Some final thoughts:

  Thyroid Awareness Month

I spent a little time with Dr. George Moore, an endocrinologist at our Woodlands Specialty Center in Bothell, and asked him a few questions that intrigued me about thyroid health. We’ve had some great, intensive posts about thyroid health this month, but there were a few things that I still wanted to know about. Here are some of the questions I asked Dr. Moore and his answers.

For people who have never had thyroid problems, what might signal that something is wrong with their thyroid and what symptoms should they look for other than the obvious goiter?

One of the most obvious symptoms of thyroid disorder is fatigue.  People also need to be watch for muscle weakness in the upper arms or legs which could suggest thyroid problems.  Changed bowel habits can be an indicator that something is wrong with the thyroid, as well as significant changes in the heart rate—either up or down.  You might also experience changes in temperature tolerance -- heat or cold.   You don’t have to have all of these symptoms. You could have one, some or all.

I know that there are many thyroid conditions, but what do you see most in adolescents and what role does genetics play in that?

Adolescence is a time when you’re going to see immunological kinds of diseases such as hypothyroid, hyperthyroid, Graves Disease or Hashimoto’s Thyroiditis. It’s believed that rapid hormonal changes like going through puberty set off the immune system and when it goes off, it goes looking for organs to attack. It attacks the thyroid because the thyroid has one of the richest blood flows per gram of tissue of any tissue in the body so there are more immune cells in the organ.  Barriers between circulation and tissue are not real firm, so it can get easier access to antigens.

Many people have a genetic predisposition to thyroid disease, but it is not directly inherited.  If Mom has it, a child is more likely to have it. But it is not a direct one-to-one inheritance. It's an increase in risk. Also, some unusual thyroid cancers are inherited.

Statistically, do men or women have more thyroid problems?

The relative rate of occurrence for women to men is 3:1. That goes back to hormonal swings maybe. No one knows for sure.

Do people with thyroid conditions tend to have other problems like autoimmune disease, diabetes, or heart problems?

Thyroid conditions can lead to other autoimmune disease, adrenal disease, celiac disease, pernicious anemia or vitiligo and it is connected to Type 1 Diabetes.  If you have an overactive thyroid you can get arrhythmias of the heart and it is a big risk factor for atrial fibulation in old people. Hypothyroidism can be associated with increased levels of cholesterol.

I asked Dr. Moore if there was anything else that he thought was important for our readers to know about thyroid disease. Here is his answer.

If you feel a lump or bump in your neck, you should consult a physician for evaluation as you may need an ultrasound, biopsy, or nuclear scan. Thyroid nodules (bumps in the thyroid) need to be evaluated. Although most are benign, they can become malignant, so let your doctor know if you discover one.

I want to thank Dr. Moore for taking the time to answer my questions. You can learn more about Dr. Moore here.

National Medical Group Practice Week

is celebrated this week in January

Western Washington Medical Group proudly honors our nation’s medical group practices during National Medical Group Practice Week in January. We support the medical group practice managers, physicians, staff, communities and patients who help make group practice a collaborative, high-quality and cost-effective form of health care delivery.

Please join us in recognizing these hardworking professionals.

Physicians in group practices have been credited with many medical innovations. Following are a few noted firsts that occurred in a group practice: 

	The discovery of a link between smoking tobacco and lung cancer – 1939, the Ochsner Clinic Foundation, New Orleans.
	The use of a heart-lung machine during open-heart surgery – 1955, the Mayo Clinic, Rochester, Minn.
	The performance of prelaunch examinations on U.S. astronauts – 1959, Lovelace Clinic (now Lovelace Sandia Health System), Albuquerque, N.M.
	The use of electromagnetic imaging – 1974, Virginia Mason Medical Center, Seattle.
	The use of lithotripsy to treat kidney stones – 1985, Virginia Mason Medical Center, Seattle.

Join us in celebrating with all the many hard working people who staff group practices around the country and who care for the health of our families.

Information courtesy of The Medical Group Management Association (MGMA), the nation's principal voice for medical group practices since 1926, created National Medical Group Practice Week in 2003.

What can you make with a da Vinci robot?

Dr. Fong uses the da Vinci Robot 

to make snowflakes at Swedish Edmonds

Dr. Fong practices at the Western Washington Medical Group Urology Department at 4310 Colby Avenue, Suite 203, Everett, WA  98203. You can learn more here.

