All things thyroid; a discussion on thyroid heath with Dr. Paul Sack

Unlock the mysteries of thyroid health with our special guest, Dr. Paul Sack from MedStar Union Memorial Hospital in Baltimore. Ever wondered how a tiny gland in your neck can orchestrate the harmony of your body's systems? Dr. Sack reveals the critical role of the thyroid gland, its impact on overall health, and the complexities of diagnosing conditions like hyperthyroidism, hypothyroidism, Graves' disease, thyroid nodules, and thyroid cancer. Through our conversation, gain a deeper understanding of how these conditions can mimic other health issues and the vital role endocrinologists play in managing them.

Thyroid nodules and thyroid cancer can be puzzling topics, but Dr. Sack breaks them down clearly. Discover how ultrasounds are pivotal in evaluating thyroid abnormalities and why size isn't always indicative of function. Delve into the reasons behind thyroid enlargement and the challenges in determining which nodules require further investigation. We also discuss the relatively low risk of thyroid cancer turning life-threatening and the circumstances under which surgical intervention becomes necessary. This episode is filled with insights into potential genetic, environmental, and random factors that contribute to thyroid nodule formation.

Graves' disease, an autoimmune condition leading to hyperthyroidism, is another key topic. Dr. Sack explains its effects on the body, including the link to thyroid eye disease and the exacerbating role of smoking. We explore treatment options like medication, radioactive iodine, and surgery. Hear about the intriguing relationship between thyroid dysfunction and diabetes, especially type 1 diabetes, and the importance of regular screening. The conversation wraps up with practical advice on diet, medication management, and lifestyle choices to support thyroid health. Tune in for expert advice and actionable tips to navigate thyroid-related health concerns.

For more episodes of MedStar Health DocTalk, go to medstarhealth.org/doctalk.

Transcript

Debra Schindler: 0:05

Comprehensive, relevant and insightful conversations about health and medicine happen here on MedStar Health DocTalk. I once heard a doctor say that the endocrine system is like an orchestra when it's functioning well and it's in sync, the result is beautiful music. When it's functioning well and it's in sync, the result is beautiful music. But the health of a tiny butterfly-shaped gland known as the thyroid can throw the entire endocrine system out of whack and all the instruments in the orchestra are playing out of sync. That could equate to a litany of health issues. Today we are talking about possible conditions that affect the thyroid gland, including hyper and hypothyroidism, graves' disease, thyroid nodules and thyroid cancer and the connection to diabetes. Endocrinologist Dr Paul Sack is here with us at MedStar Union Memorial Hospital in Baltimore to learn more about the symptoms, how these conditions are diagnosed and treatment options. I'm your host, debra Schindler. Dr Sack, thanks for being here today.

Dr. Paul Sack: 1:09

Thanks for having me.

Debra Schindler: 1:10

The thyroid seems to be one of those anatomy parts that we tend to forget about. What exactly is the thyroid? What does it do?

Dr. Paul Sack: 1:18

So the thyroid is kind of the thermostat for the body. When things aren't running well, we don't really notice it. When the thyroid't running well, we don't really notice it. When the thyroid is not working so well, we definitely notice it. And so, in general, we think about the thyroid as when it's dysfunctional, either underactive or overactive. When you're overactive, everything revs up, and when you're underactive, everything slows down.

Debra Schindler: 1:42

So I mentioned the doctor and the orchestra. What do you think he meant by that? When it's out of sync, when it's not functioning well, that it's out of whack. What does he mean by that?

Dr. Paul Sack: 1:53

The thyroid hormone is actually one of the ways that all of our cells of the body kind of function. It promotes certain proteins for being made and kind of helps our metabolism. And so it's not one thing that the thyroid affects. The thyroid actually affects every cell of our body. So, again, if the thyroid's overactive, then everything is revved up and so you'll feel hot and sweaty and jittery and anxious and your bowels will change, women's menstrual cycles will change, mood will change. It just affects everything. And the opposite occurs when you're underactive, again because the thyroid hormone that's made by the thyroid is acting on every cell of the body.

Debra Schindler: 2:35

It sounds like some of those symptoms would be easily dismissed as something else that we wouldn't automatically think about our thyroid something else that we wouldn't automatically think about our thyroid.

Dr. Paul Sack: 2:47

That's one of the difficulties in diagnosing thyroid disease is that when somebody's thyroid numbers are a little bit off and they feel terrible, it may not be the thyroid. And vice versa. When someone feels terrible and no one remembers to check the thyroid function, we may miss it and think it's something else. So it's a mimicker of other conditions. For example, one of the main symptoms of underactive thyroid is weight gain and depression. Well, unfortunately there are a lot of reasons to have weight gain and depression and not all of them are thyroid. So again, there's a lot of back and forth routine trying to figure out what is thyroid and what isn't.

Debra Schindler: 3:17

And how would they then know to come to you as an endocrinologist? What is an endocrinologist, by the way?

Dr. Paul Sack: 3:23

The endocrinologist is somebody who manages the different hormone systems of the body, so typically in my average day it's treating a lot of patients with diabetes, but a significant portion also with thyroid disorders, disorders of the pituitary gland, adrenal gland and other kind of random things that happen with our hormone system.

Debra Schindler: 3:47

Okay, so I'm going to go through a list of some thyroid conditions and just get your maybe a little explanation on each. What is hyperthyroidism?

Dr. Paul Sack: 3:54

So hyperthyroidism is when there is too much thyroid hormone in the body. Those hormones that the thyroid makes are called T4 and T3. And when there's too much of those hormones it really revs up the system. There's a few reasons for that. Graves' disease is one, but you can also have just parts of the thyroid thyroid nodules that are overactive, and there's some other random ones. Someone can take too much thyroid hormone. There's a couple of rare cases of hamburger thyrotoxicosis, which is when butchers aren't very careful and add the thyroid into the hamburger meat and that can cause hyperthyroidism, although that doesn't happen very often. Wow.

Debra Schindler: 4:36

How would they do that?

Dr. Paul Sack: 4:37

Not careful, but thyroid from cow and pig is actually how some of the original thyroid replacement medications were made, before there was synthetic thyroid hormone to be given as a pill.

Debra Schindler: 4:50

Hypothyroidism.

