The Thyroid Gland
For Some, Psychiatric Trouble May Start in Thyroid
By Harriet Brown : NY Times : November 21, 2011
In patients with depression, anxiety and other psychiatric problems, doctors often find abnormal blood levels of thyroid hormone. Treating the problem, they have found, can lead to improvements in mood, memory and cognition.
Now researchers are exploring a somewhat controversial link between minor, or subclinical, thyroid problems and some patients’ psychiatric difficulties. After reviewing the literature on subclinical hypothyroidism and mood, Dr. Russell Joffe, a psychiatrist at the North Shore-Long Island Jewish Health System, and colleagues recently concluded that treating the condition, which affects about 2 percent of Americans, could alleviate some patients’ psychiatric symptoms and might even prevent future cognitive decline.
Patients with psychiatric symptoms, Dr. Joffe said, “tell us that given thyroid hormones, they get better.”
The thyroid, a bow-tie-shaped gland that wraps around the trachea, produces two hormones: thyroxine, or T4, and triiodothyronine, known as T3. These hormones play a role in a surprising range of physical processes, from regulation of body temperature and heartbeat to cognitive functioning.
Any number of things can cause the thyroid to malfunction, including exposure to radiation, too much or too little iodine in the diet, medications like lithium, and autoimmune disease. And the incidence of thyroid disease rises with age. Too much thyroid hormone (hyperthyroidism) speeds the metabolism, causing symptoms like sweating, palpitations, weight loss and anxiety. Too little (hypothyroidism) can cause physical fatigue, weight gain and sluggishness, as well as depression, inability to concentrate and memory problems.
“In the early 20th century, the best descriptions of clinical depression were actually in textbooks on thyroid disease, not psychiatric textbooks,” Dr. Joffe said.
But doctors have long disagreed about the nature of links between psychiatric symptoms and thyroid problems.
“It’s the chicken-and-egg question,” said Jennifer Davis, assistant professor of psychiatry and human behavior at Brown University. “Is there an underlying thyroid problem that causes psychiatric symptoms, or is it the other way around?”
Dr. Davis said it is common for people with thyroid problems to be given a misdiagnosis of psychiatric illness.
Leah Christian, 29, tried antidepressants 10 years ago for depression and anxiety. They did not help. “I just stayed down,” said Ms. Christian, a child care worker in San Francisco.
A few years ago, still struggling, she asked her doctor to refer her to a therapist. The doctor ran a thyroid panel first and found that Ms. Christian had an autoimmune disease called Hashimoto’s thyroiditis, a common cause of hypothyroidism.
Ms. Christian was given levothyroxine, a synthetic thyroid hormone replacement. Her depression and anxiety disappeared, she said: “Turns out, all my symptoms were thyroid-related.”
In a sense, she was lucky; her hormone levels were clearly in the abnormal range. “Normal” levels of thyroid stimulating hormone, or TSH, range from 0.4 to 5. (The higher the TSH level, the less active the thyroid.) Most endocrinologists agree that a score of 10 or over requires treatment for hypothyroidism.
But for people with scores between, say, 4 and 10, things get murkier, especially for those who experience such vague psychiatric symptoms as fatigue, mild depression or just not feeling like themselves.
Some doctors believe these patients should be treated. “If somebody has a mood disorder and subclinical hypothyroidism, that could be significant,” said Dr. Thomas Geracioti, a professor of psychiatry at the University of Cincinnati College of Medicine.
Dr. Geracioti has used thyroid hormones to treat performers with debilitating stage fright; one high-level musician recovered completely, he said.
The idea of treating subclinical hypothyroidism is controversial, especially among endocrinologists. Thyroid hormone treatment can strain the heart and may aggravate osteoporosis in women, noted Dr. Joffe. On the other hand, failing to treat the condition can also stress the heart, and some studies suggest it may increase risk of Alzheimer’s disease and other dementias.
And then there is the misery quotient, which is hard to quantify. “People tend to discount the quality-of-life issues related to residual depression and anxiety,” Dr. Joffe said.
Women are far more likely to develop thyroid problems than men, especially past age 50, and some experts believe that gender accounts for some reluctance to treat subclinical disease. “There’s a terrible bias against women who come in with subtle emotional complaints,” Dr. Davis said. “These complaints tend to be pushed aside or attributed to stress or anxiety.”
Psychiatric symptoms can be vague, subtle and highly individual, noted Dr. James Hennessey, director of clinical endocrinology at Beth Israel Deaconess Medical Center in Boston.
Another complication: It’s not clear to many experts what “normal” thyroid levels really are.
“A patient might have a TSH of 5, which many clinicians would say isn’t high enough to be associated with symptoms,” Dr. Hennessey said. “But if that person’s set point was around 0.5, that 5 would represent a tenfold increase in TSH, which might very well represent disease for that individual.”
In a study published in 2006, researchers in Anhui Province, China, used brain scans to evaluate patients with subclinical hypothyroidism both before and after treatment. They found tangible improvements in both memory and executive function after six months of levothyroxine therapy.
With funds from the National Institutes of Health, Dr. Joffe and researchers at Boston University recently began a trial to tease apart the relationship between subclinical hypothyroidism and certain mood and cognitive symptoms in people over age 60. The results won’t be known for at least a few years. But some clinicians aren’t waiting.
“I personally feel patients with TSH between 5 and 10, especially with psychiatric symptoms, warrant a trial of thyroid medication,” Dr. Hennessey said.
When to Treat a Sluggish Thyroid
By Ingfei Chen : NY Times : March 13, 2009
The symptoms are a laundry list of vague, common and easily overlooked complaints: tiredness, weight gain, ice-cold hands, thinning hair, constipation, depression and forgetfulness, to name a few. But for more than 10 million Americans, more often women than men, such woes are signs of something seriously wrong — a full-blown case of hypothyroidism, in which an underactive thyroid gland fails to crank out enough hormones.
The deficiency is easily treated by replenishing the missing hormones with synthetic ones. The benefits can be stunning, almost instantly restoring some patients to their former selves and reversing the heart risks that can come with long-term unchecked hypothyroidism.
But despite the availability of a highly successful therapy for hypothyroidism, calibrating the correct drug dosage remains a challenge for patients and their doctors. And for certain patients with thyroids that are only slightly out of whack, determining whether treatment is warranted at all remains a subject of intense debate.
Roughly 20 percent of people on thyroid replacement therapy receive more hormone than they need. “It’s easy to inadvertently overtreat people with too much medication, which may have deleterious effects,” said Dr. David S. Cooper, director of the Johns Hopkins Thyroid Clinic in Baltimore.
Potential problems include irregular heart rhythms, especially for those over 60. Over-replacement may also weaken bones, with older patients and postmenopausal women at particular risk.
Undertreatment is also a worry — 20 percent of people on thyroid hormone don’t take enough medication. This can be particularly problematic in pregnant women, because an inadequate thyroid hormone supply raises the risk of miscarriage and premature birth and may harm brain development in the fetus. There is strong consensus that many pregnant women with hypothyroidism need an increase in their dose of thyroid medication. But that hazard has touched off a debate over whether every woman who is newly pregnant or contemplating pregnancy should be screened and treated for thyroid abnormalities.
Perhaps the most difficult issue in hypothyroidism is whether to treat one group of patients at all: those with a mildly lethargic thyroid, a condition known as subclinical hypothyroidism.
Some experts, and many patient advocates, urge that anyone with mild hypothyroidism be treated to relieve any symptoms and stave off overt thyroid failure and future cardiovascular trouble. Other clinicians think treatment is unwarranted, saying there is insufficient evidence that replacement therapy protects the heart in these patients, let alone makes them feel better.
Much of the controversy surrounds the question of what constitutes “normal” thyroid function.
The standard test for diagnosing hypothyroidism checks for blood levels of a hormone called thyroid-stimulating hormone, or T.S.H., that is secreted by the brain. Acceptable levels of the hormone, which does exactly what its name says, are considered to be roughly 0.5 to 4.1 milliunits per liter.
But some groups advocate lowering the upper limit of normal. The American Association of Clinical Endocrinologists, for instance, calls for dropping that value to 3.0 to identify otherwise undiagnosed cases — a controversial move that would more than double the count of all Americans considered to have abnormal thyroid function.
Complicating the picture is recent research suggesting that a normal T.S.H. level changes with age, and that the upper limit of normal may be much higher in the elderly.
Experts previously thought that subclinical hypothyroidism cropped up much more commonly in older people than in younger age groups, with roughly 15 percent of those 70 and above showing abnormal T.S.H. readings. A 2007 analysis, however, found that the upper limit of normal for an otherwise healthy person over 80 was 7.5, nearly double the current level.
The results imply that unless age-specific T.S.H. ranges are established, many people could be misclassified with hypothyroidism and receive unnecessary lifelong drug therapy.
Furthermore, it’s unclear whether treating subclinical hypothyroidism really helps head off heart trouble, particularly in the elderly. Though past studies have linked untreated mild hypothyroidism with an increased risk of cardiovascular problems and deaths, the research was mostly done in middle-age patients.
Newer studies hint that the elderly population is different. In an investigation of people 65 and older with mild hypothyroidism, Dr. Anne R. Cappola and colleagues at the University of Pennsylvania detected no adverse cardiovascular consequences in those who went untreated. Even more surprising, in 2004,investigators in the Netherlands reported that 85-year-olds with mild thyroid deficiency lived longer than those with normal thyroids.
Subclinical hypothyroidism “may be something bad for younger people and something that’s actually in some weird alternate universe way, good for older people,” Dr. Cooper said.
Despite the lack of a consensus on how to treat subclinical hypothyroidism in the general population, many clinicians have moved toward treating individual patients on a trial basis to see if they feel better, said Dr. Kenneth D. Burman, an endocrinologist at Washington Hospital Center in Washington, D.C., who is president of the American Thyroid Association.