We're happy to annouce...

Did you know that five of 

Western Washington Medical Group's Specialists 

were named to 

Seattle Magazine’s and US News & World Report’s 

“Top Doctors” 

lists for 2011?

Congratulations to:

Sanjeev Garhwal (Cardiac Electrophysiology)

Budge Smith (Cardiology)

George Moore (Endocrinology)

Mark Gunning (Nephrology)

David Russian (Pulmonology)

Physicians for this award were nominated by their peers.  The goal of this award is to help patients find the most respected doctors in the area who will be able to fulfill their needs.  It provides patients with valuable information about who other doctors trust and respect.

“We are proud to see so many of our members receiving the recognition of their peers and the community for their commitment to high quality patient care,” remarked Jerry Tillinger, CEO of Western Washington Medical Group. “This honor reflects a lifetime of dedication to the art of medicine and many long hours of work in service to the patients entrusted to their care." 

 

Thyroid Carcinoma - what you should know...

Thyroid Carcinoma

What is thyroid cancer?

The thyroid gland is located in the lower front of the neck, below the larynx (“Adam’s apple”) and above the collarbones.  Thyroid cancer (carcinoma) usually appears as a painless lump in this area.  In most cases, the lump affects only one side, and the results of thyroid function tests (blood tests) are usually normal.

There are four main types of thyroid cancer (Papillary, follicular, medullary and anaplastic).  Since the vast majority are either papillary or follicular, and these are the only two types treatable with radioiodine, this brochure will focus on these two types.

What are the symptoms of thyroid cancer?

Many patients with thyroid cancer have no symptoms whatsoever, and are found by chance to have a lump in the thyroid gland on a routine physical or an imaging study of the neck done for unrelated reasons (CT or MRI scan of spine or chest, carotid ultrasound, etc.)  Some patients with thyroid cancer become aware of a gradually enlarging lump in the front portion of the neck which usually moves with swallowing.  Occasionally, the lump may cause a feeling of pressure.  Obviously, finding a lump in the neck should be brought to the attention of your physician, even in the absence of symptoms.

What are the causes of thyroid cancer?

As with many types of cancer, the specific reason for developing thyroid cancer remains a mystery in the vast majority of patients.  Several known risk factors have been identified.

·         External radiation to the head or neck, especially during childhood

·         Genetic predisposition (the influence of heredity), particularly for the medullary type of thyroid cancer

·         Gender (a lump in a man’s neck is more likely to be cancerous than one in a woman’s neck)

How is thyroid cancer diagnosed?

First, your physician takes a detailed history and performs a careful physical examination, especially of the thyroid gland.  The best diagnostic approach for a specific patient will be determined by your physician after careful consideration of all the facts.  The tests available to your physician for an evaluation of the thyroid lump include, but are not limited to, the following:

• Fine-needle aspiration biopsy - this is usually done first and, if positive, significantly reduces the need for more elaborate and expensive testing
• Ultrasonography - this may be required for guidance of the fine needle biopsy if the nodule is difficult to feel
• Thyroid scan - this can be done to see if the mass is capable of concentrating radioiodine, particularly in those rare patients with associated hyperthyroidism
• Blood studies

How is thyroid cancer treated?

Fortunately, most types of thyroid cancer can be diagnosed early and cured completely, but a thoughtful and comprehensive investigation is necessary.  If thyroid cancer is suspected after review of all the information, referral to an experienced thyroid surgeon is recommended.

The usual approach is to remove the portion of the thyroid containing the lump, along with most of the remaining thyroid gland and any abnormal lymph glands.  If cancer is confirmed, further consultation with the endocrinologist is appropriate.  Radioactive iodine treatment is usually recommended in order to destroy any remaining malignant thyroid cells and to reduce the risk of recurrence of this disease.

After radioiodine therapy, thyroid medication (levothyroxine) should be started and the does carefully adjusted to each patient’s unique requirements, which will prevent the development of persistent hypothyroidism and decrease the likelihood of cancer recurrence.  Periodic monitoring is supervised by the endocrinologist, and may include ultrasound examination, radioiodine body scans, and periodic testing of a blood protein called thyroglobulin, which is found in normal thyroid cells but can also be produced by thyroid cancer cells.

