Live WebChat - NOW - with Dr. Mark Lupo, Endocrinologist

We'd like to welcome Dr. Mark Lupo, Endocrinologist, as our guest this evening from 5:00-6:00PM EST.  Dr. Lupo will be answering thryoid-related questions which were previously posted by our community members earlier this week.  

After a member-question is posted by Co-CL ChitChatNine, Dr. Lupo will answer the question with a few minutes for member comments and then another question will be posted.

I know we'll enjoy this WebChat and thank Dr. Lupo for his time!  

Let's give Dr. Lupo a warm welcome!

Your Community Leaders
Cheryl, Laura & Stella

[mommy2two2008]

Welcome and thank you Dr. Lupo!!

[laura1967]

Welcome Dr Lupo and thank you for giving your time to us tonight....hello from Fort Myers!!!

[mommy2two2008]

That's a good idea Laura - HELLO FROM LOUISIANA!

[mommy2two2008]

Will the questions post on this thread??

[Mark Lupo, M.D.]

Happy to be here.  

[Jennifer1987]

Thanks for being here, really appriciated! HELLO FROM IRELAND!

[baz5]

Thank you for your time! :)

[Mark Lupo, M.D.]

I will go ahead w/ first question as I cannot see live chat/posts.

Low vitamin D is common, would look at PTH & calcium levels first.  Then if normal, consider looking at celiac sprue antibodies.  

[ChitChatNine]

QUESTION #1:

From:  ChitChat9
Parathyroid Disease ?

Dr. Lupo,

In women over 45 yrs old who have been diagnosed with a Vitamin D Defficiency, do you find that most have this defficiency due to "lack of sunshine" without an underlying reason (i.e, parathyroids not working right), or that many who are seen by an Endocrinologist are diagnosed with parathyroid issues causing this defficiency.  I ask this ? because my primary doctor was very quick to diagnose the cause as  "lack of sunshine" even with my history of thyroid cancer.   My Endo took it much more seriously and is ruling out other possible causes (including a repeat serum Vt D test as well as Intact PTH, & rerunning thyroglobulins, etc.), before I start Vit D Treatment.  First labs were Vit D at 9.4

[mommy2two2008]

Can Vit D def. cause a person to tingle in the throat and tongue?  If so, is a safe test theory to take some form of calcium with Vit D OTC?  I have tested my cal 2 times wth my doc.  Last was 9.3.  I know that is a good number.  I get some sporatic tingles, last was Wed, Thurs and Fri.  I took some Caltrate and it stopped after 2 days.  I no longer feel it.  I just wondered if it was coincidence.

[Mark Lupo, M.D.]

SEE ANSWERS BELOW

First of all...Thank you for your time.  I have a few round about questions.  I have some heart issues in which my HR can run low for days and then drop low along with some really rough chest pains, floaters, blurred vision etc.  Anxiety is not the issue with them.  So I guess this is the one I'm most concerned with.  



I also have really bad muscle spasms threw out my body during the winter months and in the summer I get lightheaded very easy, so in order this is also a concern.  

The the third question is just plain aggravation with Doctors.  LOL Sorry.  Thank you again for your precious time.  Amy



1 a,b.)  I would like to know the relationship between thyroid issues and heart issues?      (Example, angina, PVC's and PAC's, cholesterol increases and hsCRP)
IF THERE IS EXCESS THYROID HORMONE IT WOULD CAUSE PVC AND PAC.  TOO LITTLE WOULD INCREASE CHOLESTEROL.  BOTH CAN AGGRAVATE ANGINA.


2 e.)  The relationship between thyroid and FMS and CFS symptoms?  (PlateletGal could probably word it much better than I.)
THERE IS SOME RESEARCH (NOT IN MAINSTREAM ACADEMIC THYROID) THAT HYPOTHYROID IS ASSOCIATED W/ FM AND CFS SYMPTOMS - SOMETIMES TREATING W/ T3 CAN BE HELPFUL TO THE MUSCLE SYMPTOMS.


3 e.)  Why most Doctors will not run a T3 or FT3 along with the TSH, T4 and FT4?

TSH IS THE STANDARD OF CARE BASED ON MULTIPLE STUDIES. IN SOME CASES T3 LEVELS ARE HELPFUL TO EVALUATE HYPOTHYROID, BUT ARE MOST HELPFUL IN HYPERTHYROIDISM.

[Mark Lupo, M.D.]

LOW CALCIUM CAN CAUSE THE TINGLING SENSATION -- AND LOW VIT D CAN CAUSE LOW CALCIUM -- THAT'S WHY THERE MAY HAVE BEEN SOME BENEFIT

SORRY ABOUT THE ALL-CAPS, JUST FIGURED IT WOULD BE EASIER TO RECOGNIZE MY POSTS IN THE THREAD.

[ChitChatNine]

If anybody has any comments on the discussions, feel free to post them after Dr. Lupo has answered!

I'll go first ... Celiac Sprue .. I never thought of that and thanks!  I am awaiting results as I write this and am going to ask my Endo about this, too!

C~

[manju77]

Hypothyroid questions


I had irregular periods and diagonised with hypothyroidism.The results of my test before i was on levothyroxine on November

TSH 5.934 (High)
Thyroxine(T4) 10.0
T3 uptake 30%
Free Thyroxine index 3.0

Now I am on Levothyroxine on 75 mcg and the results of the tests after 6 weeks are

Free T4 1.9 (0.7-1.8)
TSH 0.04 (0.5-6.00)

My doctor(internist) says the dosage is right as it has lowered the TSH.But I am worried it is too low now and becoming hyperthyroid from hypothyroid.

I got my periods after i was on levothyroxine ,but this  month still i haven't still got my periods yet.Is it  due to the low tsh?.

Will lowering the dosage help ?