A T.S.H. level above 10 “suggests significant hypothyroidism, and the evidence supports treating them,” he said. If T.S.H. consistently falls between 4 and 10, the best next step is more controversial, but in middle-age or younger individuals, the tendency is to offer hormone therapy.
Doctors proceed more cautiously with elderly people over, say, age 80. “If the T.S.H. is mildly high, between 5 and 10, and they’re otherwise healthy,” Dr. Burman said, “we generally don’t treat those patients.”
Hypothyroidism Overview
Hypothyroidism is a condition in which the thyroid gland does not make enough thyroid hormone.
See also:
ALTERNATIVE NAMES
Myxedema; Adult hypothyroidism
CAUSES »
The thyroid gland is located in the front of the neck just below the voice box (larynx). It releases hormones that control metabolism.
The most common cause of hypothyroidism is inflammation of the thyroid gland, which damages the gland's cells. Autoimmune or Hashimoto's thyroiditis, in which the immune system attacks the thyroid gland, is the most common example of this. Some women develop hypothyroidism after pregnancy (often referred to as "postpartum thyroiditis").
Other common causes of hypothyroidism include:
SYMPTOMS »
Early symptoms:
EXAMS AND TESTS »
A physical examination may reveal a smaller than normal thyroid gland, although sometimes the gland is normal size or even enlarged (goiter). The examination may also reveal:
Laboratory tests to determine thyroid function include:
Lab tests may also reveal:
TREATMENT »
The purpose of treatment is to replace the thyroid hormone that is lacking. Levothyroxine is the most commonly used medication. Doctors will prescribe the lowest dose possible that effectively relieves symptoms and brings your TSH level to a normal range. If you have heart disease or you are older, your doctor may start with a very small dose.
Lifelong therapy is required unless you have a condition called transient viral thyroiditis.
You must continue taking your medication even when your symptoms go away. When starting your medication, your doctor may check your hormone levels every 2 - 3 months. After that, your thyroid hormone levels should be monitored at least every year.
Important things to remember when you are taking thyroid hormone are:
OUTLOOK (PROGNOSIS)
In most cases, thyroid levels return to normal with proper treatment. However, thyroid hormone replacement must be taken for the rest of your life.
Myxedema coma can result in death.
POSSIBLE COMPLICATIONS
Myxedema coma, the most severe form of hypothyroidism, is rare. It may be caused by an infection, illness, exposure to cold, or certain medications in people with untreated hypothyroidism.
Symptoms and signs of myxedema coma include:
WHEN TO CONTACT A MEDICAL PROFESSIONAL
Call your health care provider if you have symptoms of hypothyroidism (or myxedema).
If you are being treated for hypothyroidism, call your doctor if:
PREVENTION
There is no prevention for hypothyroidism.
Screening tests in newborns can detect hypothyroidism that is present from birth (congenital hypothyroidism).
Hypothyroidism is a condition in which the thyroid gland does not make enough thyroid hormone.
See also:
- Chronic thyroiditis (Hashimoto's disease)
- Subacute thyroiditis
- Silent thyroiditis
- Neonatal hypothyroidism
ALTERNATIVE NAMES
Myxedema; Adult hypothyroidism
CAUSES »
The thyroid gland is located in the front of the neck just below the voice box (larynx). It releases hormones that control metabolism.
The most common cause of hypothyroidism is inflammation of the thyroid gland, which damages the gland's cells. Autoimmune or Hashimoto's thyroiditis, in which the immune system attacks the thyroid gland, is the most common example of this. Some women develop hypothyroidism after pregnancy (often referred to as "postpartum thyroiditis").
Other common causes of hypothyroidism include:
- Congenital (birth) defects
- Radiation treatments to the neck to treat different cancers, which may also damage the thyroid gland
- Radioactive iodine used to treat an overactive thyroid (hyperthyroidism)
- Surgical removal of part or all of the thyroid gland, done to treat other thyroid problems
- Viral thyroiditis, which may cause hyperthyroidism and is often followed by temporary or permanent hypothyroidism
- Amiodarone
- Drugs used for hyperthyroidism (overactive thyroid), such as propylthiouracil (PTU) and methimazole
- Lithium
- Radiation to the brain
- Sheehan syndrome, a condition that may occur in a woman who bleeds severely during pregnancy or childbirth and causes destruction of the pituitary gland
- Age over 50 years
- Being female
SYMPTOMS »
Early symptoms:
- Being more sensitive to cold
- Constipation
- Depression
- Fatigue or feeling slowed down
- Heavier menstrual periods
- Joint or muscle pain
- Paleness or dry skin
- Thin, brittle hair or fingernails
- Weakness
- Weight gain (unintentional)
- Decreased taste and smell
- Hoarseness
- Puffy face, hands, and feet
- Slow speech
- Thickening of the skin
- Thinning of eyebrows
EXAMS AND TESTS »
A physical examination may reveal a smaller than normal thyroid gland, although sometimes the gland is normal size or even enlarged (goiter). The examination may also reveal:
- Brittle nails
- Coarse facial features
- Pale or dry skin, which may be cool to the touch
- Swelling of the arms and legs
- Thin and brittle hair
Laboratory tests to determine thyroid function include:
Lab tests may also reveal:
- Anemia on a complete blood count (CBC)
- Increased cholesterol levels
- Increased liver enzymes
- Increased prolactin
- Low sodium
TREATMENT »
The purpose of treatment is to replace the thyroid hormone that is lacking. Levothyroxine is the most commonly used medication. Doctors will prescribe the lowest dose possible that effectively relieves symptoms and brings your TSH level to a normal range. If you have heart disease or you are older, your doctor may start with a very small dose.
Lifelong therapy is required unless you have a condition called transient viral thyroiditis.
You must continue taking your medication even when your symptoms go away. When starting your medication, your doctor may check your hormone levels every 2 - 3 months. After that, your thyroid hormone levels should be monitored at least every year.
Important things to remember when you are taking thyroid hormone are:
- Do NOT stop taking the medication when you feel better. Continue taking the medication exactly as directed by your doctor.
- If you change brands of thyroid medicine, let your doctor know. Your levels may need to be checked.
- Some dietary changes can change the way your body absorbs the thyroid medicine. Talk with your doctor if you are eating a lot of soy products or are on a high-fiber diet.
- Thyroid medicine works best on an empty stomach and when taken 1 hour before any other medications.
- Do NOT take thyroid hormone with fiber supplements, calcium, iron, multivitamins, aluminum hydroxide antacids, colestipol, or medicines that bind bile acids.
- Palpitations
- Rapid weight loss
- Restlessness or shakiness
- Sweating
OUTLOOK (PROGNOSIS)
In most cases, thyroid levels return to normal with proper treatment. However, thyroid hormone replacement must be taken for the rest of your life.
Myxedema coma can result in death.
POSSIBLE COMPLICATIONS
Myxedema coma, the most severe form of hypothyroidism, is rare. It may be caused by an infection, illness, exposure to cold, or certain medications in people with untreated hypothyroidism.
Symptoms and signs of myxedema coma include:
- Below normal temperature
- Decreased breathing
- Low blood pressure
- Low blood sugar
- Unresponsiveness
- Heart disease
- Increased risk of infection
- Infertility
- Miscarriage
- Giving birth to a baby with birth defects
- Heart disease because of higher levels of LDL ("bad") cholesterol
- Heart failure
WHEN TO CONTACT A MEDICAL PROFESSIONAL
Call your health care provider if you have symptoms of hypothyroidism (or myxedema).
If you are being treated for hypothyroidism, call your doctor if:
- You develop chest pain or rapid heartbeat
- You have an infection
- Your symptoms get worse or do not improve with treatment
- You develop new symptoms
PREVENTION
There is no prevention for hypothyroidism.
Screening tests in newborns can detect hypothyroidism that is present from birth (congenital hypothyroidism).
Pregnancy and the Thyroid
By Ingfei Chen : NY Times : March 13, 2009
Dr. Alex Stagnaro-Green is a professor of medicine and obstetrics and gynecology at Touro University College of Medicine in Hackensack, N. J. He was a member of an international panel of experts convened by the Endocrine Society that issued a clinical practice guideline in 2007 on managing thyroid dysfunction during pregnancy and after childbirth.
Q: What is the function of the thyroid gland?
A: The thyroid releases chemicals called hormones, which are like messengers that go throughout the body and brain and control the metabolism of the body. Without having thyroid hormone, people would be tired, sluggish, get dry skin, lose their hair, gain weight and have abnormal menstrual periods.
Q: You study thyroid disease during and after pregnancy. What are the connections among thyroid deficiency, pregnancy and the immune system?
A: To understand the thyroid gland during pregnancy, you need to understand autoimmune disease, which is when the immune system, instead of fighting colds or foreign proteins, turns against the body itself. Typically, the body has a mechanism to identify its own organs and own tissues, but sometimes there’s a disease called Hashimoto’s disease, where the body loses its ability to identify the thyroid as itself and starts to destroy the thyroid. You can have antibodies in your blood that indicate the immune system is attacking the thyroid gland. But early in the process the thyroid hormone levels are normal.
Hashimoto’s thyroiditis is the most common reason for an underactive thyroid in the United States, especially in women; it’s much more common in women than in men.
Q: Why is a healthy thyroid so important for a healthy pregnancy?
A: It turns out that pregnancy is like a stress test for the thyroid: the amount of thyroid hormone that needs to be released during pregnancy is increased by about 50 percent, and that’s because of some of the hormones related to pregnancy. If there is a dysfunction with the thyroid, it has been linked — especially hypothyroidism — to miscarriage, preterm delivery, and also with decreased I.Q. in the unborn child when tested at 7 to 9 years old. Furthermore, if a woman has Hashimoto’s disease with antibodies, but with the thyroid hormone levels still being normal, that’s also been associated with a two- to threefold increase of miscarriage. So that’s why all this is very important.