Dr. Paul Sack: 4:52

Yeah, so hypothyroidism, you know, is the opposite. It's where the thyroid is not functioning well, and there's a couple of reasons for that. Typically, it's the immune system that's destroying the thyroid, but sometimes we send patients to surgery so we cause the hypothyroidism. But you need a normal amount of thyroid hormone, and so when you don't have enough, we give it to you. There are a couple of different medicines that we can give, but generally we give a synthetic version of the natural hormone called T4.

Debra Schindler: 5:19

And why would someone not have enough? I mean, is it an age thing, is it menopause, and can it affect men as well?

Dr. Paul Sack: 5:26

Sure. So the main cause of hypothyroidism is Hashimoto's thyroiditis. So the word thyroiditis means inflammation of the thyroid. So you know you have appendicitis and tonsillitis. Itis just means inflammation, so thyroiditis means inflammation of the thyroid. The person who first described it was a doctor in Japan, dr Hashimoto, which is why it's called Hashimoto's thyroiditis. So that's where the immune system attacks and destroys the thyroid to varying degrees. So some people it's mild, other people their entire thyroid does not function and so that can increase over time as we age. And it is way more common in women than men for genetic reasons, although we don't have a specific gene and there are families where it's much more common. So it's not quite predictable. But if you have a few family members already with it, then you should be more concerned.

Debra Schindler: 6:19

And what happens if they have that? They gain weight. I mean, what are the health repercussions?

Dr. Paul Sack: 6:26

Sure. So let's define Hashimoto's first, and then we can talk about that. There are antibodies, that is, markers that the immune system is attacking something, and so lots of different autoimmune diseases. You can measure something in the blood that says, okay, there are, the immune system is attacking something in the blood that says, okay, there are, the immune system is attacking something. And so for Hashimoto's thyroid disease, that would be the antibodies against thyroid peroxidase. Some people just see on their lab reports TPO antibodies. So when those are elevated we consider that an autoimmune reaction against the thyroid.

Dr. Paul Sack: 7:00

However, you don't get symptoms because you have elevated antibodies. You get symptoms because you don't make enough of those hormones the T3 and the T4. So again, varying degrees of hypothyroidism will then determine your symptoms. So if you make zero thyroid hormone, if your T4 and T3 are zero, you're going to feel fairly miserable and it can occasionally be a life-threatening event, can occasionally be a life-threatening event. The other hormone that we check in the body is called TSH, which stands for thyroid stimulating hormone, and that's the signal from the brain to the thyroid. And this is really important to understand because patients frequently don't understand their blood test results. The TSH is what the brain perceives. So if you're not making enough thyroid hormone because, let's say, you have Hashimoto's thyroiditis, the TSH will go up. The brain is trying to tell the thyroid hey, let's do more. Vice versa, if you have too much thyroid hormone in your system, the TSH will go down because it's trying to tell the thyroid to do less.

Dr. Paul Sack: 7:58

So in somebody who has symptoms this typically goes. Their TSH is high from Hashimoto's. So a normal TSH, let's say, is about 0.5 to about 4, although that varies in different populations, genders and even ethnicities. If the TSH is above 6 or 7, some people may have some mild symptoms. But we have patients coming in with TSHs of 100 who don't feel bad at all, probably because they're so used to feeling so rotten. So it's really variable.

Dr. Paul Sack: 8:27

What's really challenging for us as endocrinologists is when somebody has a very mildly elevated TSH but feels miserable, they're cold and they're tired and they're depressed and they're gaining weight. And the question is is that because of the thyroid? And it's challenging. It's a nice answer because taking a pill once a day is a much easier answer than trying to deal with everything else that may be causing those symptoms. So certainly we treat people for that, but I always like to be mindful to tell patients. You know, because these symptoms are so broad and nebulous, we're going to treat this thing and we're going to follow your numbers and we're going to try to get this better, but that may not be the cause of all of the symptoms. Wow, that would be distressing for a patient, I imagine. Yeah, I mean, there are a lot of reasons again why people feel tired and gain weight and you know, there's certain things like nutrition and sleep and exercise and stress management that are independent of, you know, the hormones.

Debra Schindler: 9:22

How would you level them off with medication or change of diet?

Dr. Paul Sack: 9:26

So not in this country, but there are many countries where people are hypothyroid, underactive with their thyroid, because of iodine deficiency. We solved that problem many years ago I want to say probably a hundred years ago by adding iodine to salt. And so the reason why you see iodinized salt is really for your thyroid. There's no other reason for iodine to salt and so the reason why you see iodinized salt is really for your thyroid. There's no other reason for iodine in the body. So it's really hard to be iodine deficient. In the United States it's also in our soil and especially when you live closer to the ocean it's in the soil. So if you eat fresh fruits and vegetables it's really hard to become iodine deficient. But if you're in a landlocked country that doesn't get a lot of imported food or especially salt, in those countries and I'm thinking about places like middle of South America, afghanistan, those kinds of places that are kind of isolated you'll see a lot of people with larger thyroids and underactive thyroid, and if you just give them iodine it solves all of that.

Debra Schindler: 10:23

Which brings us to goiter. Yeah, explain that.

Dr. Paul Sack: 10:26

So goiter is just a fancy term for big thyroid.

Dr. Paul Sack: 10:30

It doesn't tell us what it's from, it just means the thyroid's big and the thyroid can be big because of iodine deficiency, although, again, in this country that's not usually the case.

Dr. Paul Sack: 10:40

The thyroid sometimes is big because everyone has a slightly different kind of size thyroid, or the thyroid could be big because there are a lot of thyroid nodules that are kind of enlarging the size of the thyroid and sometimes when the nodules get so big you can visibly see it from across the room. Most patients with thyroid nodules it's not that way. But again, we all kind of know somebody who has a very large neck and you're trying to look and see is that thyroid? Sometimes it's just extra layers of fat as well, and so we have to then figure out, well, if there is a large thyroid, at least on exam. What do we do? Well, we take a picture, and the best picture of the thyroid is the ultrasound. Most people think CT, mri, those are the fancy ones, but actually the ultrasound it's quick, it's cheap and it gives us the best definition of the borders of the normal thyroid, if there is abnormal thyroid, to look at that and then decide if this what we call goiter is something that is clinically worrisome, or not.