[mommy2two2008]

We know you're not screaming!!  Thanks for that.  My doc told me I might have shingles.  I just can't believe that as now that I did try the Caltrate, it has stopped.  I didn't take the antiviral med he gave for shingles and now I am feeling ok.

[Mark Lupo, M.D.]

QUESTION 3

A) In what situations would you/endocrinologists allow a hypothyroid patient to add cytomel to their levothyroxine to try and improve their symptoms?



A)How long does it take for a thyroid gland to stop functioning after becoming hypothyroid due to an autoimmune cause?

VARIES FROM PERSON TO PERSON.  ONE STUDY SAID THAT 5% OF PATIENTS PER YEAR LOOSE THYROID FUNCTION -- SO IN 20 YEARS ALMOST EVERYONE WITH AUTOIMMUNE THYROID DESTRUCTION WOULD BY HYPOTHYROID.

A) I've read in a medical textbook that there is a link between hypothyroidism and low ferritin levels. What causes this?
LOW FERRITIN (IRON) CAN BE CAUSED DUE TO POOR INTESTINAL ABSORPTION DUE TO HYPOTHYROIDISM OR CELIAC SPRUE (GLUTEN SENSITIVITY WHICH IS MORE COMMON IN HASHIMOTO'S PATIENTS).  OR DUE TO HEAVY MENSES WHICH IS SOMETIMES SEEN IN HYPOTHYROIDM.  

[ChitChatNine]

Dr. Lupo may be able to answer your question as we move along a bit later in the WebChat.  The posts are being taken in order from the prior posts .. let's see how it goes but wanted to mention this so you don't think it may be overlooked.

C~

[Mark Lupo, M.D.]

QUESTION 3 ---

I CONSIDER ADDING T3 (AND USE MUCH MORE CYTOMEL THAN ARMOUR - B/C I CAN FINE-TUNE THE T3 AND T4 AMOUNTS MORE PRECISELY) WHEN THERE IS FATIGUE AND BRAIN FOG.  ABOUT 15% OF PATIENTS FEEL IT HELPS SIGNIFICANTLY (ALTHOUGH MANY FEEL BETTER THE FIRST MONTH, ONLY 15% HAVE A SUSTAINED BENEFIT).

[baz5]

Why would my tsh be very high with a low Free t4  only every so often? I do have missed periods...very ofter.  I had to go to the hospital this friday for major dizzyness
(I will bring that up again) BUT they tested my thyroid at the hospital and it was normal.
Whats that about??

[ChitChatNine]

Anbyody have any comments on Dr.Lupo's responses to Questions 1, 2, 3 ?

[Mark Lupo, M.D.]

My 8 year old daughter was born without a thyroid gland and has recently been diagnosed with PVC's in her right ventrical. She is on .88 micrograms of synthroid and has not had a dose change in over 2 years. Could the cause of the PVC's be due to needing a different dose of synthroid? (Hypothyroid) Or could this possibly be caused from the synthroid itself? Her blood test are in the normal range, however she has gained weight, has issues with constipation, is emotional, lacks energy, and has muscle aches in her legs. Her blood is only tested for TSH, T4, and Free T4. Could it be possible that her body is not converting T4 to T3? There must be some type of imbalance in her body for this to suddenly be happening to her heart. I am desperate for answers that I am not getting from our doctors here.Please help with any ideas that you may have. Thank you for your time and thoughts on our specific situation.

IT IS NOT LIKELY THAT THE T4 --> T3 CONVERSION IS FAULTY.  WOULD TEST FREE T3 TO CONFIRM.  IF THE TSH, FT4, FT3 ARE ALL NORMAL THEN THYROID IS NOT LIKELY THE CAUSE -- IF THE TSH IS LOW NORMAL, DECREASING THE DOSE TO SEE IF THAT HELPS THE PVC'S WOULD BE WORTH A TRY, BUT HER OTHER SYMPTOMS ARE MORE SUGGESTIVE OF HYPOTHYROIDISM.

[huncher]

Am new to this thyroid game. After TT and RAI, I have started my back on my Synthroid .125 mg. My question is: Will the Adderall (adderrall) I take for ADD (30mg twice a day) affect the Synthroid???

[Mark Lupo, M.D.]

IF THE TSH IS CONSISTENTLY HIGH AND T4 INCONSISTENTLY LOW - THEN YOU MAY NOT BE CONSISTENT WITH THE MEDICATION....

I AM TRYING TO GET THROUGH PRE-POSTED QUESTIONS FIRST, BUT THANKS FOR THE QUESTION

[mommy2two2008]

As to a person "loosing thyroid function with hashi", is the same true when your a hashi patient with normal labs of TSH, FT4 and FT3? (swelling and non-smooth texture)

[Mark Lupo, M.D.]

ADDERAL IS NOT KNOWN TO AFFECT THYROID DOSING

[Jennifer1987]

My questions:

Hypothyroidism

- Can hypothyroidism cause the anxiety symptoms?
- When will they go/resolve?
- My TSH level is 2.41 at moment, could this level cause anxiety and the other physical symptoms?
- Could I increase my meds to bring it down to 1.0-1.5?
- How long usually untill the meds should work fully?

Thanks for your help
Jennifer.

[ChitChatNine]

Dr. Lupo, are there many Pediatric Endo's in the US?  Is it essential to have a child treated by a Ped Endo vs. one who works primarily with adults?

C~

[Mark Lupo, M.D.]

NEXT ?>

Thank you for letting us chime your brain! I have had my thyroid out since March 08.. Hurthle Cells, non cancerous.. going on almost a year. I have had my ups and downs of course. I am on Armour Thyroid. 60 one and 75 the other. I do this every other day.