Finally, an autoimmune condition called postpartum thyroiditis — again involving the immune system attacking the thyroid — can occur in the first year after a woman delivers her baby. In its classic form, the disorder unfolds as an overactive thyroid followed by an underactive thyroid followed by a return to the normal thyroid state by one year postpartum. Often, the overactive phase isn’t diagnosed because it’s typically subtle and mild, but it can result in palpitations, a tremor or rapid weight loss. Or you might not have any symptoms, and blood tests would just show the presence of antibodies against the thyroid and a mild increase in thyroid hormone levels.
Then later on with the underactive thyroid phase, there could be weight gain, sluggishness, dry skin and difficulty concentrating. Some studies, but not all, have shown an increased risk of postpartum depression. It is often hard to distinguish these symptoms from what normally goes on in the postpartum period with all the stresses of having a newborn.
Q: In 1990 you published a key study in The Journal of the American Medical Association looking at thyroid dysfunction in pregnant women. Tell us what you found.
A: We were studying postpartum thyroiditis. In the New York metropolitan area in that study, we showed that it occurs in 8.8 percent of all women. Now, you could predict who gets postpartum thyroiditis by looking at antibody status in the first trimester. Women who are antibody-positive have a 30 to 50 percent chance of postpartum thyroiditis. Women who are antibody-negative have a zero to 3 percent chance.
In our study, what we did was screen 552 women, who had normal thyroid function, for thyroid antibodies in the first trimester of pregnancy. Twenty percent of them tested positive. We followed them during pregnancy and postpartum. And what we started observing — and this was a serendipitous finding — is that women who were thyroid antibody-positive were dropping out of the study because they miscarried.
The women who were antibody-positive miscarried at twice the rate as women who were antibody-negative — 16 percent versus 8 percent. And that study has now been replicated in nine other studies with thousands and thousands of women on three to four continents. In general, research has shown anywhere between 10 to 20 percent of women of reproductive age are thyroid antibody-positive. So those women are at increased risk both for postpartum thyroiditis as well as for miscarriage.
Q: What other negative consequences of thyroid deficiency have researchers discovered, relating to pregnancy and childbirth?
A: There have been a couple of studies looking at women who have very mild or subclinical hypothyroidism. These women also have an increased risk of miscarriage in both the first and second trimester.
The next major finding was that women who have mild hypothyroidism, or who are thyroid antibody-positive, also have an increased risk of preterm delivery, giving birth before the 37th week of gestation. Preterm delivery is the No. 1 cause of neonatal morbidity and mortality in the United States.
And then, finally, there have been a number of studies looking at the impact of minimal levels of maternal hypothyroidism on the unborn child and I.Q. Probably the most famous study was conducted by Dr. James Haddow. That study showed a decrease of seven points on the I.Q. when the child was tested at 7 to 9 years old.
Q: Does correcting the thyroid deficiency reverse these bad outcomes?
A: The most exciting part of all of this are the results of the one intervention trial published to date. A researcher named Dr. Roberto Negro from southern Italy published a study in 2006 of women who were antibody-positive, but who had normal thyroid function. To half of those women he gave thyroid hormone, and to half of them he gave only a placebo.
He was able to show that the miscarriage rate in the women who got thyroid hormone and who were antibody-positive was no different than the miscarriage rate of a control group of women who didn’t have the antibodies and who didn’t take hormone. But the women who were antibody-positive who didn’t get the thyroid hormone had a miscarriage rate that was four times higher.
Similar results were seen with preterm delivery. The women who were antibody-positive and didn’t get the hormone had a tripling of the rate of preterm delivery. So the study showed a dramatic decrease in both miscarriage and preterm delivery in antibody-positive women treated with thyroid hormone versus antibody-positive women who were not treated. So this is a critically important study. There has not been a replication of it yet, but there are a couple of ongoing prospective studies looking at similar issues.
Q: What are the policy implications if those findings are confirmed?
A: The real question is, Do you recommend that all women get thyroid function tests either prepregnancy or during early pregnancy? And in the world of thyroid research, this has been an ongoing controversy and discussion, and there are different views among different organizations. The Endocrine Society put together an international group to come out with guidelines on thyroid and pregnancy, with their results published in 2007. Because Dr. Negro’s study hasn’t been replicated yet, the recommendation to date is for selective screening in high-risk women — but not a screening of all women for thyroid in pregnancy. However, I believe this can change very quickly if ongoing studies in the United Kingdom and the United States confirm Dr. Negro’s findings.
Q: Who, then, should get screening?
A: Women with a history of thyroid dysfunction or a family history of thyroid disease; a goiter; a history of being thyroid antibody-positive; symptoms of thyroid dysfunction; Type 1 diabetes or other autoimmune disease; infertility, miscarriage or preterm delivery; a history of postpartum thyroiditis; or previous radiation to the head or neck. So it’s a relatively large group.
Q: What are the cons of universal screening, at this point?
A: The downside of screening would be the expense and the concern that women would be treated, but there is not sufficient data to show that treatment works. There are four million deliveries per year in the United States. That means you would screen each of those women with a T.S.H. and thyroid antibody test. Furthermore, thyroid function tests are difficult to interpret during pregnancy, because of changes that go on hormonally. So it would take a tremendous amount of education of physicians and other health care professionals to understand how to interpret results.
Q: Let’s take the case of a woman already known to have hypothyroidism, who is planning to start a family. Can you walk through what you as an endocrinologist would do to make sure her hormone deficiency is under control during pregnancy?
A: First I educate her that about 50 to 60 percent of women who have thyroid disease and are on thyroid hormone replacement therapy will need an increase in the hormone very early in the first trimester. I explain that this is extremely important so as to prevent complications like miscarriage. And therefore we try to adjust the thyroid hormone level before a woman gets pregnant so that she’s clearly in the normal range.
Secondly, as soon as they get pregnant, I have my patients call me immediately to get thyroid function tests so that I can modify their dose as early as possible in the pregnancy. Bottom line is that as soon as a woman knows she is pregnant she should be tested and see her doctor.
Q: And after that initial adjustment in dosage, how often should she return for thyroid testing?
A: About four weeks later. If you don’t make an adjustment initially, and it’s still early in the first trimester, she should come back another time within the first trimester. And then a minimum of once in the second and once in the third trimester.
Finally, women should be seen again four to six weeks postpartum, as the dose typically needs to be adjusted, often to the dose they were on prior to becoming pregnant.
By Ingfei Chen : NY Times : March 13, 2009
Dr. Alex Stagnaro-Green is a professor of medicine and obstetrics and gynecology at Touro University College of Medicine in Hackensack, N. J. He was a member of an international panel of experts convened by the Endocrine Society that issued a clinical practice guideline in 2007 on managing thyroid dysfunction during pregnancy and after childbirth.
Q: What is the function of the thyroid gland?
A: The thyroid releases chemicals called hormones, which are like messengers that go throughout the body and brain and control the metabolism of the body. Without having thyroid hormone, people would be tired, sluggish, get dry skin, lose their hair, gain weight and have abnormal menstrual periods.
Q: You study thyroid disease during and after pregnancy. What are the connections among thyroid deficiency, pregnancy and the immune system?
A: To understand the thyroid gland during pregnancy, you need to understand autoimmune disease, which is when the immune system, instead of fighting colds or foreign proteins, turns against the body itself. Typically, the body has a mechanism to identify its own organs and own tissues, but sometimes there’s a disease called Hashimoto’s disease, where the body loses its ability to identify the thyroid as itself and starts to destroy the thyroid. You can have antibodies in your blood that indicate the immune system is attacking the thyroid gland. But early in the process the thyroid hormone levels are normal.
Hashimoto’s thyroiditis is the most common reason for an underactive thyroid in the United States, especially in women; it’s much more common in women than in men.
Q: Why is a healthy thyroid so important for a healthy pregnancy?
A: It turns out that pregnancy is like a stress test for the thyroid: the amount of thyroid hormone that needs to be released during pregnancy is increased by about 50 percent, and that’s because of some of the hormones related to pregnancy. If there is a dysfunction with the thyroid, it has been linked — especially hypothyroidism — to miscarriage, preterm delivery, and also with decreased I.Q. in the unborn child when tested at 7 to 9 years old. Furthermore, if a woman has Hashimoto’s disease with antibodies, but with the thyroid hormone levels still being normal, that’s also been associated with a two- to threefold increase of miscarriage. So that’s why all this is very important.
Finally, an autoimmune condition called postpartum thyroiditis — again involving the immune system attacking the thyroid — can occur in the first year after a woman delivers her baby. In its classic form, the disorder unfolds as an overactive thyroid followed by an underactive thyroid followed by a return to the normal thyroid state by one year postpartum. Often, the overactive phase isn’t diagnosed because it’s typically subtle and mild, but it can result in palpitations, a tremor or rapid weight loss. Or you might not have any symptoms, and blood tests would just show the presence of antibodies against the thyroid and a mild increase in thyroid hormone levels.
Then later on with the underactive thyroid phase, there could be weight gain, sluggishness, dry skin and difficulty concentrating. Some studies, but not all, have shown an increased risk of postpartum depression. It is often hard to distinguish these symptoms from what normally goes on in the postpartum period with all the stresses of having a newborn.
Q: In 1990 you published a key study in The Journal of the American Medical Association looking at thyroid dysfunction in pregnant women. Tell us what you found.
A: We were studying postpartum thyroiditis. In the New York metropolitan area in that study, we showed that it occurs in 8.8 percent of all women. Now, you could predict who gets postpartum thyroiditis by looking at antibody status in the first trimester. Women who are antibody-positive have a 30 to 50 percent chance of postpartum thyroiditis. Women who are antibody-negative have a zero to 3 percent chance.
In our study, what we did was screen 552 women, who had normal thyroid function, for thyroid antibodies in the first trimester of pregnancy. Twenty percent of them tested positive. We followed them during pregnancy and postpartum. And what we started observing — and this was a serendipitous finding — is that women who were thyroid antibody-positive were dropping out of the study because they miscarried.