Debra Schindler: 11:40

I can't honestly say that I've ever looked at someone with a fat neck and considered that they had a thyroid issue. So now I'll be looking at them differently.

Dr. Paul Sack: 11:49

There are some cases of people on TV getting diagnosed with thyroid cancer from somebody watching TV. I think there's one case of a newscaster. There's also the Seinfeld episode where they never show the aunt I think with a goiter but they refer to her frequently, so some of our listeners may remember that episode of Seinfeld.

Debra Schindler: 12:08

That's great. So the treatment for that, though, is a surgery right.

Dr. Paul Sack: 12:11

You know, goiter is again a very nonspecific term, and so people can live with a big thyroid. There's nothing wrong with having a big thyroid. If the thyroid is getting in the way with other functions that are important in the neck, like swallowing and breathing and talking, then that is a time we might consider surgery. If it's concerning for, or definitely cancerous, then obviously we're going to consider surgery.

Debra Schindler: 12:38

Even though it's large, it could still be working, functioning properly.

Dr. Paul Sack: 12:42

Correct. I mean you can have a large thyroid that is large because it's overactive. You can have a large thyroid that got big because it's nodular and still works fine. Or you could have a large thyroid that's large because it got really inflamed because of the immune system and it's not working. So the size of the thyroid, the lumpy bumpiness of a thyroid, doesn't tell us about the function. That's what the blood tests are for.

Debra Schindler: 13:03

Can you feel the lumpy bumpy from the outside? I mean by holding someone's neck.

Dr. Paul Sack: 13:08

It's really interesting when it's big enough. Yes, although I would say the majority of the patients who come to see us now in our endocrinology clinic with a thyroid nodule or large thyroid, it's found in some other way. They went to the ER and were in a car accident, so they had a CAT scan of their neck to make sure they didn't break their neck and oh, by the way, there are a few nodules. They get a CAT scan of their lungs for, let's say, they're suspicious of lung cancer or they have pneumonia, and oh, by the way, there are nodules. They have an ultrasound of their carotid artery, which is the next door neighbor to the thyroid, and oh, by the way, there are nodules. So when we didn't have all of these fancy imaging studies MRI, ct scan you'd only diagnose the people with very large thyroids. Now we have a problem, which is we are being referred more and more patients with smaller nodules that we would have never found before, and this then presents a problem, which is who do we work up? Nodules are so common.

Debra Schindler: 14:11

So it's not scary. People shouldn't be scared if they find out that they have nodules.

Dr. Paul Sack: 14:15

Yeah, I mean, it's always concerning when you have a lump somewhere. It turns out that, depending on the patient type, it's around 5% of those nodules may turn out to be cancerous. And just to reassure everyone, if you have thyroid cancer, there's still only about a 5% chance that that cancer could actually kill you. So the thyroid cancer is always a concerning diagnosis, but it's not as life altering as compared to other cancers.

Debra Schindler: 14:43

Okay, how do you get nodules?

Dr. Paul Sack: 14:47

It's a really good question that I still haven't figured out. You know there's a lot of components to all of these things, and so genetics is one, just like we talked about the underactive thyroid, but thyroid nodules can run in families. And so genetics is one, just like we talked about the underactive thyroid, but thyroid nodules can run in families. So there's some genetic component, there's probably some environmental component and there's probably just some bad luck.

Dr. Paul Sack: 15:07

Thyroid nodules happen when cells are dividing and all of our body we're always getting rid of the old stuff and putting in new stuff, and thyroid's no different. And if those thyroid cells divide in some unusual way and then there's a mutation in a gene and then they start dividing more and none of the old stuff is taken away, that area is going to grow and grow and sometimes it grows and grows into a nodule that is just on and it just makes thyroid hormone, regardless of what the pituitary is telling it. That's what we call an autonomous or hot nodule. Some nodules grow and they turn out to be cancerous because the mutations that occur just are so aggressive that those cells can never be destroyed, and then sometimes we get things like cysts, so an area of the thyroid will fill in with fluid or protein that the thyroid makes. So there's a variety of different thyroid nodules.

Debra Schindler: 15:56

In what circumstance would you refer that patient for surgery and would you treat a nodule if it wasn't cancer or getting in the way as you described?

Dr. Paul Sack: 16:09

Sure. Well, let me start from the beginning. So if somebody is diagnosed with a thyroid nodule by another test, then we always go back to the gold standard, which is the ultrasound. And the ultrasound can give us some really valuable information. And there's characteristics of nodules that are less concerning, like a simple cyst is never cancerous. But if you see a nodule that is very irregular, has lots of dense calcifications in it, lots of blood flow, almost immediately I'm very concerned about cancer. So in the nodules that are concerning, that are larger than a centimeter, we will recommend a fine needle aspiration. So just to say that, in a different way, we don't biopsy every single nodule that is over a centimeter. We biopsy the ones that we are concerned for that may be cancer.

Debra Schindler: 16:55

That sounds painful.

Dr. Paul Sack: 16:57

It's actually not. It's probably less painful even than a well. It's about the same as a blood draw. It's done as an outpatient procedure a little bit of numbing medicine injected into the skin around the nodule and then a very small needle again much smaller than what we use for blood draws is inserted into the nodule using ultrasound to make sure we're in the right place. Usually it takes two or three sticks with this, what we call a fine needle aspiration, and then we'll get a result back from our cytology pathology friends in a few days.

Dr. Paul Sack: 17:31

That kind of tell us like is this concerning for cancer? Is this normal? And then the most kind of annoying one is this is an in-between atypia, undetermined significance. And in the past we would send those patients for cancer because there was like a 20 to 30% chance of cancer. What's great now is that we have new testing in the last, let's say, 10 years. That has helped us because we can send these samples off and look for genetic mutations and if the mutations are there, let's say 10 years, that has helped us because we can send these samples off and look for genetic mutations and if the mutations are there, that's more concerning for cancer. If they're not there, we can just watch it.