The optimal frequency of further monitoring studies to be certain that the cancer does not recur will be determined by your physician.  Fortunately, most types of thyroid cancer are associated with a very good prognosis when diagnosed early and treated by a physician who is familiar with the management of this disease.

For more information please visit http://www.thyroidawareness.com/

Western Washington Medical Group has two sites for Endocrinology
and you can learn more at our website

More things you need to know during Thyroid Awareness Month

What is a Thyroid Nodule?

What is a thyroid nodule?

The thyroid gland is located in the lower front of the neck, below the larynx (“Adam’s apple”) and above the collarbone.  A thyroid nodule is a lump in or on the thyroid gland.  Thyroid nodules are common and detected in about 6.4% of women and 1.5% of men; they are less common in younger patients and occur 10 times as often in older individuals, but are usually not diagnosed.  Sometimes several nodules will develop in the same person. Any time a lump is discovered in thyroid tissue, the possibility of malignancy (cancer) must be considered.  Fortunately, the vast majority of thyroid nodules are benign (not cancerous). 

Many patients with thyroid nodules have no symptoms whatsoever, and are found by chance to have a lump in the thyroid gland on a routine physical exam or an imaging study of the neck done for unrelated reasons (CT or MRI scan of spine or chest, carotid ultrasound, etc.)  However, a minority of patients may become aware of a gradually enlarging lump in the front portion of the neck, and/or may experience a vague pressure sensation or discomfort when swallowing.  Obviously, finding a lump in the neck should be brought to the attention of your physician, even in the absence of symptoms.

Nodules can be caused by a simple overgrowth of “normal” thyroid tissue, fluid-filled cysts, inflammation (thyroiditis), or a tumor (either benign or cancerous).  Most nodules were surgically removed until the 1980s.  In retrospect, this approach led to many unnecessary operations, since fewer than 10% of the removed nodules proved to be cancer.  Most removed nodules could have simply been observed or treated medically.

It is not usually possible for a physician to determine whether a thyroid nodule is cancerous on the basis of a physical examination or blood tests.  Endocrinologists rely heavily on three specialized tests for help in deciding which nodules should be treated surgically:

• Thyroid fine needle biopsy
• Thyroid scan
• Thyroid ultrasonography

What is a thyroid needle biopsy?

A thyroid fine needle biopsy is a simple procedure that can be preformed in the physician’s office.  Many physicians numb the skin over the nodule prior to the biopsy, but it is not necessary to be put to sleep, and patients can usually return to work or home afterward with no ill effects.  This test provides specific information about a particular patient’s nodule, information that no other test can offer short of surgery.  Although the test is not perfect, a thyroid needle biopsy will provide sufficient information on which to base a treatment decision more than 75% of the time, eliminating the need for additional diagnostic studies.

Use of fine needle biopsy has drastically reduced the number of patients who have undergone unnecessary operations for benign nodules.  However, about 10-20% of biopsy specimens are interpreted as inconclusive or inadequate, that is, the pathologist cannot be certain whether the nodule is cancerous or benign.  This situation is particularly common with cystic (fluid-filled) nodules, which contain very few thyroid cells to examine, and with those nodules composed of a particular cell type called follicular.  In such cases, a physician who is experienced with thyroid disease can use other criteria to make a decision about whether or not to operate.  The fine needle biopsy can be repeated in those patients whose initial attempt failed to yield enough material to make a diagnosis.  Many physicians use thyroid ultrasonography to guide the needle’s placement.

What is a thyroid scan?

A thyroid scan is a picture of the thyroid gland taken after a small dose of a radioactive isotope, normally concentrated by thyroid cells, has been injected or swallowed.  The scan tells whether the nodule is hyperfunctioning (a “hot” nodule), or taking up more radioactivity than normal thyroid tissue does, taking up the same amount as normal tissue (a “warm” nodule), or taking up less (a “cold” nodule).  Because cancer is rarely found in hot nodules, a scan showing a hot nodule eliminates the need for fine needle biopsy.  If a hot nodule causes hyperthyroidism, it can be treated with radioiodine or surgery.

Fortunately, the vast majority (90-95%) of thyroid nodules are benign.  Unfortunately, thyroid scans show that most thyroid nodules, both benign and malignant, are cold or nonfunctioning.  Therefore, although almost all thyroid cancers are nonfunctional on scan, the majority of nonfunctional nodules are benign.  For this reason, thyroid scans are of relatively little value in most patients unless hyperthyroidism exists along with the nodule. 