The women who were antibody-positive miscarried at twice the rate as women who were antibody-negative — 16 percent versus 8 percent. And that study has now been replicated in nine other studies with thousands and thousands of women on three to four continents. In general, research has shown anywhere between 10 to 20 percent of women of reproductive age are thyroid antibody-positive. So those women are at increased risk both for postpartum thyroiditis as well as for miscarriage.
Q: What other negative consequences of thyroid deficiency have researchers discovered, relating to pregnancy and childbirth?
A: There have been a couple of studies looking at women who have very mild or subclinical hypothyroidism. These women also have an increased risk of miscarriage in both the first and second trimester.
The next major finding was that women who have mild hypothyroidism, or who are thyroid antibody-positive, also have an increased risk of preterm delivery, giving birth before the 37th week of gestation. Preterm delivery is the No. 1 cause of neonatal morbidity and mortality in the United States.
And then, finally, there have been a number of studies looking at the impact of minimal levels of maternal hypothyroidism on the unborn child and I.Q. Probably the most famous study was conducted by Dr. James Haddow. That study showed a decrease of seven points on the I.Q. when the child was tested at 7 to 9 years old.
Q: Does correcting the thyroid deficiency reverse these bad outcomes?
A: The most exciting part of all of this are the results of the one intervention trial published to date. A researcher named Dr. Roberto Negro from southern Italy published a study in 2006 of women who were antibody-positive, but who had normal thyroid function. To half of those women he gave thyroid hormone, and to half of them he gave only a placebo.
He was able to show that the miscarriage rate in the women who got thyroid hormone and who were antibody-positive was no different than the miscarriage rate of a control group of women who didn’t have the antibodies and who didn’t take hormone. But the women who were antibody-positive who didn’t get the thyroid hormone had a miscarriage rate that was four times higher.
Similar results were seen with preterm delivery. The women who were antibody-positive and didn’t get the hormone had a tripling of the rate of preterm delivery. So the study showed a dramatic decrease in both miscarriage and preterm delivery in antibody-positive women treated with thyroid hormone versus antibody-positive women who were not treated. So this is a critically important study. There has not been a replication of it yet, but there are a couple of ongoing prospective studies looking at similar issues.
Q: What are the policy implications if those findings are confirmed?
A: The real question is, Do you recommend that all women get thyroid function tests either prepregnancy or during early pregnancy? And in the world of thyroid research, this has been an ongoing controversy and discussion, and there are different views among different organizations. The Endocrine Society put together an international group to come out with guidelines on thyroid and pregnancy, with their results published in 2007. Because Dr. Negro’s study hasn’t been replicated yet, the recommendation to date is for selective screening in high-risk women — but not a screening of all women for thyroid in pregnancy. However, I believe this can change very quickly if ongoing studies in the United Kingdom and the United States confirm Dr. Negro’s findings.
Q: Who, then, should get screening?
A: Women with a history of thyroid dysfunction or a family history of thyroid disease; a goiter; a history of being thyroid antibody-positive; symptoms of thyroid dysfunction; Type 1 diabetes or other autoimmune disease; infertility, miscarriage or preterm delivery; a history of postpartum thyroiditis; or previous radiation to the head or neck. So it’s a relatively large group.
Q: What are the cons of universal screening, at this point?
A: The downside of screening would be the expense and the concern that women would be treated, but there is not sufficient data to show that treatment works. There are four million deliveries per year in the United States. That means you would screen each of those women with a T.S.H. and thyroid antibody test. Furthermore, thyroid function tests are difficult to interpret during pregnancy, because of changes that go on hormonally. So it would take a tremendous amount of education of physicians and other health care professionals to understand how to interpret results.
Q: Let’s take the case of a woman already known to have hypothyroidism, who is planning to start a family. Can you walk through what you as an endocrinologist would do to make sure her hormone deficiency is under control during pregnancy?
A: First I educate her that about 50 to 60 percent of women who have thyroid disease and are on thyroid hormone replacement therapy will need an increase in the hormone very early in the first trimester. I explain that this is extremely important so as to prevent complications like miscarriage. And therefore we try to adjust the thyroid hormone level before a woman gets pregnant so that she’s clearly in the normal range.
Secondly, as soon as they get pregnant, I have my patients call me immediately to get thyroid function tests so that I can modify their dose as early as possible in the pregnancy. Bottom line is that as soon as a woman knows she is pregnant she should be tested and see her doctor.
Q: And after that initial adjustment in dosage, how often should she return for thyroid testing?
A: About four weeks later. If you don’t make an adjustment initially, and it’s still early in the first trimester, she should come back another time within the first trimester. And then a minimum of once in the second and once in the third trimester.
Finally, women should be seen again four to six weeks postpartum, as the dose typically needs to be adjusted, often to the dose they were on prior to becoming pregnant.
Getting a Handle on Your Underactive Thyroid
By Ingfein Chen : NT Times : March 9, 2009
Dr. Anne R. Cappola is an endocrinologist and assistant professor of medicine in the division of endocrinology, diabetes and metabolism at the University of Pennsylvania School of Medicine. Here are five things she thinks every patient with an underactive thyroid should know.
1. There is no known way to prevent hypothyroidism.
“One thing that we tell people is that they didn’t do anything to cause this,” Dr. Cappola said. The most common cause of thyroid hormone deficiency is an inherited predisposition to develop an inflammation of the thyroid gland, called Hashimoto’s disease. In other cases, hypothyroidism is triggered by certain medications, like lithium or interferon; then the problem is often reversible.
2. The only way to diagnose hypothyroidism is through a blood test.
Doctors measure thyroid-stimulating hormone levels to assess a person’s thyroid function.
3. Thyroid hormone replacement is the gold standard treatment.
“You can’t cure hypothyroidism, you just replace,” Dr. Cappola said. Restoring thyroid hormone levels is the only solution that relieves the fatigue, weight gain, coldness and other symptoms caused by hypothyroidism. Endocrinologists agree that levothyroxine is the best medication to use. Left untreated, thyroid deficiency may foster a higher risk of cardiovascular disease and heart failure.
4. Regular thyroid checks are critical.
Although too little thyroid hormone can cause problems, so can taking too much. Over-replacement of hormone may lead to hyperthyroidism, potentially resulting in osteoporosis or an irregular heartbeat. Doctors need to “monitor people very closely and keep them in the normal range,” Dr. Cappola said. After first starting thyroid hormone medication, patients take another T.S.H. test six weeks later; their dose is adjusted as needed. “They keep getting tested six weeks after each dose change until they’re in the normal range,” Dr. Cappola said. “Once they’re stable, they only need to be checked once a year.”
5. Certain events alter how much thyroid hormone the body requires.
During pregnancy, for example, women often need much more of the hormone. For the elderly, hormone requirements may go down with increasing age. People with celiac disease, who have difficulty with absorption in the small intestine, also may need higher levothyroxine doses. And while certain unrelated remedies — like antacids and calcium or iron supplements — can hinder absorption of the hormone, other drugs, like phenobarbital for treating seizures, increase it. If any of these situations apply to you, consult your doctor about raising or lowering your thyroid hormone intake as appropriate. Sometimes the solution is simpler: If you begin taking a multivitamin containing iron, for example, take it at a different time of day than your hormone pill.
By Ingfein Chen : NT Times : March 9, 2009
Dr. Anne R. Cappola is an endocrinologist and assistant professor of medicine in the division of endocrinology, diabetes and metabolism at the University of Pennsylvania School of Medicine. Here are five things she thinks every patient with an underactive thyroid should know.
1. There is no known way to prevent hypothyroidism.
“One thing that we tell people is that they didn’t do anything to cause this,” Dr. Cappola said. The most common cause of thyroid hormone deficiency is an inherited predisposition to develop an inflammation of the thyroid gland, called Hashimoto’s disease. In other cases, hypothyroidism is triggered by certain medications, like lithium or interferon; then the problem is often reversible.
2. The only way to diagnose hypothyroidism is through a blood test.
Doctors measure thyroid-stimulating hormone levels to assess a person’s thyroid function.
3. Thyroid hormone replacement is the gold standard treatment.
“You can’t cure hypothyroidism, you just replace,” Dr. Cappola said. Restoring thyroid hormone levels is the only solution that relieves the fatigue, weight gain, coldness and other symptoms caused by hypothyroidism. Endocrinologists agree that levothyroxine is the best medication to use. Left untreated, thyroid deficiency may foster a higher risk of cardiovascular disease and heart failure.
4. Regular thyroid checks are critical.
Although too little thyroid hormone can cause problems, so can taking too much. Over-replacement of hormone may lead to hyperthyroidism, potentially resulting in osteoporosis or an irregular heartbeat. Doctors need to “monitor people very closely and keep them in the normal range,” Dr. Cappola said. After first starting thyroid hormone medication, patients take another T.S.H. test six weeks later; their dose is adjusted as needed. “They keep getting tested six weeks after each dose change until they’re in the normal range,” Dr. Cappola said. “Once they’re stable, they only need to be checked once a year.”
5. Certain events alter how much thyroid hormone the body requires.
During pregnancy, for example, women often need much more of the hormone. For the elderly, hormone requirements may go down with increasing age. People with celiac disease, who have difficulty with absorption in the small intestine, also may need higher levothyroxine doses. And while certain unrelated remedies — like antacids and calcium or iron supplements — can hinder absorption of the hormone, other drugs, like phenobarbital for treating seizures, increase it. If any of these situations apply to you, consult your doctor about raising or lowering your thyroid hormone intake as appropriate. Sometimes the solution is simpler: If you begin taking a multivitamin containing iron, for example, take it at a different time of day than your hormone pill.
New Call for More Thyroid Options
By Sumathi Reddy : WSJ : August 5, 2013
Some people with hypothyroidism, or underactive thyroid glands, are organizing and agitating. Their complaint? That traditional means for diagnosing and treating the condition don't work for all patients.