I just fell ill with a terrible stomach bug. My labs were drawn in the hospital at that time and a week after ...my levels weren't necessarily improving. My iron levels were rock bottom. I am on Repliva now for three weeks. Is it possible that someone like myself, thyroidless, that after being ill it takes awhile longer to recooperate?



Also, does Celiac Disease and the thyroid and have any relation? My Endo said he would possibly test for this is if that were the steps needed to take?

CELIAC IS MORE COMMON IN HASHI -- BOTH AUTOIMMUNE DISEASE
IF THE THYROID REPLACEMENT IS CONSISTENTLY NORMAL, THERE SHOULD NOT BE A DELAY IN RECOVERY/REPLETING IRON DEFICIENCY

[ChitChatNine]

PRE POSTED QUESTIONS are being taken first .. at the end if we have time, Dr. Lupo will try to address any others.  Just wanted to mention this so you don't think your important question is being overlooked.

Thanks,
C~

[laura1967]

We need to let Dr Lupo get through posted questions first before new questions are added, unless it pertains to Your question he is answering. Thank you, otherwise this will get too confusing for everyone.
:)

[Mark Lupo, M.D.]

PED ENDOS HAVE MORE EXPERIENCE W/ CHILDREN -- MOST OF US ADULT ENDOS (EVEN THOSE WHO ONLY DO THYROID) STILL START AT AGE 15-18 FOR PATIENTS.

[Mark Lupo, M.D.]

Posted by kitty9309, Jan 19, 2009 10:49AM



Question for Dr. Lupo:



How important is the free t4 and free t3 in deciding if treatment for hypothyroidism is optimal?

TSH REMAINS THE GOLD-STANDARD - THE T4 AND T3 ARE SECONDARY IN THE CURRENT STANDARD OF CARE APPROACH.

Is the free t3 level able to detect a "conversion" problem? (That is a big issue on thyroid forums)
YES -- IF THE T3 IS LOW (CONSISTENTLY) THEN THERE MAY BE A PROBLEM W/ THE DE-IODINASE ENZYME.


My endo said the free t3 is too labile and can't be relied upon (if in the normal range).

T3 IS LABILE FOR PATIENTS TAKING T3 -- OTHERWISE IT IS ONLY SOMEWHAT LABILE.  BUT IF CONSISTENTLY NORMAL, THEN ....IT'S NORMAL AND NOT ADDITIONALLY HELPFUL TO THE EVAL

He told me he goes by the TSH and symptoms in most cases.

THAT IS THE STANDARD OF CARE.

His is very-open minded, however. Will give Cytomel a trial if symptoms remain despite optimal labs.

WE DO AS WELL -- USUALLY 5MCG ONCE OR TWICE A DAY -- IF THERE IS A DEFINITE BENEFIT THAT IS SUSTAINED (IE MORE THAN 3-6 MONTHS) THEN WE STICK WITH IT. REMEMBER TO DECREASE THE T4 DOSE (20MCG FOR EVERY 5 MCG OF CYTOMEL ADDED) WHEN DOING THIS.



Thanks so much for your time.

[shannon828]

Dr. Lupo,

Hello and thank you for you time.  I had a TT in April 2008 and 150 mc of RAI in May of 2008.  My post RAI scans showed two foci of thyroid tissue and my TG was at 1.  Since then I have had two blood panels run, my TSH is down to .51, but my TG is still at 1.  My understanding is that both numbers aren't suppressed.  My question is, does a TG number of 1 indicate that my thyroid tissue still exists?  Could this be that the RAI is still killing off the remaining tissue or should I be concerned about "recurrence"?  I had an ultrasound in October that showed no enlarged lymph nodes and no thyroid tissue.  I am now scheduled for Thyrogen stimulated scan on Thursday.

Thanks.

[Mark Lupo, M.D.]

Hello Dr. Lupo - you have been of great help to me this past year. I have an enlarged heterogeneous thyroid but my blood values have always been fine (TSH, FT4 and FT3)  also had negative antibodies.  I am being treated with Armour (60 mcg) and my ENT (and you) have suggested I have Hashi with normal antibodies.  I stopped taking the Armour (stupid, I know that now) about 3-4 weeks ago to see if I really needed it and for most of it, I have been o.k.  Now the neck fullness feeling is coming back, my submental salavary gland on the right is swollen again (not noticeably to anyone else unless I manipulate my tongue in an certain direction), my parotid gland close to the ear feels swollen (again, not visibly) my ear is full feeling again and my right eye has a sort of numb vague feeling around it.  That eye also has a sort of pressure behind it.



My ENT has always suggested I have Hashi.  Which, after a year of the on and off swelling, aches and pains, etc., I would have to agree.  They have never found a "nodule" per se, just the enlargement and non smooth texture.  I have had conflicting report via US, the last suggested a Multinodular Goiter with no discrete nodules.



My questions I guess now are:



1) How possible is it that this is Hashi with normal antibodies; and if it is, how do you usually treat?

10-15% OF HASHI HAVE NEG ANTIBODIES.  IF THE TSH IS NORMAL (0.3-3.0) I USUALLY DON'T TREAT BUT THERE ARE EXCEPTIONS BASED ON INDIVIDUAL SITUATIONS.  

2) Is Thyroid Eye Disease common among Hashi patients, and if so, how do you treat that?

IT IS NOT COMMON, BUT DOES HAPPEN.  I SEND PATIENTS TO NEURO-OPHTHALMOLOGISTS W/ EXPERIENCE IN THYROID EYE DISEASE -- THEY WILL TREAT WITH SUPPORTIVE CARE (EYE DROPS, SUNGLASSES, ELEVATE HEAD OF BED, EYE LUBRICANT GEL AT NITE) FIRST THEN CONSIDER STEROIDS THEN CONSIDER RADIATION OR SURGERY.