What is thyroid ultrasonography?

Thyroid ultrasonography is a procedure for obtaining pictures of the thyroid gland by using high frequency sound waves that pass through the skin, bounce off the inner structures of the neck, and are converted into a “live” image by a computer.  It can visualize nodules as small as 2 to 3 mm.  Ultrasound studies were first used to distinguish thyroid cysts (fluid-filled nodules) from solid nodules.  Cysts are usually benign, and solid nodules are potentially cancerous.  Most nodules, however, have both solid and cystic components, and very few purely cystic nodules occur.  Therefore, ultrasonography alone is rarely able to distinguish between a benign (non-cancerous) nodule and a malignant (cancerous) one.

A more important use of thyroid ultrasonography is in guiding the placement of a biopsy needle to decrease the frequency of inadequate specimens.  Such guidance allows the biopsy sample to be obtained from the solid portion of those nodules that are both solid and cystic, and it avoids getting a specimen from the surrounding normal thyroid tissue if the nodule is small.

Even when a thyroid biopsy sample is reported as benign, the size of the nodule should be monitored.  A thyroid ultrasound examination provides an objective and precise method for a detection of a chance in the size of the nodule.  A nodule with a benign biopsy that is stable or decreasing in size is unlikely to be malignant or require surgical treatment.

How are thyroid nodules treated?

Your endocrinologist will use the above mentioned tests to arrive at a recommendation for optimal management of your nodule. Most patients who appear to have benign nodules require no specific treatment, and can simply be followed expectantly.  Some physicians prescribe levothyroxine with hopes of preventing nodule growth or reducing the size of cold nodules, while radioiodine may be used to treat hot nodules.

If cancer is suspected, surgical treatment will be recommended.  The primary goal of therapy is to remove all thyroid nodules that are cancerous (and, if malignancy is confirmed, remove the rest of the thyroid gland along with any abnormal lymph glands).  If surgery is not recommended, it is important to have regular follow-up of the nodule by a physician experienced in such an evaluation.

For more information please visit http://www.thyroidawareness.com/

Western Washington Medical Group has two Endocrinology sites
and you can learn more at our website.

Thyroid Awareness Month

What is hyperthyroidism?

Hyperthyroidism develops when the body is exposed to excessive amounts of thyroid hormone. This disorder occurs in almost I% of all Americans and affects women 5 to 10 times more often than men. In its mildest form, hyperthyroidism may not cause recognizable symptoms. More often, however, the symptoms are discomforting, disabling, or even life-threatening.

What are the features of hyperthyroidism?

When hyperthyroidism develops, a goiter (enlargement of the thyroid) is usually present and may be associated with some or many of the following symptoms:

• Fast heart rate, often more than 100 beats per minute

• Anxious, irritable, argumentative

• Trembling hands

• Weight loss, despite eating the same amount or even more than usual

• Intolerance of warm temperatures and increased likelihood to perspire

• Loss of scalp hair

• Rapid growth of fingernails and tendency of fingernails to separate from the nail bed

• Muscle weakness, especially of the upper arms and thighs

• Loose and frequent bowel movements

• Smooth and thin skin

• Change in menstrual pattern

• Increased likelihood for miscarriage

• Prominent "stare" of the eyes

• Protrusion of the eyes, with or without double vision (in patients with Graves' disease)

• Irregular heart rhythm, especially in patients older than 60 years of age

• Accelerated loss of calcium from bones, which increases the risk of osteoporosis and fractures

What are the causes of hyperthyroidism?

GRAVES' DISEASE

Graves' disease (named after Irish physician Robert Graves) is an autoimmune disorder that frequently results in thyroid enlargement and hyperthyroidism. In a minority of patients, swelling of the muscles and other tissues around the eyes may develop, causing eye prominence, discomfort or double vision. Like other autoimmune diseases this condition tends to affect multiple family members. It is much more common in women than in men, and tends to occur in younger patients.

Toxic Multi-nodular Goiter

Multiple nodules in the thyroid can produce excessive thyroid hormone, causing hyperthyroidism. Often diagnosed in patients over the age of 50, this disorder is more likely to affect heart rhythm. In many cases, the person has had the goiter for many years before it becomes overactive.