Grass roots patient-activist organizations with names like ThyroidChange and Thyroid Patient Advocacy, and the doctor-founded National Academy of Hypothyroidism, say that the current screening test for hypothyroidism leaves out some symptomatic patients and that the main medication used to treat patients, doesn't always alleviate many symptoms.
They are calling for doctors to be open to other therapies, including a combination of synthetic hormones and the use of natural, animal-based ones.
"There are so many unhappy thyroid patients," says Ridha Arem, an endocrinologist and director of the Texas Thyroid Institute, who founded the journal Clinical Thyroidology. He believes recommended screening and treatment options for hypothyroidism—which occurs when thyroid glands fail to produce enough hormones to keep the body's metabolism working properly—aren't always adequate.
Many of his mainstream medical counterparts disagree. "The vast majority of people are fine on the standard therapy," says Jeffrey Garber, an associate professor of medicine at Harvard Medical Center and chair of the American Association of Clinical Endocrinologists Thyroid Scientific Committee. Still, he says, "there's a whole group out there who just thinks we're clueless."
Dr. Garber, one of the authors who updated the clinical-practice guidelines for hypothyroidism last year, says while there have been some intriguing studies looking at different therapies, more research is needed.
Hypothyroidism, the most common thyroid disorder, is most often caused by an autoimmune disorder called Hashimoto's disease, in which the body's immune system attacks the thyroid.
The thyroid is a U-shaped gland composed of soft tissue that sits in the front lower part of the neck. The tissue releases chemicals, or thyroid hormones, that circulate through the bloodstream and affect the metabolic system, and other functions in the body. When thyroid hormone levels are too low, people start to feel sluggish and tired. Other symptoms can include weight gain, hair loss, constipation, muscle aches, high cholesterol and depression.
The wide range of symptoms, so similar to those of many other diseases, can make diagnosis tough. When testing the thyroid-stimulating hormone (TSH) levels—generally used as the deciding factor in putting patients on medication—higher ones signal a more underactive gland. But because TSH levels fluctuate within an individual, testing alone may dismiss worthy patients, says Dr. Arem of the Texas Thyroid Institute. He says he uses a more narrow range of TSH when diagnosing patients and looks at other factors, as well, such as family history and ultrasound tests of the thyroid gland.
Newborns and pregnant woman are routinely tested. Experts recommend screening all women over the age of 35 every five years.
For treatment, guidelines generally call for the prescription of levothyroxine, a synthetic version of a hormone called thyroxine, or T4, which is produced by the thyroid. The gland also produces one other hormone, Triiodothyronine, or T3.
Most doctors, says Dr. Arem, generally prescribe T4-only medications. But such medications may leave some patients with lingering symptoms such as fatigue and depression and, in some cases, low T3 levels.
Some patients go to alternative health professionals to get prescriptions for drugs such as desiccated thyroid extract (DTE) prepared from animal thyroid glands, which include a combination of T4 and T3.
The danger here, Dr. Arem says, is such patients could end up with an excessive amount of T3, resulting in symptoms of overactive thyroids, such as anxiety and a fast or irregular heart rate. He advocates a combination approach with amounts tailored to the individual.
Michelle Bickford, 36, co-founder of advocacy group ThyroidChange, was diagnosed with Hashimoto's when she was 11. She was on levothyroxine for years, but found she still suffered from symptoms such as depression, anxiety and fatigue. "When I complained of these things to my doctors they generally just told me to go see a dermatologist or go see a psychiatrist," says the adjunct communications professor at Montclair State University in New Jersey.
About six months ago, she got a prescription for a combination, animal-derived medication. "I feel much better," she said. "I have a lot of energy, I started to lose weight."
Most studies looking at combination approaches show conflicting results. One study, published in May in the Journal of Clinical Endocrinology & Metabolism, conducted a randomized controlled double-blind trial using levothyroxine and DTE.
About half the patients preferred the DTE therapy, which led to modest weight loss. But it didn't result in a significant improvement in quality of life, as measured by a patient questionnaire. The study's authors said in a news release that it showed DTE may be a good alternative therapy for a limited number of patients. Harvard's Dr. Garber says there may be certain subsets who are genetically programmed to respond to such combination therapies.
Dr. Garber, like many endocrinologists, uses T4 medications with the vast majority of his patients. Occasionally he'll also use conservative doses of a synthetic T3 drug, but he virtually never prescribes the animal-derived form, he says, because of complications that could arise for women trying to get pregnant or in early pregnancy, as well as individuals with heart disease.
Doctors Hear Patients’ Calls for New Approaches to Hypothyroidism
Wider treatment options for a hormone condition easily mistaken for other illnesses
Melinda Beck : WSJ :April 11, 2016
Doctors and patients have been at each other’s throats for decades over how to treat a little gland in the neck—and patients may be gaining ground.
The butterfly-shaped thyroid gland produces hormones that regulate virtually every system in the body. Not enough production of thyroid hormones, known has hypothyroidism, can cause fatigue, weight gain, depression and other metabolic and fertility problems. Too much, the less common hyperthyroidism, can cause heart palpitations, tremors and bone loss.
Because those symptoms can have several other causes, many doctors diagnose thyroid disorders mainly with blood tests. Many also rely on a single form of treatment for hypothyroidism, which has made the synthetic hormone levothyroxine (Synthroid and other brands) among the most prescribed medications in the world.
But a vocal group of patients say they haven’t gotten better on levothyroxine, though their blood tests have returned to normal. They’ve banded together online to share their frustrations and promote alternative therapies.
Some top endocrinologists are coming around to their view. Studies have confirmed that 5% to 15% of patients don’t get better on levothyroxine alone. Discoveries of gene variations may help explain why.
“More doctors are thinking, ‘Have we missed something? Could there be a role for combination therapy in some patients?’ ” saysJacqueline Jonklaas, an endocrinologist at Georgetown University Medical Center.
“I credit this to patients pushing doctors and saying, ‘You don’t know what you’re talking about. I don’t feel fine,’ ” says Antonio Bianco,president of the American Thyroid Association. Dr. Bianco, who is also chief of endocrinology at Rush University Medical Center in Chicago, says he has refocused the research to search for answers for such patients.
Dr. Jonklaas and Dr. Bianco co-wrote the association’s 2014 guidelines, which acknowledged that not all patients improve on levothyroxine. The guidelines said there was insufficient evidence to recommend other therapies, but many task force members thought they could be used on an individual basis, Dr. Jonklaas says.
Plenty of endocrinologists remain guarded about alternate thyroid treatments. James Hennessey, chief of endocrinology at Beth Israel Deaconess Medical Center in Boston, notes that a long list of other conditions have symptoms similar to thyroid disorders, including obesity, diabetes, sleep apnea, depression, kidney failure, congestive heart failure and chronic fatigue. He says doctors should investigate them all before trying alternative thyroid treatments.
HOW DOCTORS TEST THYROIDSSome patients want doctors to try more than one test:
A TSH test measures thyroid-stimulating hormone, or TSH, a signal from the pituitary gland that the body needs more thyroid hormone.
A Free T3 test measures triiodothyronine, or T3, the active thyroid hormone. High levels may indicate Graves’ disease. Low levels may signal thyroid deficiency.
A Free T4 test measures thyroxine, or T4, in the bloodstream that can be converted to T3 in the tissues. High levels indicate hyperthyroidism. Low levels indicate hypothyroidism.
Tests measure thyroid peroxidase antibodies, or TPOAb, or thyroglobulin antibodies, or TgAb. High levels indicate the autoimmune condition Hashimoto’s disease is affecting the thyroid.
A physical exam checks the thyroid gland for nodules or tumors.
An estimated 20 million Americans suffer from hypothyroidism, according to the American Thyroid Association. Other estimates run as high as 60 million, depending on the criteria used. About 80% are women and about 60% are undiagnosed, in part because the symptoms mimic other disorders.
Many endocrinologists urge primary-care physicians to check thyroid levels before treating patients for depression, bipolar disorder, diabetes, high cholesterol and infertility problems. But some patients say many doctors don’t.
Hypothyroidism was treated for decades with extracts made from dried, or desiccated, pig thyroids. Brands such as Armour Thyroid supplied both of the hormones secreted by the thyroid gland—thyroxine (T4) and triiodothyronine (T3).
For years, doctors adjusted dosages based on patients’ symptoms. But overdoses, leading to heart problems and bone loss, were common, experts say.
In the 1970s, researchers developed a test for thyroid-stimulating hormone (TSH), the signal the pituitary gland sends the thyroid to release more hormones. (An elevated TSH level means thyroid levels are low.) Scientists also discovered that the hormone T4 is converted to T3, the more active form, in the tissues. And they determined that giving patients synthetic T4—levothyroxine—was all that was needed to return TSH levels to normal.
Mary Shomon, who was diagnosed with hypothyroidism in 1995, became an early activist, writing on About.com on thyroid issues and later founding her own site,thyroid-info.com.But some hypothyroid patients didn’t feel better on levothyroxine alone—and couldn’t convince their doctors they still had thyroid issues.
She says many women recognize their symptoms when they learn about hypothyroidism or have symptoms persist after they are treated. But all too often, doctors dismiss them as whiny or lazy if their TSH is in the normal range.
“It’s so much easier to tell a woman to get up off the couch or hand her a prescription for antidepressants,” says Ms. Shomon, who is based in Washington, D.C.
Despite the new approach by some doctors, she says she still hears from women who have trouble getting doctors to listen to their symptoms. “I’ve had people tell me they were ‘fired’ by their doctors for asking for T3,” she says.
She and other patient activists urge doctors not to test TSH alone, but also T4 and T3 levels, and thyroid antibodies, a sign of the autoimmune condition Hashimoto’s disease, in which the immune system mistakenly attacks the thyroid gland. “With Hashimoto’s, you can have the whole laundry list of symptoms and all your other levels will look normal,” she says.