3) I have been reading up on Sjorgen Syndrome due to my inflammed submental gland.  Do you think this is a posibility given the sporatic swelling of the gland? I don't feel that it is affecting my eye, I don't have "dry eye" but I do have a constant grainy feeling and redness around the iris with a heavyness in the upper lid.

SJOGREN'S IS AN AUTOIMMUNE DISEASE  LIKE HASHI -- TEST SS-A AND SS-B ANTIBODIES AND CONSIDER LIP BIOPSY TO DIAGNOSE.


Thanks so much for all you do for thyroid patients!  Given my small town has only one ENDO and I had an AWEFUL experience with the man, you have been a saving grace for me for the past year!  Thanks ~Kim
YOUR WELCOME.

[ChitChatNine]

As time permits, Dr. Lupo may be able to come back to your ? .. he is going in order from those posted earlier in the week .. just wanted to mention so your important question doesn't seem as if it's been overlooked .. C~

[Mark Lupo, M.D.]

REGARDING THE TG AND TSH IN CANCER

MAKE SURE THE TG IS MEASURED ON DAY OF THE WHOLE BODY SCAN (IE ON DAY 5 OF THE THYROGEN PROTOCOL)

ALSO HAVE A NECK ULTRASOUND BY AN EXPERIENCED THYROID CLINICIAN.

A TG OF 1.0 W/ TSH OF 0.51 SUGGESTS SOME REMNANT BUT HARD TO KNOW WHAT IS GOING ON -- THE TG TREND WILL BE MOST IMPORTANT.

[mommy2two2008]

Thanks for the answers Dr. Lupo -- since the cal w/ D supplements, most of those feelings are now gone.  My Dr. suggested I could have the thyroid removed now since its been a year of really not much relief from the swelling that goes on.  What do you think about that??

[Mark Lupo, M.D.]

Posted by Jennifer1987

Jan 19, 2009 11:16AM



To: Dr. Lupo

Subject: Hypothyroidism.



Iv been on medication (50mcg Eltroxin) For 2 months now for hypothyroidism. I just got my last test results back:

THS . . . . . . . 2.41 (was 6.5)

FT4. . . . . . . .12

FT3. . . . . . . . 4.32

Anti TPO  . . . . . <0.01

Thyroglobulin . . . . . .  .123.00



All my levels seem normal but Im still suffering with symptoms, physical and mental, the worst being anxiety/depression...It has improved from what it was at the start!

Other symptoms are: muscle pains/weakness, pains im my knees and elbows,tiredness, puffy eyes, black marks under my eyes, occational headaches, finger/wrist pains, cols hands/feel, sensitive to col majority of the time, vivid dreams, still sleepy when i wake in mornings (1 o clock in the day really). These would be the worst at moment.



My questions:



- Can hypothyroidism cause the anxiety symptoms?
YES - BUT USUALLY IT'S AGGRAVATING AN UNDERLYING ANXIETY

- When will they go/resolve? VARIES -- IF HYPOTHYROID WAS THE ONLY CAUSE (WHICH IT USUALLY IS NOT) THEN WITHIN 2-3 MONTHS OF NORMALIZING TSH

- My TSH level is 2.41 at moment, could this level cause anxiety and the other physical symptoms?
DEPENDS -- COULD TRY TO INCREASE THE DOSE A BIT TO TARGET A LOWER TSH AND SEE HOW YOU RESPOND -- IT'S HARD TO PREDICT (IE TRIAL & ERROR)
- Could I increase my meds to bring it down to 1.0-1.5?

- How long usually untill the meds should work fully?

2-3 MONTHS ONCE OPTIMAL TSH

Thanks for your help

Jennifer.

[ChitChatNine]

How is a measure of Thyroglobulin in a cancer patient who has had only a partial an indicator of some sort ?  Would it be for autoimmune  .. if 1/2 the thyroid is still there it is confusing what would the results show ?  In other words is it useless for a partial thyroidectomy patient to have thyro taken to see if return of cancer?

C~

[ChitChatNine]

The above was a comment in response to the TG test in Thy Cancer

[Mark Lupo, M.D.]

HARD TO KNOW - I HAVE HAD PATIENTS WHO HAVE NECK DISCOMFORT AFTER THYROIDECTOMY, SO IT'S NOT ALWAYS THE THYROID.  DEPENDS ON SIZE OF GOITER, ETC.  

[SueYoung55]

I found out a week ago that I have hypothyroidism. TSH was 39.29. I don't have all of the rest of the test results back so I don't know much more. My primary is an internist and she said I also have decreased kidney function that she believes may be caused by the hypothyroidism. I just finished all my treatments for breast cancer and I honestly believe that this issue was caused by the radiation to my neck. My father and my sister have it as well, so the family history is there.

My question to you is this. Given my recent history with cancer, should I look for a specialist in this area now or should I let my primary take care of me. I am meeting with her tomorrow afternoon to go over what she knows about my test results. My ignorance of this disease is appalling, but thanks to you and the lovely people on this site, I am learning some of it.

Thank you for your time.

[ChitChatNine]

Dr. Lupo is answering pre-posted questions from earlier this week in the community.  However, any questions not answered will be posted on Dr. Lupo's Expert Forum where he'll be answering these questions within the next week or so.

Dr. Lupo's Expert Forum
http://www.medhelp.org/forums/show/120

C~

[Mark Lupo, M.D.]

. Lupo,



1.) What constitutes a "normal" fluctuation in a patient's TSH levels over the course of a day? I.e. would a TSH of 4.0 at 9am be likely to drop to 1.4 by 1pm? Also, what is a "normal" fluctuation in TSH levels over the course of several weeks, or months, assuming no major changes in the patient's life?

TSH WILL FLUCTUATE 0.5-1.5 POINTS ON AVERAGE -- TENDS TO BE HIGHEST IN EARLY MORNING HOURS.  