Dr. Paul Sack: 18:03

So let's say we've done a fine needle aspiration on a nodule and it says that it's normal, there's no sign of cancer, there's benign findings. Then we typically will follow that with an ultrasound periodically, maybe once a year, and then, if it doesn't grow at all, we may not do it at all unless the patient complains. If the nodule, though, comes back suspicious for definitely cancer, now we get our surgery colleagues involved, and that's a long discussion to have about thyroid cancer. We have to decide if we just take out the side that has a nodule or do we take out both sides, and there's some pros and cons of doing that. In the past, I think most of us would say that we over-treated thyroid cancer. We were very aggressive for something where a disease that wasn't aggressive. So we have to really be mindful of trying to make sure we do the right procedure on the right patient. But in general again, only about 5% of patients who have known thyroid cancer actually succumb to the thyroid cancer.

Debra Schindler: 19:01

So you said you take out the side, which suggests to me that you're taking out the whole thyroid, you're not just taking out the nodule.

Dr. Paul Sack: 19:09

Right. So from a surgical standpoint you can't just take out a nodule. You have to take out either both lobes or one of the lobe. And you mentioned the very beginning butterfly shape so people can look it up on the internet. But yes, there are two lobes and kind of a connection in the middle, almost like a butterfly would look. But yeah, it's a very vascular structure so you can't just take out part of it. I mean it would bleed and bleed. So you kind of take out half or you take out whole.

Debra Schindler: 19:35

Well, what happens then to the orchestra or the endocrine system if the whole thyroid is gone?

Dr. Paul Sack: 19:41

Sure. So one of the reasons we sometimes recommend half is that usually the other half that remains can make enough of those hormones I mentioned before the T3, the T4. Sometimes not, so we have to follow that after those surgeries. But if you don't have any thyroid hormone because we took it all out, then you take medicine for the rest of your life and that's something that we call levothyroxine. Other people may know the name brand Synthroid. Or we can sometimes give desiccated thyroid extract from, let's say, cow or pig thyroid, and there's a long discussion on the pros and cons of that. But we basically give the right amount by following those blood tests to try to figure out what the pituitary, that brain, wants, and that TSH value will give us that answer. So we adjust the medicine to try to get that TSH back into a normal range again, around one or two.

Debra Schindler: 20:31

And if there is thyroid cancer and you take out the thyroid, is chemo or radiation a part of that treatment?

Dr. Paul Sack: 20:37

So typically, when we take out the thyroid, the surgeons will get everything out. If there is concerns, though, that the cancer has spread beyond the thyroid itself and most typically that would be the lymph nodes around the thyroid the surgeon may also try to remove those, and then, less and less but it's still pretty common we give a dose of radioactive iodine, so we talked about iodine earlier in the podcast. Iodine is the main building block for thyroid hormone. These hormones, T3 and T4, well, they're called that because T3 has three molecules of iodine and T4 has four molecules of iodine, and so the thyroid cells that remain after thyroid surgery whether they're normal or whether they're cancer they want iodine. That's what their job is to take up iodine and make that thyroid hormone. So after the thyroid is taken out, we can basically clean up the little bits and pieces that the surgeon couldn't get by giving a pill of radioactive iodine.

Dr. Paul Sack: 21:32

Now that sounds scary. Radiation and radioactive iodine. It's actually like the least exciting thing we ever do. We bring somebody into the nuclear medicine department at the hospital, they swallow a pill and they go home. You don't turn into Spider-Man. You don't turn into the Incredible Hulk. You do have to kind of stay about six feet, apart from people for about three days, but that's about it, and then slowly over time that iodine will again kill off any remaining cells. What's great about that treatment is then we can actually take a picture of the body and see where the iodine went. So if somebody has thyroid cancer, the surgeon takes out what we think is the majority of it and then we give radioactive iodine which then cleans up the rest, and then we can take a picture to say, okay, it did go to the right side of the neck. We need to follow that area in the future to make sure that that doesn't come back.

Debra Schindler: 22:19

It's interesting that you mentioned that because I was going to ask a friend of mine. You had mentioned Graves' disease before and a friend of mine had diagnosed with that and she was young. She was in her early, maybe 30s and the treatment involved her being isolated because of radioactivity of some sort. I never really understood what that was about, but it sounds like she was taking that pill.

Dr. Paul Sack: 22:40

Yeah, so that's the other reason we use it. But let's step back, because we haven't really defined Graves' disease yet. Yes, so Graves' disease is a particular cause of overactive thyroid or hyperthyroidism. It was described by an Irish doctor named Dr Grave. So some people when they have Grave's disease they think, oh my God, I'm going to the grave. Typically that's not the case. So Grave's disease is another problem with the immune system. So I described Hashimoto's, which is a destructive process to the thyroid.

Dr. Paul Sack: 23:10

Grave's disease is a process where the immune system makes something that looks exactly like that pituitary hormone, that TSH, and when the normal TSH goes to the thyroid cells it basically just turns on a switch.

Dr. Paul Sack: 23:22

So the thyroid cells make thyroid hormone. When you have Graves' disease and you make this other protein called thyroid stimulating immunoglobulin, so it is a immunoimmune system globulin protein, so it's a protein made by the immune system that stimulates the thyroid, the poor thyroid cells are just told to go, so they just turn on and they're just making, making, making, so the thyroid gets bigger, they make a ton of that T3 and T4 and that can make people feel just terrible. Again. You get the heart racing and the sweats and the anxiety and tremors and weight loss and bowel dysregulation and menstrual dysfunction. It's a really challenging disease to deal with if you don't know what it is. Some of those people who have Graves' disease will get the eye disease with Graves and that would be that same thyroid-stim stimulating immunoglobulin, causing a different kind of swelling, kind of behind the eyes, pushing the eyes out. So you've ever seen somebody kind of with very prominent eyes that could?

Debra Schindler: 24:25

be yeah.

Dr. Paul Sack: 24:27

And again, some people just look that way naturally and that's just the way they're built. But uh, frequently it's because they have had or actively have Graves' disease. Um, so there's a couple of different ways to treat Graves' disease. So one is the old way was time. So the immune system sometimes just kind of goes away, that TSI goes down and a lot of people will go back to normal. But that's not a great way to live for several years or decades. So we have to get in the way of the thyroid, and one way is to block the thyroid from taking up iodine. So again, if that's the thing that's causing the extra thyroid hormone, now let's block it.