She has since founded a website, Hypothyroid Mom, which gets nearly 1 million unique visits a month. “I think my life’s mission is to get universal thyroid screening for pregnant women,” she says.Another patient activist,Dana Trentini of Jersey City, N.J., was diagnosed with hypothyroidism after her first pregnancy in 2006. But her second pregnancy ended in miscarriage—in part, she believes, because her prescribed dose of T4 brought her TSH level only down to 8. Experts now recommend that pregnant women have a TSH below 2.5.
Some patients insist they feel better on Armour Thyroid and other natural thyroid extracts that deliver T3 as well as T4. But manufacturing shortages and industry consolidation have made such products difficult to find at times.
Many doctors are wary, because such animal thyroid extracts contains a higher ratio of T3 to T4 than humans have and could raise the risk of heart and bone problems.
Some doctors are more comfortable prescribing synthetic T3—brand name Cytomel—which comes in very small doses.
Giving Cytomel alone, or in combination with T4, has been tested in nearly two dozen clinical trials. Results have been mixed—in part, some researcher say, because T3 peaks and fades very quickly in the bloodstream, so it’s difficult to sustain therapeutic levels.
“It’s not the golden ticket,” says Elizabeth McAninch, an endocrinologist at Rush University Medical Center. “I have some patients who feel better on combination therapy and some who don’t.”
Dr. Jonklaas and other researchers involved in the 2014 guidelines also hope to do a clinical trial with 1,200 hypothyroid patients on either T4 alone, T3 and T4 in combination or desiccated thyroid extract. They also plan to test participants for genetic variations and hope to identify subsets of patients who respond better to one treatment or another.
Meanwhile, she and other endocrinologists say they are increasingly willing to try a small dose of T3 in patients who don’t feel better on T4 alone.
“I tell patients I don’t have a clinical trial that shows this is the right thing to do, but based on my experience, I suggest we try this for three or six months,” Dr. Bianco says. “If there’s no clear evidence of benefit, we’ll discontinue it.”
“The important thing is to try to make the patient feel better and do it in a safe way,” he says.
Hashimoto's Disease: A Primer
How to spot and treat the leading cause of an underactive thyroid.
By Sumathi Reddy : WSJ : August 5, 2013
Some people with hypothyroidism, or underactive thyroid glands, are organizing and agitating. Their complaint? That traditional means for diagnosing and treating the condition don't work for all patients.
Grass roots patient-activist organizations with names like ThyroidChange and Thyroid Patient Advocacy, and the doctor-founded National Academy of Hypothyroidism, say that the current screening test for hypothyroidism leaves out some symptomatic patients and that the main medication used to treat patients, doesn't always alleviate many symptoms.
They are calling for doctors to be open to other therapies, including a combination of synthetic hormones and the use of natural, animal-based ones.
"There are so many unhappy thyroid patients," says Ridha Arem, an endocrinologist and director of the Texas Thyroid Institute, who founded the journal Clinical Thyroidology. He believes recommended screening and treatment options for hypothyroidism—which occurs when thyroid glands fail to produce enough hormones to keep the body's metabolism working properly—aren't always adequate.
Many of his mainstream medical counterparts disagree. "The vast majority of people are fine on the standard therapy," says Jeffrey Garber, an associate professor of medicine at Harvard Medical Center and chair of the American Association of Clinical Endocrinologists Thyroid Scientific Committee. Still, he says, "there's a whole group out there who just thinks we're clueless."
Dr. Garber, one of the authors who updated the clinical-practice guidelines for hypothyroidism last year, says while there have been some intriguing studies looking at different therapies, more research is needed.
Hypothyroidism, the most common thyroid disorder, is most often caused by an autoimmune disorder called Hashimoto's disease, in which the body's immune system attacks the thyroid.
The thyroid is a U-shaped gland composed of soft tissue that sits in the front lower part of the neck. The tissue releases chemicals, or thyroid hormones, that circulate through the bloodstream and affect the metabolic system, and other functions in the body. When thyroid hormone levels are too low, people start to feel sluggish and tired. Other symptoms can include weight gain, hair loss, constipation, muscle aches, high cholesterol and depression.
The wide range of symptoms, so similar to those of many other diseases, can make diagnosis tough. When testing the thyroid-stimulating hormone (TSH) levels—generally used as the deciding factor in putting patients on medication—higher ones signal a more underactive gland. But because TSH levels fluctuate within an individual, testing alone may dismiss worthy patients, says Dr. Arem of the Texas Thyroid Institute. He says he uses a more narrow range of TSH when diagnosing patients and looks at other factors, as well, such as family history and ultrasound tests of the thyroid gland.
Newborns and pregnant woman are routinely tested. Experts recommend screening all women over the age of 35 every five years.
For treatment, guidelines generally call for the prescription of levothyroxine, a synthetic version of a hormone called thyroxine, or T4, which is produced by the thyroid. The gland also produces one other hormone, Triiodothyronine, or T3.
Most doctors, says Dr. Arem, generally prescribe T4-only medications. But such medications may leave some patients with lingering symptoms such as fatigue and depression and, in some cases, low T3 levels.
Some patients go to alternative health professionals to get prescriptions for drugs such as desiccated thyroid extract (DTE) prepared from animal thyroid glands, which include a combination of T4 and T3.
The danger here, Dr. Arem says, is such patients could end up with an excessive amount of T3, resulting in symptoms of overactive thyroids, such as anxiety and a fast or irregular heart rate. He advocates a combination approach with amounts tailored to the individual.
Michelle Bickford, 36, co-founder of advocacy group ThyroidChange, was diagnosed with Hashimoto's when she was 11. She was on levothyroxine for years, but found she still suffered from symptoms such as depression, anxiety and fatigue. "When I complained of these things to my doctors they generally just told me to go see a dermatologist or go see a psychiatrist," says the adjunct communications professor at Montclair State University in New Jersey.
About six months ago, she got a prescription for a combination, animal-derived medication. "I feel much better," she said. "I have a lot of energy, I started to lose weight."
Most studies looking at combination approaches show conflicting results. One study, published in May in the Journal of Clinical Endocrinology & Metabolism, conducted a randomized controlled double-blind trial using levothyroxine and DTE.
About half the patients preferred the DTE therapy, which led to modest weight loss. But it didn't result in a significant improvement in quality of life, as measured by a patient questionnaire. The study's authors said in a news release that it showed DTE may be a good alternative therapy for a limited number of patients. Harvard's Dr. Garber says there may be certain subsets who are genetically programmed to respond to such combination therapies.
Dr. Garber, like many endocrinologists, uses T4 medications with the vast majority of his patients. Occasionally he'll also use conservative doses of a synthetic T3 drug, but he virtually never prescribes the animal-derived form, he says, because of complications that could arise for women trying to get pregnant or in early pregnancy, as well as individuals with heart disease.
Doctors Hear Patients’ Calls for New Approaches to Hypothyroidism
Wider treatment options for a hormone condition easily mistaken for other illnesses
Melinda Beck : WSJ :April 11, 2016
Doctors and patients have been at each other’s throats for decades over how to treat a little gland in the neck—and patients may be gaining ground.
The butterfly-shaped thyroid gland produces hormones that regulate virtually every system in the body. Not enough production of thyroid hormones, known has hypothyroidism, can cause fatigue, weight gain, depression and other metabolic and fertility problems. Too much, the less common hyperthyroidism, can cause heart palpitations, tremors and bone loss.
Because those symptoms can have several other causes, many doctors diagnose thyroid disorders mainly with blood tests. Many also rely on a single form of treatment for hypothyroidism, which has made the synthetic hormone levothyroxine (Synthroid and other brands) among the most prescribed medications in the world.
But a vocal group of patients say they haven’t gotten better on levothyroxine, though their blood tests have returned to normal. They’ve banded together online to share their frustrations and promote alternative therapies.
Some top endocrinologists are coming around to their view. Studies have confirmed that 5% to 15% of patients don’t get better on levothyroxine alone. Discoveries of gene variations may help explain why.
“More doctors are thinking, ‘Have we missed something? Could there be a role for combination therapy in some patients?’ ” saysJacqueline Jonklaas, an endocrinologist at Georgetown University Medical Center.
“I credit this to patients pushing doctors and saying, ‘You don’t know what you’re talking about. I don’t feel fine,’ ” says Antonio Bianco,president of the American Thyroid Association. Dr. Bianco, who is also chief of endocrinology at Rush University Medical Center in Chicago, says he has refocused the research to search for answers for such patients.
Dr. Jonklaas and Dr. Bianco co-wrote the association’s 2014 guidelines, which acknowledged that not all patients improve on levothyroxine. The guidelines said there was insufficient evidence to recommend other therapies, but many task force members thought they could be used on an individual basis, Dr. Jonklaas says.
Plenty of endocrinologists remain guarded about alternate thyroid treatments. James Hennessey, chief of endocrinology at Beth Israel Deaconess Medical Center in Boston, notes that a long list of other conditions have symptoms similar to thyroid disorders, including obesity, diabetes, sleep apnea, depression, kidney failure, congestive heart failure and chronic fatigue. He says doctors should investigate them all before trying alternative thyroid treatments.
HOW DOCTORS TEST THYROIDSSome patients want doctors to try more than one test:
A TSH test measures thyroid-stimulating hormone, or TSH, a signal from the pituitary gland that the body needs more thyroid hormone.
A Free T3 test measures triiodothyronine, or T3, the active thyroid hormone. High levels may indicate Graves’ disease. Low levels may signal thyroid deficiency.
A Free T4 test measures thyroxine, or T4, in the bloodstream that can be converted to T3 in the tissues. High levels indicate hyperthyroidism. Low levels indicate hypothyroidism.
Tests measure thyroid peroxidase antibodies, or TPOAb, or thyroglobulin antibodies, or TgAb. High levels indicate the autoimmune condition Hashimoto’s disease is affecting the thyroid.
A physical exam checks the thyroid gland for nodules or tumors.