2.) What is the connection, if any, between the thyroid gland and the pineal gland? Have patients with pineal cysts been known to have thyroid disease, even if a neoplasm in the pineal region isn't directly correlated to the thyroid disease (i.e. perhaps it causes hypothalamic dysfunction or some problems with blood flow to the pituitary)?

NO WELL KNOWN CLINICAL CONNECTION THAT IS PERTINENT/USEFUL

3.) What causes the actual "heterogeneous" texture of the thyroid typically seen in Hashimoto's patients? In patients not diagnosed with Hashimoto's, but still presenting with consistent heterogeneity of the thyroid (1+ years), what might this mean?

LYMPHOCYTE (IMMUNE SYSTEM CELLS) THAT ATTACK THE THYROID -- ULTRASOUND MAY DETECT THIS BEFORE THE ANTIBODIES BECOME POSITIVE.

4.) How do endocrinologists go about diagnosing a patient with Graves or Hashimoto's if the patient has negative bloodwork for thyroid antibodies, or borderline negative levels? Does it then become primarily a clinical diagnosis?

ULTRASOUND APPEARANCE AND IN GRAVES, AN I-123 SCAN.  ALSO THE TREND OF THYROID FUNCTION TESTS IS HELPFUL -- IE, PERSISENT HYPO OR HYPER AFTER 6-8 WEEKS IS MORE SUGGESTIVE OF AUTOIMMUNE THYROID DISEASE (IN ABSENCE OF OTHER CAUSE) RATHER THAN A TEMPORARY THYROIDITSI

Thank you so much!



Julia

[Mark Lupo, M.D.]

Dr. Lupo, thank you for being here tonight. we appreciate your time.

My question is:



Can a person that has been on meds for hypoT, expect their thyroid to start functioning normally and DC the medication? Does this happen, even if rarely?


THIS CAN HAPPEN -- WOULD TEST ANTIBODIES, IF POSITIVE, THEN WOULD BE RELUCTANT TO STOP (DC) THE MEDICATION.  MOST PATIENTS DO NOT HAVE A RECOVERY AND ONLY CONSIDER STOPPING THE MEDICATION IF MONITORED BY YOUR PHYSICIAN.

[Mark Lupo, M.D.]

To: Dr Lupo



Thank you for being here. I am over a year post TT and a high dose of RAI (341). I have experienced jaw, neck and ear pain which has gotten progressively worse. I have recently been diagnosed and begun treatment for Salivary Gland Burnout. I am scheduled for a dialation procedure on the 30th of this month in an attempt to reopen the ducts however I have been told that this is a temporary fix and the glands need to begin functioning on their own. The procedure involves threading graduated sizes of balloon caths into the ducts. I have been taking antiobiotics, using hot compresses to release some of the fluid and pressure as well as anti inflammatories and lots and lots of water. The sour candy causes extreme swelling so I don't use it very often. To date the Parotid Gland is the only gland that can be treated with dialation however I have pain and fluid under my jaw and in my neck which involve the submandibular & sublingual glands. The dialation is not a permanent fix. Are you aware of any other options that may be available for damaged glandular tissue? I have read a study about stem cell transplant written by RS Redman of the Oral Pathology Research Lab at the VA Med Ctr in Washington and published in Biotechnic & Histochemistry Volume 83, Issue 3&4 June 2008. I am looking for any and all information and options. The condition is very painful making it difficult to sleep and the release of fluid causes nausea and heartburn and it is becoming increasingly difficult to eat. In my employment I use the telephone regularly and it is painful to have the phone touching my face. Thank you in advance for any information that you may have.


WISH I HAD A GOOD ANSWER TO THIS -- WOULD LOOK INTO UNIVERSITY OR SPECIALTY CENTERS W/ ENT EXPERTISE IN SALIVARY GLAND PROBLEMS.  THIS IS A MAJOR PROBLEM WITH HIGH DOSE RAI.

[mommy2two2008]

As for the answer for Julia -- if the heterogenosity (sorry for spelling error) is there before the antibodies appear in blood tests and your doc medicates you on a small dose (.25 levo first then 1 gr Armour) can that stop the antibodies from turning positive?  

[Mark Lupo, M.D.]

To: Dr. Lupo

Hypothyroid questions



Hi Dr. Lupo,

Let me begin by thanking you for your time!  



I recently had RAI for hyperthyroidism (Graves Disease).  It has been 2 months since my procedure. I know my labs from month 1 & 2 extremely fluctuate which my Dr. mentioned isn't normal.  



1) When labs fluctuate as quickly as mine, is there anything I can do to prevent such upswings and downturns? Is there any additional tests that I should ask my Dr. to include on my labs? Please see below Lab test results.
THIS IS COMMON -- THE FIRST MONTH IS USUALLY HIGH OR NORMAL THEN THE LEVELS DROP AT 2-3 MONTHS.  THE KEY IS TO START THE LEVOTHYROXINE EARLY.....


2) How long does it take to move from a TSH of 96.3 to a level where I will feel better. I am currently taking Levoxyl 0.075 mg for 2 weeks now.
THIS WAS A LARGE TSH SWING UPWARDS -- YOU WILL LIKELY NEED MORE THAN 75MCG ULTIMATELY -- IT IS TYPICALLY WEIGHT BASED -- 0.7MCG/POUND.


2) What books could you recommend as I learn to manage hypothyroidism.  I am looking for a reference that will help with diet, exercise, pain management, etc.

THERE IS NOT A SPECIFIC DIET OR BOOK (DESPITE THE ONES THAT ARE SO WELL MARKETED....)  IT IS REGULAR EXERCISE (CONSIDER CONSULTING WITH AN EXERCISE PHYSIOLOGIST TO DEVELOP A ROUTINE FOR YOU -- THIS IS INDEPENDENT OF THE THYROID PROB) AND EAT A BALANCED DIET AND TAKE A VITAMIN.  