Dr. Paul Sack: 25:02

We may not be able to change the immune system, and so there's some medicines called methimazole and propothyreuracil that we can give and people may have to take that forever or maybe wait it out until again time kind of declines the immune response. Or we get rid of the thyroid. So one way to get rid of the thyroid is surgery. So again, if the thyroid's not there, it's really hard for it to be overactive. So a surgeon can take out a thyroid and then we have to give the thyroid hormone back.

Dr. Paul Sack: 25:29

Or, in the case of your friend, we give a radioactive iodine dose. So again, an overactive thyroid really wants iodine and the radioactive iodine will get into those thyroid cells and basically kill the thyroid from the inside out. And that's really a great way. Surgery is just something we rarely recommend unless the thyroid's really big, getting in the way of swallowing, breathing, talking the radioactive iodine. You end up with the same result, which is a non-functional thyroid without surgery. So again, somebody would come in, get a pill of radioactive iodine, be self-isolated for a couple of days and then over the next few weeks to months we would track the thyroid levels and then start replacement thyroid medicine once the thyroid becomes underactive.

Debra Schindler: 26:11

So if someone's on that medication, do their eyes return to normal? Have you seen that happen?

Dr. Paul Sack: 26:17

Sure. So you know it's interesting. There are people who can get the Graves eye disease and their thyroid is never affected. That's rare, so I just make that point. The other thing is only about 50% of people with Graves disease will get the eye disease and sometimes they're independent of each other and sometimes it's one eye and not the other and honestly I don't know if we really understand why Smoking is a big factor in this. So if you do smoke, it can get a lot worse. If you get radioactive iodine, sometimes that can set it off, especially in people who smoke. So that's one of our factors that we consider when we're thinking about who should get radioactive iodine.

Dr. Paul Sack: 26:55

But if the eye disease is really bad, it can be threatening to their sight. You're pushing the eye forward and the muscles are gonna get trapped and so some people can get double vision or blurred vision and you really need to clear grit from our eyes. You need to blink, and so if your eyes are pushed so far forward that you can't close your eyes all the way at night or just to blink to get the grit away, it can start to scratch the cornea. So it can be a surgical issue. So surgery is one option to try to decompress that area and get back there and kind of let the eyes kind of recede back into the socket. Steroids, which are anti-inflammatory drugs that has been used in the past, but recently we actually have a new drug that if people are seeing commercials for thyroid eye disease they'll know about that. That can actually change the immune system and reduce the inflammation from the eye disease, which can hopefully decrease the need for surgery and high-dose steroids, which have other problems.

Debra Schindler: 27:58

Is it hard to get a diagnosis of thyroid disease?

Dr. Paul Sack: 28:03

Many patients I see, especially with hyperthyroidism, eventually come to care, and that may be in the emergency room, might be with a primary care doctor. But if you go back in time you can kind of point to oh, that's when you started losing weight, that's when you but a lot of people just it. It's not hard in that if you go to a doctor and they're thinking about it or they just screen people sometimes because it's so common you just get those two blood tests the TSH and the T4 levels. It's fairly straightforward, but someone has to think about it. Either the patient or the provider has to say, okay, we need to test you.

Debra Schindler: 28:41

And do they look for that in every blood test, if you go and give blood or do a panel of blood work?

Dr. Paul Sack: 28:47

So that's a really good point. You know we do screening tests because we think things are common enough and the screening tests are cheap enough to justify doing them frequently. So when you get your routine blood work at a doctor's office, you might get kidney function, a glucose level, maybe a blood count to make sure you're not anemic. You might get kidney function, a glucose level, maybe a blood count to make sure you're not anemic. The thyroid test is not currently recommended as a routine screening test to do like, let's say, annually or, you know, semi-annual, every five years. There's no good recommendation on that. However, it's symptom and kind of history kind of generated. So if somebody has significant weight change, let's say they have atrial fibrillation or irregular heart rate, you're definitely going to check for thyroid because that's one of the main causes for atrial arrhythmias. If someone comes in with just feeling terrible, like, it's an easy test to do, it's fairly cheap, so a lot of people are going to get that checked just because they say something to their provider.

Debra Schindler: 29:48

Should primary care physicians request that more often? Do you think?

Dr. Paul Sack: 29:53

No, I think we're doing a fairly good job at screening. You know, I think there's a lot of issues in accessing healthcare in our country, so some people who really need to get healthcare and be checked aren't being checked. I do get frustrated when somebody has their thyroid checked six times in a year because they just don't feel good. I mean, if it's normal, it's normal.

Debra Schindler: 30:12

Okay.

Dr. Paul Sack: 30:13

So I think it can go both ways. Most of the time, though, the primary care doctors should be able to treat the hypo, the underactive thyroid. That's a fairly straightforward management. If the thyroid is not making enough hormone, we start prescribing the levothyroxine, and once you are prescribed that, it takes about four to six weeks to kind of get to a new steady state. So then we check another test and then we kind of see how we're doing, and then we make another adjustment, if needed, on the thyroid hormone, and then that keeps on going until we kind of get to a good place, and then it's followed once or twice a year the hyperthyroidism. I think most people would say that would be going to the endocrinologist Now. Having said that, I do see patients with hypothyroidism because it's been challenging for their primary care doctor to get the right dose or there's other factors.

Debra Schindler: 30:58

I want to ask about thyroid nodules one question before we move on, and that is if they aren't treated, could they go away on their own move?

Dr. Paul Sack: 31:06

on, and that is, if they aren't treated, could they go away on their own? So typically thyroid nodules that are solid, they don't. They're there and they can get to a certain size and then stop growing. But you can get nodules that are four or five, six centimeters and again they may not be cancerous but they can get in the way. But they grow so slowly that it's not something where suddenly you're going to stop breathing or suddenly you're not going to be able to swallow. It's going to be a slow and steady pace.

Dr. Paul Sack: 31:30

The ones that can kind of come and go, kind of get bigger and get smaller, are the cysts. So just like you can fill up a water balloon and make it bigger or leak some out and make it smaller, cysts can do that. So sometimes people will kind of feel something just overnight just pop up and they're freaking out because they're like what is this? And we you know it's typically some kind of bleeding into a known nodule that just suddenly got bigger. That can be painful and scary, but that's typically something that's just going to get better on its own.

