood flow the presence of some calcium deposits in the thyroid nodule that would maybe increase our level of suspicion a little bit more a biopsy is not recommended for nodules or lumps that are purely cystic or fluid-filled because you can imagine there's no cells in such a structure and the risk of cancer is essentially zero it's literally just a little water balloon a lump that's sitting in your neck so for these sort of structure no matter what size generally we don't recommend a biopsy for those and more recently in the past few years when we do the biopsy itself we send it to the pathologist for them to look at the cells underneath the microscope we can also now offer in some centers molecular marker testing so this is using the same biopsy sample that you use that you extracted with the needles itself and send it for genetic testing to see if there's some sort of mutation genetically that would suggest that your thyroid cancer risk in that nodule might be a little bit higher or lower if that result comes back in the middle indeterminate you can't really say if it's cancerous or benign non cancerous so in those borderline results molecular marker testing is offered and perhaps beneficial okay and if you have more than one thyroid nodule multiple thyroid nodules they should really receive the same evaluation as if you had a single solitary thyroid nodule so for example in this picture a person has two separate lumps or thyroid nodules you should be evaluated separately for its separate chance of thyroid cancer okay all right and by the way I don't know if I'll address this later I forget but in any single nodule their risk of thyroid cancer is quite low the majority of these are benign and not cancerous only about 10% or even up to 15% at most is an underlying thyroid cancer so I just want to reassure everyone because very common to have thyroid nodules but the majority of them are not cancerous okay okay so those took a live outside word cancer specifically it is the most common cancer within endocrinology there's different sort of subtypes classifications of what the thyroid cancer can be the most common by far making up about 80 85 % of all thyroid cancers is something called papillary thyroid cancer risk factors for all sorts of thyroid cancer might include women in general a history of radiation directly to the head or neck region perhaps while you were growing up or as a result of other procedures that you might have had in adolescence or young life so in this country there used to be some radiation procedures done in sort of the older folks the older generation we don't do this anymore for tonsils or for acne we haven't done this in this country for many many decades so I would be very surprised if someone had that done even even as a history of that probably in the 50s or the 40s 1950s and 40s and also if there's a family history of thyroid cancer there are some types of thyroid cancer that travel a little bit more frequently and certain families but the majority of actually thyroid cancer is not inherited question a CT scan or like an MRI or one of those radiology procedures do they confer much radiation you know we think that a single study you like that a cat scan is probably not gonna confer enough radiation to result in a thyroid cancer problem but the risk is always there because it is some radiation right but at the doses I'm talking about our direct radiation to the thyroid in dedicated and perhaps frequently repeated doses over the course of perhaps another treatment for something else so in general rady radiologic procedures do not confer much risk if done only once or twice okay so diagnosis of thyroid cancer this is initially found usually as a thyroid nodule that lump or bump within the thyroid gland either by palpation because your doctor felt it or you felt it or because you had a cat scan or other imaging that happened to look at the thyroid and we see a little bump in there so the thyroid nodule it biopsy is performed again for bumps or lumps that are fairly large no one or one and a half centimeters but only again less than probably one in ten or at most 15 percent of those will be an underlying thyroid cancer and then the thyroid cancer is confirmed by aspiration removal of a part of that thyroid nodule the cells are sent down through pathology and the confirmed by those results and then off you go for referral for thyroid surgery removal of the entire thyroid gland yes question oh I heard transplants no we don't have that currently unfortunately in this is the current era of Medicine yet all we can do is replace the thyroid normal levels with the medications that we talked about for hypothyroidism but once the thyroid is removed it is removed okay thank you for the question so um treatment for for thyroid cancer first step is that thyroid surgery using a you know real surgery making an incision in small cancers it would be at most one or one and a half inches of a scar that is well healed if done in a very good center by very experienced surgeon followed by perhaps consideration of radioactive iodine so the thought of radioactive iodine is that even in the best hands of the best surgeon in the entire world there's going to be probably small microscopic amounts of thyroid cells remaining in your neck that we just can't see they're very very small they're microscopic and those cells can be normal thyroid tissue but they could also be part of that siren cancer that was removed so for that reason radioactive iodine might be considered in folks with more advanced I read cancer in which we want to give radiation and zap away any even microscopic amounts that might be remaining because there in cancer can recur even up to twenty thirty years later we want to sort of fix everything at the outset and then for advanced cancers perhaps more metastatic disease and which cancer has spread throughout the body siren surgery and radioactive iodine might have limited use and so very rarely for these advanced cancers we refer to an oncologist for chemotherapy that's usually not done unless the situation is very very advanced and then how do we monitor you it's done in combination with the endocrine surgery and the endocrinologist but I usually like to see people at least once or twice a year after thyroid cancer after their surgery and perhaps even after the radioactive iodine we look at a combination of blood tests because we can actually test for that thyroid protein through a very simple blood test and or a combination of neck imaging to see structurally if anything has recurred thyroid surgery is just in answer to this previous question it is performed under general anesthesia usually requires one overnight stay best performed by a surgeon with a lot of experience and at a center with high volume remember the the potential side effects that it can occur with thyroid surgery so that's potential damage to the parathyroid glands the fourth on the two on the right two on the left that are controlling the way our body utilizes calcium not related to the thyroid gland at all except it has some similarity in its name and or the vocal cords which are also in the area of the thyroid so irritation of the temperature of the vocal cords might give you temporary