An estimated 20 million Americans suffer from hypothyroidism, according to the American Thyroid Association. Other estimates run as high as 60 million, depending on the criteria used. About 80% are women and about 60% are undiagnosed, in part because the symptoms mimic other disorders.
Many endocrinologists urge primary-care physicians to check thyroid levels before treating patients for depression, bipolar disorder, diabetes, high cholesterol and infertility problems. But some patients say many doctors don’t.
Hypothyroidism was treated for decades with extracts made from dried, or desiccated, pig thyroids. Brands such as Armour Thyroid supplied both of the hormones secreted by the thyroid gland—thyroxine (T4) and triiodothyronine (T3).
For years, doctors adjusted dosages based on patients’ symptoms. But overdoses, leading to heart problems and bone loss, were common, experts say.
In the 1970s, researchers developed a test for thyroid-stimulating hormone (TSH), the signal the pituitary gland sends the thyroid to release more hormones. (An elevated TSH level means thyroid levels are low.) Scientists also discovered that the hormone T4 is converted to T3, the more active form, in the tissues. And they determined that giving patients synthetic T4—levothyroxine—was all that was needed to return TSH levels to normal.
Mary Shomon, who was diagnosed with hypothyroidism in 1995, became an early activist, writing on About.com on thyroid issues and later founding her own site,thyroid-info.com.But some hypothyroid patients didn’t feel better on levothyroxine alone—and couldn’t convince their doctors they still had thyroid issues.
She says many women recognize their symptoms when they learn about hypothyroidism or have symptoms persist after they are treated. But all too often, doctors dismiss them as whiny or lazy if their TSH is in the normal range.
“It’s so much easier to tell a woman to get up off the couch or hand her a prescription for antidepressants,” says Ms. Shomon, who is based in Washington, D.C.
Despite the new approach by some doctors, she says she still hears from women who have trouble getting doctors to listen to their symptoms. “I’ve had people tell me they were ‘fired’ by their doctors for asking for T3,” she says.
She and other patient activists urge doctors not to test TSH alone, but also T4 and T3 levels, and thyroid antibodies, a sign of the autoimmune condition Hashimoto’s disease, in which the immune system mistakenly attacks the thyroid gland. “With Hashimoto’s, you can have the whole laundry list of symptoms and all your other levels will look normal,” she says.
She has since founded a website, Hypothyroid Mom, which gets nearly 1 million unique visits a month. “I think my life’s mission is to get universal thyroid screening for pregnant women,” she says.Another patient activist,Dana Trentini of Jersey City, N.J., was diagnosed with hypothyroidism after her first pregnancy in 2006. But her second pregnancy ended in miscarriage—in part, she believes, because her prescribed dose of T4 brought her TSH level only down to 8. Experts now recommend that pregnant women have a TSH below 2.5.
Some patients insist they feel better on Armour Thyroid and other natural thyroid extracts that deliver T3 as well as T4. But manufacturing shortages and industry consolidation have made such products difficult to find at times.
Many doctors are wary, because such animal thyroid extracts contains a higher ratio of T3 to T4 than humans have and could raise the risk of heart and bone problems.
Some doctors are more comfortable prescribing synthetic T3—brand name Cytomel—which comes in very small doses.
Giving Cytomel alone, or in combination with T4, has been tested in nearly two dozen clinical trials. Results have been mixed—in part, some researcher say, because T3 peaks and fades very quickly in the bloodstream, so it’s difficult to sustain therapeutic levels.
“It’s not the golden ticket,” says Elizabeth McAninch, an endocrinologist at Rush University Medical Center. “I have some patients who feel better on combination therapy and some who don’t.”
Dr. Jonklaas and other researchers involved in the 2014 guidelines also hope to do a clinical trial with 1,200 hypothyroid patients on either T4 alone, T3 and T4 in combination or desiccated thyroid extract. They also plan to test participants for genetic variations and hope to identify subsets of patients who respond better to one treatment or another.
Meanwhile, she and other endocrinologists say they are increasingly willing to try a small dose of T3 in patients who don’t feel better on T4 alone.
“I tell patients I don’t have a clinical trial that shows this is the right thing to do, but based on my experience, I suggest we try this for three or six months,” Dr. Bianco says. “If there’s no clear evidence of benefit, we’ll discontinue it.”
“The important thing is to try to make the patient feel better and do it in a safe way,” he says.
Hashimoto's Disease: A Primer
How to spot and treat the leading cause of an underactive thyroid.
- Who gets it? Some .1% to 5% of adults in Western nations are affected—especially middle-aged women.
- Symptoms: Fatigue, hair loss, weight gain, constipation, dry skin, elevated cholesterol, concentration problems, depression, muscle aches and a visibly enlarged thyroid gland, or goiter.
- Causes: Experts aren't exactly sure, but believe it could be caused by genes or environmental factors, such as viral attacks.
- Risks: Untreated, it can lead to birth defects in pregnant women, mental health issues and heart problems.
- Diagnosis: A blood test measures the level of thyroid-stimulating hormone, or TSH, that regulates the gland's functioning. A higher TSH signals a more underactive gland.
- Common Treatment: A synthetic hormone called levothyroxine, which mimics thyroxine (T4), a hormone made by the thyroid gland. Some patients prefer combining T4 with T3, another thyroid-produced hormone.
Thyroid cancer is a disease in which malignant cancer cells form in the tissues of the thyroid gland. Found more often in women, the National Cancer Institute estimates 60,022 new cases of thyroid cancer will be diagnosed in the United States in 2013.
Like most forms of cancer, thyroid cancer can be broken down into several different types or subgroups, says Jochen Lorch, MD, an oncologist with Dana-Farber’s Head and Neck Cancer Treatment Center. Most types of thyroid cancer are treatable and in some cases, curable, Lorch says.
Papillary – This is the most common type of thyroid cancers and is classified as a “differentiated” thyroid cancer. Papillary thyroid cancer is a slow-growing cancer that forms into small, finger-like shapes.
Typically, thyroid cancer is found more often in women. Of the estimated 60,022 new cases diagnosed in 2013, 45,000 will be women. Some inherited syndromes can also predispose people to thyroid cancer, including multiple endocrine neoplasia type 2A and type 2B. Other risk factors include radiation exposure and having a history of goiters.
3. What are the symptoms of thyroid cancer?
In most cases, a lump in the neck is detected by a physician during a routine physical exam. Other problems that could be signs of thyroid cancer include trouble breathing, trouble swallowing, or hoarseness.
4. How do doctors test for thyroid cancer?
If a lump is found, patients are sent to an endocrinologist where an ultrasound is done. The endocrinologist will also use a small needle to remove some tissue or fluid from the thyroid to examine it for cancer cells.
5. What are the treatment options for thyroid cancer?
The primary treatment for thyroid cancer is surgery. This can involve removing part of or the entire thyroid. If the cancer spreads to the lymph nodes, a lymphadenectomy may be done as well. Subsequent surgeries can be done to remove cancer cells that return.
After surgery, a doctor may use radioactive iodine therapy for differentiated thyroid cancers (papillary and follicular). With these treatments, the cure rate for differentiated thyroid cancers is around 90 percent
There are also a limited number of chemotherapy options available for recurrent or aggressive forms of thyroid cancer. Patients with these forms of thyroid cancer may also consider taking part in a clinical trial.
Like most forms of cancer, thyroid cancer can be broken down into several different types or subgroups, says Jochen Lorch, MD, an oncologist with Dana-Farber’s Head and Neck Cancer Treatment Center. Most types of thyroid cancer are treatable and in some cases, curable, Lorch says.
Papillary – This is the most common type of thyroid cancers and is classified as a “differentiated” thyroid cancer. Papillary thyroid cancer is a slow-growing cancer that forms into small, finger-like shapes.
- Follicular – A slow-growing thyroid cancer that forms in the follicular cells of the thyroid. It is also classified as a differentiated thyroid cancer.
- Poorly differentiated thyroid cancer – A sub-type of papillary and follicular thyroid cancer that is frequently also classified as differentiated thyroid cancer.
- Anaplastic – A rare, aggressive type of thyroid cancer categorized as an“undifferentiated” thyroid cancer. The malignant cells in this type of cancer look very different from normal thyroid cells.
Typically, thyroid cancer is found more often in women. Of the estimated 60,022 new cases diagnosed in 2013, 45,000 will be women. Some inherited syndromes can also predispose people to thyroid cancer, including multiple endocrine neoplasia type 2A and type 2B. Other risk factors include radiation exposure and having a history of goiters.
3. What are the symptoms of thyroid cancer?
In most cases, a lump in the neck is detected by a physician during a routine physical exam. Other problems that could be signs of thyroid cancer include trouble breathing, trouble swallowing, or hoarseness.
4. How do doctors test for thyroid cancer?
If a lump is found, patients are sent to an endocrinologist where an ultrasound is done. The endocrinologist will also use a small needle to remove some tissue or fluid from the thyroid to examine it for cancer cells.
5. What are the treatment options for thyroid cancer?
The primary treatment for thyroid cancer is surgery. This can involve removing part of or the entire thyroid. If the cancer spreads to the lymph nodes, a lymphadenectomy may be done as well. Subsequent surgeries can be done to remove cancer cells that return.
After surgery, a doctor may use radioactive iodine therapy for differentiated thyroid cancers (papillary and follicular). With these treatments, the cure rate for differentiated thyroid cancers is around 90 percent
There are also a limited number of chemotherapy options available for recurrent or aggressive forms of thyroid cancer. Patients with these forms of thyroid cancer may also consider taking part in a clinical trial.
It’s Not Cancer: Doctors Reclassify a Thyroid Tumor
Gina Kolata : NY Times : April 14, 2016
An international panel of doctors has decided that a type of tumor that was classified as a cancer is not a cancer at all.
As a result, they have officially downgraded the condition and thousands of patients will be spared removal of their thyroid, treatment with radioactive iodine and regular checkups for the rest of their lives, all to protect against a tumor that was never a threat.