THERE ARE GOOD THYROID PATIENT BOOKS -- I CANNOT RECOMMEND ANY SPECIFIC TITLE THOUGH AS I WOULD INEVITABLY LEAVE ONE OUT

12/10/08: Month 1 post RAI  (no Levoxyl)

TSH: 0.04         normal lab ranges [.34 - 4.82]

Free T4: 1.36    normal lab ranges [0.60 - 1.60]



1/8/09: Month 2 post RAI (no Levoxyl)

TSH: 96.3        normal lab ranges [.34 - 4.82]

Free T4: 0.43   normal lab ranges [0.60 - 1.60]



Thanks,

Selvi

[Mark Lupo, M.D.]

MEDS DON'T NECESSARILY STOP THE ANTIBODIES FROM COMING.  EVEN SELENIUM NEEDS MORE RESEARCH BEFORE SUGGESTING ITS USE

[shannon828]

Thank you for your answer.  I had a thyroid ultrasound in October by Dr. McArdle at Beth Israel Deaconess in Boston.  He is part of the Thyroid Center there and specializes in Thyroid ultrasounds.  After looking at my neck he said "I see absolutely nothing, no tissue, no enlarged Lymph nodes, nothing."  Additionally, the Tg has stayed at 1.0 since my TT, hasn't raised, but hasn't gone down either.

My labs are scheduled for Friday, but my scan is actually Thursday (M/T Thyrogen shots, W I123 dose, Th scan, labs Fri).

Also at ,51 TSH I am feeling tired all the time, dry skin, etc.  Do some people experience these symptoms when hyper rather than hypo?

[Mark Lupo, M.D.]

Posted by: Super_sally888

Jan 19, 2009 10:54PM



To: Dr Lupo



Topic: Hypothyroid  & Pregnancy



Thank you so much for your time and support. I am sure I speak for all of us here, who so greatly appreciate your information sharing and educating us.



1. I understand that it is very important to maintain good thyroid hormone levels (high normal) in early pregnancy, and that the baby will start to generate it's own thyroid hormones about 12 weeks AOG.  Does it matter if hormone levels become low normal (as measured by FT3 and FT4) in third trimester, or should levels still be adjusted to keep high normal target even during third trimester?

LOW NORMAL FREE T4 AND T3 CAN BE SEEN -- IF THE TSH AND TOTAL T4 ARE NORMAL, THERE IS LIKELY NO PROBLEMS ESP IN 3RD TM



2. Is it normal practice that the increased dose of thyroid hormones is reduced back to the prepregnancy dose immediately after the delivery? Or would there be an adjustment period?
THIS IS NORMAL PRACTICE, PROVIDED PRE-PREG LEVELS WERE ON TARGET.


3. My Endo told me that women with hypothyroid often have problems breastfeeding.  Is this your experience?  Is there anything that can be done to increase breastfeeding success?

I HAVE NOT SEEN THIS W/ CONTROLLED HYPOTHYROID

(I am 38, now 37 weeks pregnant with first baby: hypothyroid - FT3,FT4 low normal & TSH below limits treated w/ thyroxine 200 mcg plus dessicated 155 mcg, GD treated w/ humulin 30 units/d, & pituitary microadenoma - prepregnancy had high prolactin levels treated with bromocriptine).





Thank you.

[mommy2two2008]

I am beginning to understand this now.  Thanks! :)

[ChitChatNine]

I get classic hypo symptoms when hyper .. opposite of what is expected like brain fog when TSH is <1.5 .. most get that when hypo?  Good comment Shannon .. many fall into this category ?~

C~

[Mark Lupo, M.D.]

Posted by: Twilight_Princess

Jan 19, 2009 11:21PM



To: Dr Lupo

Subject: Hypothyroid



What I want to know is I had a complete hysterectomy in February 2008 and I opted NOT to take hormone replacement therapy - could this have an effect on my thyroid? I am beginning to think it is wrecking havoc on everything from not taking hormones.

THIS SHOULD NOT AFFECT A NORMAL THYROID -- IF YOU ARE PRE-DISPOSED TO A THYROID PROBLEM, IT MAY TRIGGER IT.


I also have a 2 cm tumor on my left adrenal gland. This was discovered by accident by having a CT scan done on my abdomen. So far the tumor hasn't grown since Feb. 2006. My Endo tells me the tumor is "just there", so as far as I'm concerned it's undiagnosed. Could this tumor also be causing havoc on my thyroid and hormones? Not sure what to think anymore.

THIS IS NOT LIKELY RELATED TO THYROID AND SHOULD NOT ALTER THINGS.  WOULD HAVE ADRENAL TESTING TO MAKE SURE IT IS NOT "FUNCTIONAL"

[Mark Lupo, M.D.]

Posted by: 4helen

Jan 20, 2009 03:09AM



To: Dr. Lupo

e) Other



Is it possible to shrink an FNA (Thy3 - inconclusive - 4 cm) nodule other than by surgical means?  
RADIOACTIVE IODINE CAN SOMETIMES SHRINK BENIGN NODULAR GOITER
BUT IF BY INCONCLUSIVE YOU MEAN SUSPICIOUS FOR FOLLICULAR NEOPLASM/CANCER -- IT SHOULD LIKELY BE REMOVED, ESP AT 4CM.


Is there any thumb rule 'growth metric' of how many centimeters per year a follicular neoplasm grows, or is this entirely individual?

IT VARIES FROM PERSON TO PERSON,

Thx kindly Leaders and Dr Lupo       : )

==========================

[Mark Lupo, M.D.]