hoarseness again the major complication should occur in a good center with a good surgeon less than 1% of the time and again permanent hypothyroidism will require lifelong thyroid hormone replacement okay this is again just a reminder of radioactive iodine treatment for thyroid cancer we already talked about this for the treatment of Graves disease so I'm not going to talk about a great detail but as a reminder it can it it should be considered also in patients with a history of thyroid cancer as well - that the way those remaining thyroid cancer cells that might be there microscopically the prognosis of thyroid cancer is usually quite good if it's found early and in lower stages so this is pertains to people who might be young and we define thyroid cancer staging for you know types of age as less than 45 years old usually gives you stage one if it's confined to the thyroid patients with small cancers to begin with which are more usually more completely resected and removed by the thyroid surgery papillary thyroid cancers of all the thyroid cancer subtypes are probably the ones that are the ones that confer the best prognosis because they tend to be confined to the thyroid gland itself and not spread and then in fact the patients with low stage disease stage one disease have a hundred percent survival at ten years so really in the in a good center that's treating all the aspects of thyroid cancer well it really should to have no impact on your life and mortality okay so in summary I tried to really go over in brief what hypothyroidism is and it's under active thyroid requires seven hormone replacement probably for the rest of your life hyperthyroidism is an overactive thyroid gland the most common cause is Graves disease an autoimmune disease and some folks might have thyroid eye disease from the Graves disease so that excess thyroid hormone should be treated to be removed and take away the stress from your heart in your bones siren nodules are lumps physically in the thyroid usually with no effect on thyroid hormone production and the majority of them are benign not cancerous but if thyroid cancer happens to be found in the little thyroid lump the nodule treatment of surgery and possibly radioactive iodine as a follow-up are recommended so I hope I've gone through the entire spectrum of what thyroid disease is that both our dysfunction as well as thyroid lumps in cancer I'm happy to take any questions and thank you very much I have a few cars I'm happy to provide and I can give you that the via this so I'm glad I'm glad it was this is why we come to a setting like this because we're not rushed in clinic okay question in the back okay yeah the type of surgeon that does siren surgeries there are many general surgeons do do thyroid surgery if it's but you know I work at the UCLA under conductor and in the same office our dedicated endocrine surgeons so the only type of surgery they do are for endocrine diseases mostly the thyroid and parathyroid so you know generally it is recommended to go to a center and to a person with a lot of experience and that might be defined as an endocrine surgeon also physicians that are years knows doctors or otolaryngologists also do pirate surgery so depending on where you are in this mmunity and where which position you are working with your endocrinologist they might refer you to different folks oh good question so the question is if we have a suspicious or even a proven siren cancer by biopsy removal some of the cells of that nodule and you know a thyroid surgery is recommended how much of the thyroid is usually resected or removed it depends really everything depends on the size of that thyroid nodule and also if we notice that it might have spread to surrounding lymph nodes in the area because usually that's the first root of spread it surrounds it goes into the surrounding tissues that fat the muscles you know etc but then it goes outside of the thyroid into the lymph nodes of the body lymph nodes are very common we always know our leftovers are good they help us by infection but those are the also though the structures in which thyroid cancer might go first so depending if we see in a large lymph node and we biopsy even the limb no we prove that it's spread outside to the lymph node then it's more of a more extensive surgery so only in the setting of no lymph node involvement and the thyroid cancer is very very small confined to one side without any other nodules all over the thyroid gland might a thyroid surgeon consider only taking half of the thyroid gland but it makes it really difficult to monitor for recurrence because we are unable to then use the thyroid blood test to figure out if the thyroid cancer came back because you do have a little bit of normal thyroid tissue remaining so that blood test is irrelevant and so we can only rely on a very good and careful ultrasound to see if it has come back that might miss me I'm having difficulty swallowing sometimes not all the time yes trouble swallowing that was one of the symptoms of a thyroid nodule if it becomes big enough it can interfere with three being talking swallowing talking etc so it's not a bad idea to go get it palpated or at least ultrasound it even to see if there is the structure there that's in the way question here well well so we're talking about is under active thyroid or hypothyroidism becoming increasingly common I think perhaps not I think we're getting better at diagnosing it or pay more attention to it but if you look at the trends of an overactive thyroid gland it still has remained probably less than 5% of the general population for now even old studies and they're the same rates under active thyroid gland yeah less than 5% depending on the series so you know the big there's a big study a couple decades ago Colorado at a health fair that percent I believe was about four four point something percent and that figure has generally remained the same so probably paying more attention to it the causes of hypothyroidism yes um a good question what if you don't have one of the listed causes of an underactive thyroid gland and that could be very very very true and common and we just call that that's and we just call that sort of in the other category so it's just called regular hypothyroidism in sometimes we can't find a reason but the treatment is still the same yeah that's actually quite common as well question for us suspicious large - spontaneous oh do not all sizes decrease over time usually not unless there are those types that are fluid filled completely so like a little water balloon the assistant that I was talking about because you can imagine the water moves in and out of the thyroid cyst but for solid structures they generally either stay the same or they can grow and that's why we monitor you with the thyroid ultrasound every so often you know probably once a year to make sure that that size has at least stayed the same yeah okay I think we're out of time thank you so much for everyone's attention

Channel: UCLA Health

Views: 117,325

Keywords: thyroid, hypothyroidism, hyperthyroidism, thyroid nodules, thyroid cancer, angela leung md, ucla health, ucla endocrinology

Id: RxlazJyQPjM

Length: 81min 49sec (4909 seconds)

Published: Thu Jun 23 2016