Debra Schindler: 31:58

What's the connection between the thyroid or thyroid dysfunction and diabetes?

Dr. Paul Sack: 32:04

Sure. So the main connection is actually to type one diabetes, not type two. So type two, just to remind you, is kind of the disease of obesity and being older, not being as active. Type one, though, is the autoimmune condition, so where the immune system attacks the pancreas, and so a large number of people who have type 1 diabetes, they'll have other autoimmune conditions, and the most common autoimmune condition in almost anybody is thyroid. About 10% of the population has these antibodies against the thyroid, so not all of them develop hypothyroidism. So in every single patient who has type 1 diabetes, we're screening them for thyroid disease once a year, once every other year because we know it's so common.

Debra Schindler: 32:48

And what would be the treatment? Would it be different?

Dr. Paul Sack: 32:50

No same thing. If your thyroid is underactive, we give replacement hormone and that's the majority of my patients who have type 1 who get thyroid disease. It is the underactive form, but occasionally you can also get the Graves' disease, which is the autoimmune overactive form.

Debra Schindler: 33:05

Okay, so we discussed the imaging for diagnosis.

Dr. Paul Sack: 33:09

So again, ultrasound. Ultrasound is the best way to look at a thyroid, just ultrasound. Yeah, so the place where CT comes in, as I said, is sometimes that's where we pick it up.

Debra Schindler: 33:19

Just serendipity yeah.

Dr. Paul Sack: 33:23

But sometimes we will do a CT, especially if surgery is considered. So the surgeon has a better understanding of kind of where things are in relationship to themselves, for instance where the trachea or the windpipe is, and kind of how far the thyroid goes down. Typically the thyroid goes to about our clavicles, our collarbone, but some people actually the thyroid can grow so large it gets to the top of the heart, and so a surgeon obviously doesn't want to find that out during the operation. They want to know that ahead of time. So if there's concerns that it is pushing into the mediastinum, that's another place where the CAT scan can be quite helpful. And then for cancer patients, especially if you're trying to figure out if it's other places, we'll sometimes order a CT.

Dr. Paul Sack: 34:05

The tricky thing about a CT is a lot of times that's with contrast and that's iodinated. Contrast, that's iodine. So sometimes if we have to do a CT with contrast, then we give the person a lot of iodine. And if we're trying to think about treating the person with radioactive iodine now, we're waiting three to six months to get the iodine out of their system. Six months to get the iodine out of their system. So we just have to be thinking forward in terms of, like, what we're doing now and how that's going to affect things later. But again, the ultrasound which personally I do in the office, but it's something that can be done at the hospital or at advanced radiology, you know maybe takes 10 or 20 minutes. There's no radiation involved, and so it's a very simple test.

Dr. Paul Sack: 34:43

Now the next thing that some people ask me is well, should everyone just get an ultrasound of their thyroid, like just to find out if they have nodules? So there was a very interesting report out of South Korea, which has a national health system and they have a really good screening of certain things let's say, mammograms, looking for osteoporosis, chest x-rays and at some point they added in a thyroid ultrasound as part of their routine screening tests, and over the next 10 years, the rates of thyroid cancer diagnosis just went crazy high. At the same time, though, if you look at the rates of death from thyroid cancer, no change. So the point is there is a lot of insignificant thyroid cancer out there that if we do nothing, it doesn't matter, and so we have to be very careful about doing screening tests and causing undue harm on patients, where maybe not even knowing sometimes is a better thing.

Dr. Paul Sack: 35:44

And so this is the challenge, and this is kind of the controversy now in the management of thyroid cancer is, just because someone has it, we have to decide who would actually benefit from a major operation, getting radioactivized, on having to be on pills the rest of their life. And so there's more to come on that, I think, the advent of doing the genetics on certain tumors this would be helpful because then we can kind of know, like, okay, based on these certain genetics, this is one that's going to be more aggressive, less aggressive. So I think we're getting there, but that's still one of the actually the hardest things not making the diagnosis but actually trying to figure out what do we do about this?

Dr. Paul Sack: 36:20

Yeah, you don't want to cause more harm.

Debra Schindler: 36:23

That is fascinating because it's such the opposite message of most cancer discussions.

Dr. Paul Sack: 36:28

Oh, certainly. I mean, if you think about lung cancer, you want to get on that as soon as you possibly can. Colon cancer, breast cancer, like that is going to get you right If you don't get on it right away, and thyroid cancer is one of those. That's actually not the case. I think prostate cancer would be an equivalent kind of cancer where a lot of them are very slow growing and again the treatment may be worse than the disease until you hear about that one person where it spread quickly. And same thing for thyroid cancer. Like most of the time it's something that we can take care of. Patients are going to do great and then occasionally it's very aggressive.

Debra Schindler: 37:02

And thyroid cancer is typically contained. It doesn't spread.

Dr. Paul Sack: 37:06

Again, typically yes, but it can spread to bones and lungs and other places, but again, typically it's in the neck. We take it out and we monitor.

Debra Schindler: 37:15

What's a thyroid uptake test?

Dr. Paul Sack: 37:18

Sure.

Dr. Paul Sack: 37:18

So we talked about using iodine for treatment. We give a pretty good dose of iodine that gets in there and kills off the thyroid. Well, we can give test doses, very small doses, of radioactive iodine. We can give radioactive iodine in a pill form and it goes to places that take up iodine, which again typically is the thyroid. Sometimes it goes a little bit to the salivary glands and other places. We can take a picture of the body and see where that went. So when we think about a thyroid uptake it's also usually paired with a scan. So that's the scan part.

Dr. Paul Sack: 37:48

So someone gets a tiny dose of radioactive iodine. We take a picture of the body. We kind of see where the iodine goes. Does it go to the left side of the thyroid, the right side of the thyroid, both sides? Does it not really go anywhere? And then we can also do the uptake, which is basically you know how much radiation was in the pill before the person swallowed it, and then you can actually check and see how much radiation is in the area of the neck, so how much of that iodine that the person swallowed ended up in the thyroid, and so we have normal values. So usually at about two hours about five to 10% of that radiation gets there and about 24 hours the person comes back. The next day we do the same test. Gets there, and about 24 hours the person comes back. The next day we do the same test and they just literally are just sitting up next to a little tube that counts the amount of radiation coming out of their neck and then we kind of see, and so at 24 hours it's usually around 20 or 30%. So if somebody has Graves' disease and again that thyroid just really wants all that iodine, you can have 60, 70, 80% of the iodine getting up to the thyroid. So that's a good way to kind of figure out. Okay, we know somebody is hyperthyroid, but why? So we order this thyroid uptake and thyroid scan test with nuclear medicine and they can kind of those results can help us determine what it's from.