Posted by:  ambo02

Jan 20, 2009 12:54PM



To: Dr. Lupo



Thank you for you time!  I'm 50yr old  with no thyroid. Had 2 differents surgeries cause of goiter(complex cyst 7.5cm)  Tried RAI didn't work actually got bigger so had surgery 2007.  I'm on Armour 90 and right now having problem with TSH of 52. Going to new Dr cause my other one moved. Just haven't been feeling well. (gall bladder removed, divertiltis and getting colds easy)  Since I don't have a thyroid should I get  it checked reg.  And can you start to grow another thyroid nodule?


TSH OF 52 IS VERY HIGH -- THE DOSE OF MEDICATION OR REGIMEN NEEDS TO BE RECONSIDERED/ADJUSTED.  YOU NEED REGULAR FOLLOW-UP FOR LEVELS BUT THE NODULES ARE NOT LIKELY TO FOLLOWUP

[Mark Lupo, M.D.]

Posted by: porkchoptx

Jan 20, 2009 11:45PM



To: Synthroid and Dialysis Treatment



Dr. Lupo,



Does synthroid wash out during dialysis treatments?  Normally take the pill at 7am. Dialysis treatment is at 10am.  Treatment lasts approx 3 hours 15 minutes.


NO - IT IS NOT SIGNIFICANTLY "DIALYZED" -- FOLLOWING TSH LEVELS ON A REGULAR BASIS WILL ENSURE THAT THINGS ARE STABLE

[JOY2000]

Do you know anything about the NIH study with the parathyroid hormone pump?  Any opinion  on it?

JOY2000

[Mark Lupo, M.D.]

Autoimmune



Thank you for your time!  I will try and make this quick.  At age 33 I had a stroke...reasons unknow...doctors think possible migraine induced. I did have a PFO corrected shortly after....just in case that was the cause.  I have always had painful joints, infections and actually alot of "Lupus" symptoms growing up but I have always tested negative on my ANA's.  Until recently when I decided to see a Rheumatologist (9/08) because I thought enough is enough.  I tested positive for Anti-nuclear antibody ab (A) , Thyroid Microsomal ab >1300, Vitamin D level low, DHEA level low, Free T4 1.1, TSH 5.97.  My Doctor seems to think I have UCTD but now doing some research I am wondering why Hashimoto's wasnt a consideration.  I will be talking to my Rheumatologist about it but I wanted to here what you had to say.  I am also going to set up an appointment with an Endocrinologist.  Any thoughts? Thank you for your time! I forgot to tell you that my Rheumatologist put me on methotrexate for the UCTD. How do you feel about that? I am also on Lexapro 10mg, Inderal 80 mg, Aspirin 325mg. I am now also taking fish oil, One a day vitamin and vitamin D daily. I am a little weary of being on methotrexate personally.  I am trying to trust my doctor but the more I read and ask questions the more I am unsure.

LOOKS LIKE YOU HAVE HASHIMOTOS WITH EARLY HYPOTHYROIDISM -- GIVEN THE COMPLEX HISTORY, I WOULD CORRECT THIS VARIABLE W/ A LOW DOSE OF 25-50MCG OF LEVOTHYROXINE TO BRING THE TSH TO AROUND 1.0 THEN SEE IF THAT HELPS ANY SYMPTOMS.

METHOTREXATE IS COMMONLY USED FOR CTD BUT HAS MANY SIDE EFFECTS -- MAKE SURE TO REVIEW THESE W/ THE RHEUM.  IT DOES NOT HAVE A ROLE IN TREATING THYROID PROBLEMS

[Mark Lupo, M.D.]

I DON'T KNOW ABOUT THE TRIAL OF PARATHYROID HORMONE PUMP -- I IMAGINE IT WOULD BE FOR PATIENTS WITH HYPOPARATHYROIDISM (USUALLY POST-SURGICAL) AND NOT FOR PATIENTS WITH OSTEOPOROSIS (WHO ARE TREATED W/ FORTEO INJECTIONS - PTH - ONE A DAY)

[baz5]

I am not on any thyroid meds right now. I am the one who went to the emergency hospital to find out all of my thyroid tests are now normal...what does that mean?

[ChitChatNine]

Dr. Lupo will have time for one more question.  

Thanks for your time participating in this wonderful live WebChat with Dr. Mark Lupo.  Any questions not answered during today's WebChat will be moved over to Dr. Lupo's Doctor-to-Patient Forum and answered this coming week by Dr. Lupo

http://www.medhelp.org/forums/show/120

C~

[Mark Lupo, M.D.]

Posted by: laura1967

Jan 21, 2009 06:30PM



To: Dr Lupo



Thank you for your time here Dr Lupo. I am one of the community leaders here and I would like to touch on 2 questions that are asked frequently.



1- Can a person have Both Graves and Hashimoto's? Or is it only considered Graves regardless of both tests showing positive.

AUTOIMMUNE THYROID DISEASE SHOULD BE CONSIDERED A SPECTRUM -- HYPO ON ONE END (HASHI) AND HYPER ON THE OTHER (GRAVES).  SO A PERSON COULD SWING FROM ONE PICTURE TO ANOTHER.....

2- Do you know an approximate timeframe that one would expect from Hashimoto antibodies attacking the thyroid to completely destroy of the gland?

IT VARIES FROM PERSON TO PERSON -- HARD TO PREDICT.

Thank You.

Laura

[mommy2two2008]

Great chat!  Thanks so much for your time.  I think a lot of people will get answers with the information provided!

[baz5]

I did not take my methotrexate last night due to my trip to the hospital.  Would skipping a dose be that awful for me?  I have a sneaking suspision thats what put me there in the first place.

[Aurorah]

tyvm for you time today Dr. Lupo

[Mark Lupo, M.D.]