Their conclusion — and the data that led to it — are reported Thursday in the journal JAMA Oncology. The change is expected to affect about 10,000 of the nearly 65,000 thyroid cancer patients a year in the United States. It may also offer grist to those who have been arguing for the reclassification of some other forms of cancer, including certain lesions in the breast and prostate.
The reclassified tumor is a small lump in the thyroid that is completely surrounded by a capsule of fibrous tissue. Its nucleus looks like a cancer but the cells have not broken out of their capsule, and surgery to remove the entire thyroid followed by treatment with radioactive iodine is unnecessary and harmful, the panel said. They have now renamed the tumor. Instead of calling it “encapsulated follicular variant of papillary thyroid carcinoma,” they now call it “noninvasive follicular thyroid neoplasm with papillary-like nuclear features,” or Niftp. The word “carcinoma” is gone.
Many cancer experts said the reclassification was long overdue. For years there have been calls to downgrade small lesions in the breast, lung and prostate, among others, and to eliminate the term “cancer” from their name. But other than the renaming of an early stage urinary tract tumor in 1998, and early stage ovarian and cervical lesions more than two decades ago, no group other than the thyroid specialists has yet taken the plunge.
In fact, said Dr. Otis Brawley, chief medical officer at the American Cancer Society, the name changes that occurred went in the opposite direction, scientific evidence to the contrary. Premalignant tiny lumps in the breast became known as stage zero cancer. Small and early stage prostate lesions were called cancerous tumors. Meanwhile imaging with ultrasound,M.R.I.’s and C.T. scans find more and more of these tiny “cancers,”especially thyroid nodules.
“If it’s not a cancer, let’s not call it a cancer,” said Dr. John C. Morris, president-elect of the American Thyroid Association and a professor of medicine at the Mayo Clinic. Dr. Morris was not a member of the renaming panel.
Over the last decade, Dr. Nikiforov had watched as pathologists began classifying noninvasive tumors as cancers and attributed the change to rare cases in which patients had a tumor that had broken out of its capsule, did not receive aggressive treatment and died of thyroid cancer. Worried doctors began treating all tumors composed of cells with nuclei that looked like cancer nuclei as if they were cancers. But this young woman’s story drove Dr. Nikiforov over the edge.
“I told the surgeon, who was a good friend, ‘This is a very low grade tumor. You do not have to do anything else.’” But the surgeon replied that according to practice guidelines, she had to remove the woman’s entire thyroid gland and treat her with radioactive iodine. And the woman had to have regular checkups for the rest of her life.
“I said, “That’s enough. Someone has to take responsibility and stop this madness,’” Dr. Nikiforov said.
He brought together the international panel of experts — 24 renowned pathologists, two endocrinologists, a thyroid surgeon, a psychologist who knew the impact a cancer diagnosis can have, and a patient. The group collected a couple of hundred cases from multiple centers throughout the world — patients who had tumors that were contained within fibrous capsules and those that had broken out. All agreed that by the current criteria every one of those tumors would be classified as a cancer. And all of the patients had been followed for at least 10 years. The patients with the encapsulated tumors had not been treated after their tumors were removed.
None of the patients whose tumors stayed within their capsules had any evidence of cancer after 10 years. But some of the patients whose tumors had broken out of their capsules had complications, including death, from thyroid cancer despite treatment.
“This study said it is not the presence of nuclear features but the presence of invasion that can make the difference between cancer and noncancer,” Dr. Nikiforov said. Patients whose tumors are confined within their capsules “have an excellent prognosis,” he said. “They do not need a thyroidectomy. They do not need radiotherapy. They do not need to be followed up every six months.”
But if those tumors are not cancers, what should they be called?
“Ten different names were submitted and the voting went on, back and forth,” said one member of the panel, Dr. Gregory W. Randolph, director of the thyroid and parathyroid surgical clinic at Harvard’s Massachusetts Eye and Ear Infirmary. They finally settled on Niftp in part because its acronym, which he pronounced as “Nift-P” was catchy, he said. The new name, the reclassification, he added, is “just awesome,” because it explicitly defines those small nodules in the thyroid as nonmalignant.
In an editorial he and his colleagues submitted to the journal Thyroid, they report that eight leading professional societies from around the world signed on to the declassification and to the new name. They write in the editorial that doctors may be violating the principle of “first, do no harm” in treating patients with these tumors as though they have invasive cancer.
Dr. Nikiforov says he owes it to patients with reclassified tumors to tell them they never had cancer after all. At the University of Pittsburgh Medical Center, he and others are going to start reviewing medical records and pathology reports to identify previous patients and contact them. He estimates there have been about 50 to 100 each year at the medical center. They no longer have to go back for checkups. They lose the shadow of cancer that the diagnosis hung over their lives.
Informing these patients, Dr. Nikiforov said, “is a moral obligation of doctors.”
Gina Kolata : NY Times : April 14, 2016
An international panel of doctors has decided that a type of tumor that was classified as a cancer is not a cancer at all.
As a result, they have officially downgraded the condition and thousands of patients will be spared removal of their thyroid, treatment with radioactive iodine and regular checkups for the rest of their lives, all to protect against a tumor that was never a threat.
Their conclusion — and the data that led to it — are reported Thursday in the journal JAMA Oncology. The change is expected to affect about 10,000 of the nearly 65,000 thyroid cancer patients a year in the United States. It may also offer grist to those who have been arguing for the reclassification of some other forms of cancer, including certain lesions in the breast and prostate.
The reclassified tumor is a small lump in the thyroid that is completely surrounded by a capsule of fibrous tissue. Its nucleus looks like a cancer but the cells have not broken out of their capsule, and surgery to remove the entire thyroid followed by treatment with radioactive iodine is unnecessary and harmful, the panel said. They have now renamed the tumor. Instead of calling it “encapsulated follicular variant of papillary thyroid carcinoma,” they now call it “noninvasive follicular thyroid neoplasm with papillary-like nuclear features,” or Niftp. The word “carcinoma” is gone.
Many cancer experts said the reclassification was long overdue. For years there have been calls to downgrade small lesions in the breast, lung and prostate, among others, and to eliminate the term “cancer” from their name. But other than the renaming of an early stage urinary tract tumor in 1998, and early stage ovarian and cervical lesions more than two decades ago, no group other than the thyroid specialists has yet taken the plunge.
In fact, said Dr. Otis Brawley, chief medical officer at the American Cancer Society, the name changes that occurred went in the opposite direction, scientific evidence to the contrary. Premalignant tiny lumps in the breast became known as stage zero cancer. Small and early stage prostate lesions were called cancerous tumors. Meanwhile imaging with ultrasound,M.R.I.’s and C.T. scans find more and more of these tiny “cancers,”especially thyroid nodules.
“If it’s not a cancer, let’s not call it a cancer,” said Dr. John C. Morris, president-elect of the American Thyroid Association and a professor of medicine at the Mayo Clinic. Dr. Morris was not a member of the renaming panel.
Over the last decade, Dr. Nikiforov had watched as pathologists began classifying noninvasive tumors as cancers and attributed the change to rare cases in which patients had a tumor that had broken out of its capsule, did not receive aggressive treatment and died of thyroid cancer. Worried doctors began treating all tumors composed of cells with nuclei that looked like cancer nuclei as if they were cancers. But this young woman’s story drove Dr. Nikiforov over the edge.
“I told the surgeon, who was a good friend, ‘This is a very low grade tumor. You do not have to do anything else.’” But the surgeon replied that according to practice guidelines, she had to remove the woman’s entire thyroid gland and treat her with radioactive iodine. And the woman had to have regular checkups for the rest of her life.
“I said, “That’s enough. Someone has to take responsibility and stop this madness,’” Dr. Nikiforov said.
He brought together the international panel of experts — 24 renowned pathologists, two endocrinologists, a thyroid surgeon, a psychologist who knew the impact a cancer diagnosis can have, and a patient. The group collected a couple of hundred cases from multiple centers throughout the world — patients who had tumors that were contained within fibrous capsules and those that had broken out. All agreed that by the current criteria every one of those tumors would be classified as a cancer. And all of the patients had been followed for at least 10 years. The patients with the encapsulated tumors had not been treated after their tumors were removed.
None of the patients whose tumors stayed within their capsules had any evidence of cancer after 10 years. But some of the patients whose tumors had broken out of their capsules had complications, including death, from thyroid cancer despite treatment.
“This study said it is not the presence of nuclear features but the presence of invasion that can make the difference between cancer and noncancer,” Dr. Nikiforov said. Patients whose tumors are confined within their capsules “have an excellent prognosis,” he said. “They do not need a thyroidectomy. They do not need radiotherapy. They do not need to be followed up every six months.”
But if those tumors are not cancers, what should they be called?
“Ten different names were submitted and the voting went on, back and forth,” said one member of the panel, Dr. Gregory W. Randolph, director of the thyroid and parathyroid surgical clinic at Harvard’s Massachusetts Eye and Ear Infirmary. They finally settled on Niftp in part because its acronym, which he pronounced as “Nift-P” was catchy, he said. The new name, the reclassification, he added, is “just awesome,” because it explicitly defines those small nodules in the thyroid as nonmalignant.
In an editorial he and his colleagues submitted to the journal Thyroid, they report that eight leading professional societies from around the world signed on to the declassification and to the new name. They write in the editorial that doctors may be violating the principle of “first, do no harm” in treating patients with these tumors as though they have invasive cancer.
Dr. Nikiforov says he owes it to patients with reclassified tumors to tell them they never had cancer after all. At the University of Pittsburgh Medical Center, he and others are going to start reviewing medical records and pathology reports to identify previous patients and contact them. He estimates there have been about 50 to 100 each year at the medical center. They no longer have to go back for checkups. They lose the shadow of cancer that the diagnosis hung over their lives.
Informing these patients, Dr. Nikiforov said, “is a moral obligation of doctors.”