Dr. Paul Sack: 38:59

One of the things we didn't talk about yet as a cause of hyperthyroidism is called thyroiditis. Now we said Hashimoto's thyroiditis is inflammation. But you can get a virus, you can get some kind of flare in your immune system that just suddenly your thyroid gets inflamed and destroyed. Now eventually that can end up being underactive. But in that immediate time you are releasing all of the thyroid hormone that you have made ahead of time all at once, so you can get a transient episode of hyperthyroidism.

Dr. Paul Sack: 39:28

So again, you release all this thyroid hormone. Now, eventually you've released it all. So then it's going to either go back to normal or go under active. In that situation that thyroid uptake will be zero, the thyroid's destroyed, it won't take up anything. And so this is one of the ways that we can differentiate if we're not quite sure about the cause of hyperthyroidism Is it thyroiditis? Is it Graves' disease? Is it that three centimeter nodule on the right side of the thyroid? So if it is, all of the iodine just goes to that one nodule, nowhere else. So it's a way for us to differentiate the different causes of hyperthyroidism.

Debra Schindler: 40:03

Okay, speaking of causes, I'd like to get your response to some of the suggested reasons why people have troubles with their thyroid.

Dr. Paul Sack: 40:11

Stress. So stress is interesting. In the hospital, a lot of people are under a fair amount of stress. They're very ill, and in stressful times the thyroid blood tests can change in response to that stress. However, if you follow them without doing anything else, typically the thyroid numbers go back to normal. So typically stress doesn't cause thyroid illness, but it can cause some abnormalities in the blood test, and so that's actually one of the more challenging things we have to do is try to figure out is that slight change in either the TSH or the T4 level because of that acute illness, or is it because of something else? Is it because they actually do have a real thyroid disease?

Debra Schindler: 40:55

Not eating well, and what's the impact of these starvation diets?

Dr. Paul Sack: 41:01

So that is an extra kind of stress and so it would be transient as well. The stress that you put on your body when you're not eating is extensive People starving to death. They may have slight changes in their thyroid function, but again, it's not going to cause Graves' disease. It's not going to suddenly trigger the immune system, which is typically what causes thyroid disease.

Debra Schindler: 41:26

Okay, too much or too little vitamins?

Dr. Paul Sack: 41:29

Yeah, so the only vitamin that really matters in this situation is iodine, and we talked about that earlier. In this part of the world it's really hard not to take an iodine. Again, it can happen if you only eat, let's say, packaged food, processed food, but a lot of that has salt in it and that salt has iodine in it. The only other supplement or vitamin that actually has some impact on Graves' disease, especially Graves' eye disease, could be selenium, again something that we don't really think about as a major vitamin that we're getting in, but sometimes that can help sometimes decrease the inflammation of the eyes.

Debra Schindler: 42:03

Before we get away from the food factor, I found it interesting that the foods that were identified to be good for your thyroid health are milk yogurt this seems so random, but Brazilian nuts.

Dr. Paul Sack: 42:13

Yeah, iodine, iodine, iodine, iodine. So again, these are foods high in iodine.

Debra Schindler: 42:18

Chicken, beef, fish and eggs.

Dr. Paul Sack: 42:19

Yeah, yeah. So again, that's the reason. Again, in this country it's hard to I feel like I said this so many times now it's hard to not have iodine.

Debra Schindler: 42:29

Right, and then the ones that were not good for your thyroid seems pretty obvious as well. Fast food, processed food and gluten.

Dr. Paul Sack: 42:38

I think gluten is the one that's very interesting. Not everyone who goes on a gluten-free diet and feels much better is because they have an immune problem. But again, gluten allergies are real. That's celiac disease. And so if you think about how autoimmune diseases kind of go together, if you really are triggering your immune system by eating a lot of gluten, it may trigger other immune problems at the same time. And so I think that's one.

Dr. Paul Sack: 43:02

And there's a lot of kind of non-scientific publications and information on the internet about diets and things like that for the thyroid. I don't want to say that they're wrong, but I think that what they probably have right is diets that aren't triggering the immune system, you know. And the other thing people ask me is well, if my immune system isn't the problem, why can't we just fix the immune system? And the answer is there's not a great way to do that that won't cause more harm than benefit. I mean, think about high-dose steroids for rheumatoid arthritis or lupus or things like that. Those are nasty, nasty medicines that the risk is worth the benefit. In thyroid disease that's not the case.

Debra Schindler: 43:39

What about intermittent fasting? That's very popular right now? Is that the same as a starvation diet?

Dr. Paul Sack: 43:46

I don't think we have a lot of data on that. On thyroid, I would just say as a side note, intermittent fasting makes a lot of sense in terms of trying to lose weight, but again, I don't think there's a big concern that that's going to somehow affect the thyroid function. However, I will say that thyroid hormone, when we give it as a pill, should be taken on an empty stomach. So in terms of what you eat and how you're taking your medicine, it actually makes a big difference. And the reason is is because when we swallow a pill, we have the assumption that we're getting all of that pill. That's actually not the case with thyroid. There are a lot of things that can kind of stick to it so that you never actually absorb it. So in the best case scenario, if you're taking, let's say, a hundred micrograms of levothyroxine, you're probably getting about 80. That's just the way it is, like your body is just going to, you're going to poop some of it out. But if you take it with food or take it with iron, calcium, other supplements, you might only get 50% of it. In terms of what you eat and how the thyroid hormone is absorbed, it's a big deal thyroid hormone is absorbed. It's a big deal, which is why most people are told take it first thing in the morning on an empty stomach with water and wait about 45 minutes to an hour until you do anything else in terms of putting things into your stomach, which can be really challenging for some patients. The other thing about taking thyroid medicine is that most pills that we take last let's say, a few hours, maybe up to a day, and then it gets out of your system and you take the next pill. It gets out of your system. So if you're taking blood pressure pills and you missed your blood pressure medicines today, your blood pressure will be high today and you get them back on them tomorrow. Your blood pressure will be better tomorrow. Well, it turns out that the thyroid hormone that we give the levothyroxine, the T4 lookalike medicine it actually gets out of your system after about four weeks. So if you miss a dose today, that missed dose is going to kind of be a cumulative effect over the next four weeks. So one of the reasons why people have a hard time keeping their thyroid levels in a good range is because they don't realize that oh, I just missed one or two a week. No, well, that's going to effectively lower their dose by 20%. And so it's really important that, as we're looking at thyroid tests, we actually talk to our patients and find out. Okay, tell me how you're doing taking this medicine In the last week, how many pills have you missed?