Toxic Nodule

A single nodule or lump in the thyroid can also produce more thyroid hormone than the body requires and lead to hyperthyroidism. This disorder is not familial.

SUBACUTE THYROIDITIS

This condition of unknown cause is characterized by painful thyroid gland enlargement and inflammation, which results in the release of large amounts of thyroid hormones into the blood. Fortunately, this condition usually resolves spontaneously. The thyroid usually heals itself over several months, but often not before a temporary period of low thyroid hormone production (hypothyroidism) occurs.

POSTPARTUM THYROIDITIS

5% to 10% of women develop mild to moderate hyperthyroidism within several months of giving birth. Hyperthyroidism in this condition usually lasts for approximately 1-2 months. It is often followed by several months of hypothyroidism, but most women will eventually recover normal thyroid function. In some cases, however, the thyroid gland does not heal, so the hypothyroidism becomes permanent and requires lifelong thyroid hormone replacement

SILENT THYROIDITIS

Transient (temporary) hyperthyroidism can be caused by silent thyroiditis, a condition which appears to be the same as postpartum thyroiditis but not related to pregnancy. It is not accompanied by a painful thyroid gland.

EXCESSIVE IODINE INGESTION

Various sources of high iodine concentrations, such as kelp tablets, some expectorants, amiodarone (Cordarone, Pacerone - a medication used to treat certain problems with heart rhythms) and x-ray dyes, may occasionally cause hyperthyroidism in certain patients.

OVERMEDICATION WITH THYROID HORMONE

Patients who receive excessive thyroxine replacement treatment can develop hyperthyroidism. They should have their thyroid hormone dosage evaluated by a physician at least once each year and should NEVER give themselves "extra" doses.

How is hyperthyroidism diagnosed?

Characteristic symptoms and physical signs of hyperthyroid ism can be detected by a physician. In addition, tests can be used to confirm the diagnosis and to determine the cause.

TSH (THYROID-STIMULATING HORMONE OR THYROTROPIN TEST)

A low TSH level in the blood is the most accurate indicator of hyperthyroidism. The body shuts off production of this pituitary hormone when the thyroid gland even slightly overproduces thyroid hormone. If the TSH level is low, it is very important to also check thyroid hormone levels to confirm the diagnosis of hyperthyroidism.

OTHER TESTS

• Free T4 (thyroxine) and Free T3 (tri iodothyronine) - the active thyroid hormones in the blood. When hyperthyroidism develops, free T4 and T3 levels rise above previous values in that specific patient (although they may still fall within the normal range for the general population), and are often considerably elevated.

• TSI (thyroid-stimulating immunoglobulin) - a substance often found in the blood when Graves' disease is the cause of hyperthyroidism. This test is ordered infrequently, since it rarely affects treatment decisions or helps in the diagnosis.

• Radioactive iodine uptake (RAIU - a measurement of how much iodine the thyroid gland can collect) and thyroid scan (a thyroid scan that shows how the iodine is distributed throughout the thyroid gland). This information can be useful in determining the cause of hyperthyroidism and ultimately its treatment.

Sometimes a general physician can diagnose and treat the cause of hyperthyroidism, but assistance is often needed from an endocrinologist, a physician who specializes in managing thyroid disease.

How is hyperthyroidism treated?

Before the development of current treatment options, the death rate from hyperthyroidism was as high as 50%. Now several effective treatments are available, and with proper management, death from hyperthyroidism is rare. Deciding which treatment is best depends on what caused the hyperthyroidism, its severity, and other conditions present. A physician who is experienced in the management of thyroid diseases can confidently diagnose the cause of hyperthyroidism and prescribe and manage the best treatment program for each patient.

ANTITHYROID DRUGS

In the United States, two drugs are available for treating hyperthyroidism: propylthiouracil (PTU) and methimazole (Tapezole). These medications control hyperthyroidism by slowing thyroid hormone production, and are frequently used for several months after the initial diagnosis of hyperthyroidism to normalize the thyroid hormone levels. Some patients with hyperthyroidism caused by Graves' disease experience a spontaneous or natural remission of hyperthyroidism after a I 2 to I 8 month course of treatment with these drugs, and may sometimes avoid permanent under-activity of the thyroid (hypothyroidism), which often occurs as a result of using the other methods of treating hyperthyroidism. Unfortunately, the remission is frequently only temporary, with the hyperthyroidism recurring after several months or years off medication and requiring additional treatment, so relatively few patients are treated solely with anti-thyroid medication in the United States.