Posted by: rohit_786

Jan 21, 2009 08:20PM



To: Dr Lupo



Subject: Hashimoto's thyroditis / Pituitary adenoma



Thanks Dr Lupo for your time here. I have been posting my questions/answering other here for last 3 years . I have two questions.



About Me first :-



Male , 37 years , diagnose Hashimoto's in 2006



Question # 1

I recently diagnose Pituitary tumor because of hig prolactin level , the size of tumor is 6mm. My question is , do you think my hypothyriodism is because of pittuitary disorder ?.

NOT IF TSH WAS HIGH AT TIME OF INITIAL DIAGNOSIS.   MORE LIKELY IT IS PRIMARY HYPOTHYROIDISM DUE TO HASHI
UNTREATED HYPOTHYROIDISM HOWEVER CAN ELEVATE PROLACTIN.....
Question # 2:



My thyroid level keep bouncing for last 3 years, current number is TSH 1.67, FT4 = 1.37 FT3 = 3.32.



I still have muscles pain/joint pain , fatigue and still weight gain issue.Can't hold my temper , fuse very quickly and very low sex drive and low libido.


LEVELS NORMAL, NOT MUCH MORE TO DO W/ THYROID HORMONE TREATMENT.
Some more data about my hormone which is tested pretty recently



Total Testosterone 300 (300-1090)

LH  1.67 (1.5-9.0)

FSH 3.2 (3.0-10)



Free testosterone level is also in low side.



My question is , do you think those hormones are responsible for my symptoms as my thyroid numbers are fine  ?.

TESTOSTERONE IS  A BIT LOW -- MAY CAUSE SYMPTOMS.  LOW TESTOSTERONE IS SOMETIMES SEEN IN UNTREATED PROLACTINOMAS.

Current medicine



Levoxyl 88mcg/day

Bromocriptine  2.5mg/day.





I really appreciate in advance for your response.

====================

[laura1967]

Were you the one Dr Lupo just answered the question above under autoimmune and see a RA dr?

[SueYoung55]

So much to learn. Thank you for your time.

[Mark Lupo, M.D.]

LAST QUESTION FOR THIS WEBCHAT....

Posted by: bet643

Jan 21, 2009 08:48PM



To: Dr. Lupo

You are a Prince, thank you so much!!!!  After my total thyroidectomy 4 yrs. ago for pap. carcinoma and dx with hashimotos, I was placed on 150 mcg. of Synthroid.  Even though I have the problems of joint pain, brain fog, lack of sleep and all of the other lovely problems that go along with it, the most trouble I am having is heart palps. I have them quite often. I was told that it would slow down over 3 yrs. ago, but nothing yet. They cause me to lose sleep, which I do not need since I barely sleep as it is. I am worried that I will end up with a heart attack. I can't give you my labs since I will not see my Endo until this Friday, that's when he will go over my labs with me. I am a walking zombee most of the time. It takes me about 2 to 3 hrs. to function after my meds are taken at 7:00 AM and I am wiped out by 3;00 PM.  So I guess you can say that I'm only good for about 4 to 5 hrs. a day. I am concerned that my ths is alway high, but I have yet to get a good explaination on why it's alway high. I'm just so tired and  feeling weak and would like to know if it will ever get better?


IF TSH IS IN TARGET RANGE (O.5-2.5) THEN ASK ABOUT A TRIAL OF ADDING T3 -CYTOMEL --USUALLY DOES NOT HELP BUT MAY BE WORTH A TRIAL -- SEE ABOVE POSTS ON THIS.

[ChitChatNine]

THANK YOU Dr. Lupo for being our guest on this Thyroid Live WebChat!

We will refer to your valuable information for many years to come as we continue to help members with thyroid questions who are in need of support!

We thank you, also, for the time you give to answer questions on your forum on a daily basis, and we will be sure to stop by!  Dr. Lupo's Expert Forum:  http://www.medhelp.org/forums/show/120

Again Thank You -- this is the end of Thyroid Awareness Month but you have really made a difference helping us here tonight!

Thyroid Community Leaders

[Mark Lupo, M.D.]

WE WILL TRY THIS AGAIN -- MORE REAL-TIME -- IN THE FUTURE..

THANKS.

MARK LUPO

[baz5]

I do have an RA doctor.

[mommy2two2008]

Have a great evening Dr. Lupo and all!

[baz5]

Thank you for all of your time!!  It is much appreciated! :)

[shannon828]

Thank you Dr. Lupo!

[Me967]

Thank you for your time.  It was very kind for you to join us.  I bet your finger are tired!  LOL
Thanks again.  ;~)

[ChitChatNine]

Thanks Dr. Lupo and all our members for your time participating in this wonderful live WebChat!

Any unanswered question during today's WebChat will be moved over to Dr. Lupo's Doctor-to-Patient Forum and answered this coming week by Dr. Lupo!

http://www.medhelp.org/forums/show/120

C~

[Cloulou]

Although I missed the live chat, the question that I posted previously was answered. This is such a terrific forum, thank you Dr Lupo, thank you Leaders, thank you Members, this is just GREAT!!!
Cindi

[stella5349]

Again I apologize for not being part of the chat last night due to family issues.

Thank you Dr. Lupo for coming over last night and helping so many members.

[Addie61]

I had radiation on my tonsil area (neck) over 23 yrs ago and they said my thyroid would probably go out.   Now I get funny number and get examined and they come back normal everytime.  I feel like a guinea pig, they always want more blood in a 3 months to have my numbers not where they should be and after testing - NORMAL AGAIN?  What is causing this up and down numbers with my thyroid?

[Barb135]

You won't be able to reach Dr Lupo through this thread.  This is the patient forum, and this "live chat" was almost a year ago.  You will need to go the expert forum to try to reach Dr Lupo.

If you have questions that we patients might be able to help with, I'd advise that you begin a new post to ask your questions.  

Good luck.