Ultra Sound Result/Endocrinologist appt.

[veronicafm]

I went to the doctor for another reason and she was concerned with my neck and referred me for labwork and an ultrasound. Here's my results:
FINDINGS: Right lobe is 6.7 x 2.7 x 2.8 cm. Left lobe is 6.3 x 2.3 x
2.1 cm. Endometrial stripe is 9 mm. Thyroid is heterogeneous and
hyperemic. Multiple nodules are identified, the largest is on the
right 2.6 x 2.8 x 1.6 cm. Nodules are solid. Largest left lobe nodule
is 9 mm. At least, two other on the left and three other on the right
including one in the isthmus noted.

IMPRESSION: Multiple thyroid nodules including a dominant nodule.
Overall enlarged thyroid. Biopsy might be considered.

So I now have an appointment with the endocrinologist on Monday and I'm nervous. I've always been healthy and this came out of nowhere. I read they do the biopsy in the office. Is that normal? I just don't know what to be prepared for on Monday. The labwork was within normal limits (TSH 2.6). If the biopsy is normal, what would be the normal course of treatment?
Thank you. Veronica

[gimel]

MedHelp prefers we don't use doctor's names here on the main Forum, so sending a PM with info.  Just click on your name and go to personal page, then click on messages.  

[veronicafm]

My primary care doctor is ordering the labwork/ultrasound, then she will refer back to endocrinologist depending on the results. I'll send a message and see if she will over the Free T3, Vitamin D, B12 and feritin test. Who is the doctor that you recommend and I'll see if that person is on our provider list. Thanks.

[gimel]

No, he isn't.  If you are totally tied to only doctors within your HMO. then you will first have to convince them of the need for additional testing.  For that you probably need to know more about hypothyroidism and which tests are important, and also about clinical treatment.  We can help with that if you want to approach it that way.  

[veronicafm]

Thanks for the info. I'm limited to who I can see because of an HMO. I'm seeing Dr. Paul Tomasic. Was he the doctor you were going to recommend?

[gimel]

898_1 is right that many doctors would ignore your test results , and probably your symptoms as well.  For that reason you need to find a good thyroid doctor.  A good thyroid doctor will treat a hypo patient clinically by testing and adjusting Free T3 and Free T4 as necessary to relieve symptoms, without being constrained by resultant TSH levels.  You can get some good insight into clinical treatment from this letter written by a good thyroid doctor for patients that he sometimes consults with after initial tests and evaluation.  The letter is then sent to the participating doctor of the patient to help guide treatment.  In the letter, please note the statement, "the ultimate criterion for dose adjustment must always be the clinical response of the patient."

http://hormonerestoration.com/files/ThyroidPMD.pdf

A good thyroid doctor would tell you that your TSH is high enough to indicate a thyroid problem.  Also, Your Free T4 is too low in the range, and you need to be tested for Free T3, which correlates best with hypo symptoms.  So you do need to be started on thyroid meds.    In addition, since hypo patients are frequently too low in the ranges for Vitamin D, B12 and ferritin, you need to test those as well, and supplement as necessary.  Further, since Hashimoto's Thyroiditis is the most common cause for diagnosed hypothyroidism, you should test for the antibodies characteristic of Hashi's.  Those tests are Thyroid Peroxidase antibodies and Thyroglobulin antibodies, usually shown as TPO ab and TG ab.

If interested I have the name of a doctor in LV that is recommended by thyroid patients.

[898_1]

Most doctors will not medicate patient until TSH levels are above 5.5 (and not long ago (like around 2006) no medication until above 10).

[veronicafm]

It's been 6 months now and they re-did the labwork. The Free T4 went from 1.1 to .8ng/d, which was still in normal range, but the TSH went from 2.26 to 4.72 miU/l, which is now above normal range. So does this mean that my thyroid is no longer functioning properly? I've got an ultrasound scheduled for 10/22. So would the normal next step be medication?

[veronicafm]

Thanks. I just looked that up. Can't imagine having another needle put in my neck. The biopsy really wasn't that bad, but I was thinking the whole time I hope I don't have to do this again. We'll see what the doctor's opinion is on the 14th. Thanks for always responding with helpful info.

[898_1]

I can't type today either :)
Lymphoctic thyroiditis is another name for Hasimoto's thyroidis.
A  non-surgical treatment procedure for the cyst is ethanol ablation (PEI)

[veronicafm]

I can't type today, lymphoctic thyroiditis.

[veronicafm]

Sorry - I didn't scroll all the way over, it said consistent with chronic lymphoctic thyroiditic.

[veronicafm]

I see my results online, it says "Pathology results of right thyroid biopsy reveals benign thyroid nodule    with cystic component."  How is that normally treated?

[898_1]

Repeated biopsy is recommended if nodule changes its structure (becomes calcified, shows sign of increased blood flow or cystic degeneration).
The surgery for longstanding multinodular goiter in patient over 40 has higher risk of complication compared to the different cases. It is hard to say anything else before biopsy results.

[veronicafm]

I went to my appointment. He said my thyroid is functioning normally. He's recommending the biopsy because of the size, but expects it to be fine. He then recommended a repeat ultrasound in 6 months. If the goiter has grown, then repeat the biopsy. If it stayed the same, to repeat ultrasound at one year. He said he could remove it, if I wanted but then I'd start the lifelong medication. It doesn't make sense to do that if my thyroid is functioning normally. He said there's no medicine to make the size go down and I basically will have to let him know when it's interferring with my life. It seems like a lifelong monitoring.

[898_1]

the nodule this size should be prominent during swallowing.
benign nodules are monitored; some nodules are treated with PEI (cystic and complex)

[898_1]

it  signifies either inflammation (swelling) which may go down or if it is longstanding condition it means thyroid is trying to satisfy demands for thyroid hormone by increasing its size.

[veronicafm]

Thank you for responding. The report doesn't say anything more about the condition of my lymph nodes. I was surprised that it said the biggest one is on the right, because the one on the left seems bigger to me. I've not been exposed to radiation in past, healthy childhood. I grew up on East coast until 16 then have lived in Southwest since then so I don't know if either is an iodine deficient region. What does the large volume signify?

[898_1]

In general multiple nodularity is sign of past inflammatory process, exposure to the radiation in childhood, Hashimoto’s thyroiditis or growing up in iodine – deficient region.
The report misses following details:
What is condition of your lymph nodes?
What are the characteristics of 2.6 x 2.8 x 1.6 cm nodule; can you feel it by touching your neck?
What is the blood flow pattern in the largest nodule?
In terms of the size the most common volume of thyroid is 7.3 ml (cu cm)
Yours is Per Brunn et al:
Right lobe is 6.7 x 2.7 x 2.8 cm. (24 cu cm)
Left lobe is 6.3 x 2.3 x 2.1 cm (14.5 cu cm)
Total 40.cu cm
Isthmus is 9 mm (normal 2.3 mm)