Anti-thyroid drugs may cause an allergic reaction in about 5% of patients who use them. This usually occurs during the first six weeks of drug treatment. Such a reaction may include rash, hives, fever, or joint pain, but after discontinuing use of the drug, the symptoms resolve within one to two weeks, and there is no permanent damage.

A more serious effect, but occurring in only about I in 250-500 patients during the first four to eight weeks of treatment, is a rapid decrease of white blood cells in the bloodstream. This could increase susceptibility to serious infection. Symptoms such as a sore throat, joint aches, infection, or fever should be reported promptly to your physician, and a blood cell count should be done immediately. In nearly every case, when a person stops using the medication, the white blood cell count returns to normal. Anti-thyroid drugs may very rarely cause liver problems, which can be detected by monitoring blood tests. Your physician should be contacted if there is yellowing of the skin ("jaundice"), fever, loss of appetite, or abdominal pain.

RADIOACTIVE IODINE TREATMENT

Iodine is an essential ingredient in the production of thyroid hormone. Each molecule of thyroid hormone contains either 4 (T4) or 3 (T3) molecules of iodine. Since most overactive thyroid glands are quite hungry for iodine, it was discovered in the 1940's that the thyroid could be "tricked" into destroying itself by simply feeding it radioactive iodine. The radioactive iodine is given by mouth, usually in capsule form, and is quickly absorbed from the bowel. It then enters the thyroid cells from the bloodstream and gradually destroys them. Maximal benefit is usually noted within three to six months.

It is not possible to reliably eliminate "just the right amount" of the diseased thyroid gland, since the effects of the radioiodine are slowly progressive on the thyroid cells. Therefore, most endocrinologists strive to completely destroy the diseased thyroid gland with a single dose of radioiodine. This results in the intentional development of an underactive thyroid state (hypothyroidism), which is easily, predictably and inexpensively corrected by lifelong daily use of oral thyroid hormone replacement therapy. Although every effort is made to calculate the correct dose of radioiodine for each patient, not every treatment will successfully correct the hyperthyroidism, particularly if the goiter is quite large, and a second dose of radioactive iodine is occasionally needed.

In the 50+ years and hundreds of thousands of patients (including a former President of the United States and his wife!) in which radioiodine has been used no serious complications have been reported. Since the treatment appears to be extraordinarily safe, simple, and reliably effective, it is considered by most thyroid specialists in the United States to be the treatment of choice for those types of hyperthyroidism caused by overproduction· of thyroid hormones.

S URGICAL REMOVAL OF THE THYROID

Although seldom used now as the preferred treatment for hyperthyroidism, operating to remove most of the thyroid gland may occasionally be recommended in certain situations, such as a pregnant woman with severe disease in whom radioiodine would not be safe for the baby, removal of a clinically suspicious thyroid nodule coexisting with hyperthyroidism, or for rare patients with Graves' disease who have severe protrusion of their eyes. In such patients, permanent hypothyroidism usually results, and lifelong thyroxine replacement is required.

OTHER TREATMENTS

A drug from the class of beta-adrenergic blocking agents (which decrease the effects of excess thyroid hormone) may be used temporarily to control hyperthyroid symptoms while one of the abovementioned treatments becomes effective. In cases where hyperthyroidism is caused by thyroiditis or excessive ingestion of either iodine or thyroid hormone, this may be the only type of treatment required. Of course, taking too much of either substance should also be corrected.

Appropriate management of hyperthyroidism requires careful evaluation and ongoing care by a physician experienced in the treatment of this complex condition.

For more information please

visit www.thyroidawareness.com

Western Washington Medical Group has two offices for Endocrinology

and you can learn more at our website.

Prepared by the American Association of Clinical Endocrinologists (AACE), a not-for-profit national organization of highly qualified specialists in hormonal and metabolicdisorders whose primary professional activities focus on providing high-quality specialty care to patients with endocrine problems such as thyroid disease.

Supported by an unrestricted educational grant from Abbott Laboratories.

© 2006 AACE- Permission is granted for reproduction of this publication.