Dr. Paul Sack: 45:56

Or if you do miss a pill, what do you do about it? Because some people think, well, if I don't take it in the morning, I can't take it at all. No, you could take it later in the day on an empty stomach. In fact, you could take it later on the day with something in your stomach. That's still better than not getting anything. So I know this sounds surprising, but us doctors actually have to talk to and listen to patients occasionally. But this is important in terms of trying to figure out how to get the right dose for the right person and most patients we can get it and they slip. They went on vacation, they ran out of pills or something like that happens, fine. And just again, we figure it out. Some patients, man, it just seems like we can never find the right dose. So that's where it gets more challenging.

Debra Schindler: 46:34

What's the most unique case you've ever had.

Dr. Paul Sack: 46:36

So there's a couple. We think about these two different diseases, of overactive and underactive, of being mutually exclusive, but really it's just kind of two sides to the same coin. You have immune system that can block or destroy the thyroid. You have an immune system that can activate it. So I had a patient who I still see today, who actually has other autoimmune conditions, and she was hypothyroid for about 40 years, four zero. And all of a sudden, about 10 years ago, her thyroid test started to look like she didn't need as much thyroid hormone. So we cut down the thyroid hormone. We got labs in four weeks Still too much. Cut down the thyroid hormone Got labs in four weeks Still too much. Stopped the thyroid hormone Got labs in four weeks Still too much. She developed Graves. So after 40 years of hypothyroidism she actually flipped.

Debra Schindler: 47:22

She wasn't producing enough for 40 years of hypothyroidism. She actually flipped. She wasn't producing enough for 40 years and then, all of a sudden, she went the other way.

Dr. Paul Sack: 47:29

Yeah. So then we gave her radioactive iodine, we made her hypothyroid for permanent and now she's back on her replacement medication. So there are cases like that. That can be a little head scratching but again, with careful thinking and evaluating the lab tests we can figure it out.

Debra Schindler: 47:45

What do you think happened to do that?

Dr. Paul Sack: 47:47

So you know most people with underactive thyroid. We assume that the thyroid is destroyed, the immune system has caused inflammation and destroyed it. But you can actually get antibodies Again. That's this stuff from the immune system that just gets to that receptor on the thyroid cells and just blocks it. So instead of destroying anything, it just kind of gets in the way.

Debra Schindler: 48:06

But that's very unusual.

Dr. Paul Sack: 48:08

Yeah, that's less usual, although that's also a reason why sometimes it's really hard to find the right dose for people, because their immune system can kind of like block it a little bit or block it more, and then we're trying to chase it Again. As I said, most of the time patients with hypothyroidism can be managed by their primary care doctor. These are some of the times where the endocrinologist could even be confused by what's going on.

Debra Schindler: 48:32

What's your final message? What takeaway do you have for listeners?

Dr. Paul Sack: 48:36

Sure.

Debra Schindler: 48:37

We've covered a lot of ground, yeah.

Dr. Paul Sack: 48:39

I mean hypothyroidism is common. As I said, the antibodies can be found up into 10% of the population. As I said, the antibodies can be found up into 10% of the population. And so you know, if you're experiencing symptoms that just don't seem right to you again, for underactive, it's kind of everything slowing down and for overactive, everything revving up you want to ask your doctor like, could this be my thyroid that's causing these issues? If you notice a lump on your neck, you should bring it to your provider's attention. Definitely would need to follow that up with the ultrasound. Again, don't be too worried if there's a nodule. About 50% of women over the age of 80 have a thyroid nodule. And of course, if you look at 60 and 50 and 40-year-olds, it's a little bit less, but it's so common. So don't get too worried. The ultrasound will kind of point us in the right direction. And again, even if the nodule turns out to be suspicious for cancer or definitely cancer, majority of cases are fairly straightforward Do surgery, can treat it with radioactive iodine and just follow over time.

Dr. Paul Sack: 49:37

It's challenging for me to say what I'm about to say. Is that not everything that you think might be thyroid is the thyroid, and so sometimes people's thyroid numbers are normal and they still think but it has to be my thyroid, and I gently try to say, well, no, let's try to figure out something else. Because what the test that we're checking is is the brain happy with the amount of thyroid hormone in the system? If the brain's happy, that's in most situations that's the sign that we're giving the right amount of thyroid hormone, or at least that your own thyroid is making the right amount of thyroid hormone.

Dr. Paul Sack: 50:08

There's so many other things that again contribute to people feeling bad, and in our society it's again poor sleep hygiene, not exercising, eating poorly, gaining weight, being stressed, feeling depressed. And again it's a convenient thing to say it must be my thyroid, I'll take a pill and make it all better, and in some cases it actually does work. But more often than not, when people come in with those kind of complaints, put their thyroid test on normal. It's not the thyroid and we need to look for other things. I think that that's something we have to get back to is living a healthier lifestyle. Again, that may not change the autoimmune stuff that's going on with our thyroid, but it can make us feel better.

Debra Schindler: 50:45

Thank you for sharing your expertise with us today. It's been very interesting and, like I said, we've covered a lot of ground, but it's been very interesting and, I hope, helpful.

Dr. Paul Sack: 50:54

I really appreciate you asking me to come. Thank you.

Debra Schindler: 50:57

For more information on any of the thyroid conditions we discussed today, or to make an appointment in either the Baltimore or DC region, go to our website medstarhealthorg. Backslash services. Backslash thyroid hyphen disorders.