ThyroidChange

A Call for Improved Thyroid Treatment Options

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Did you know that there is a controversy regarding the treatment of thyroid disease? Harvard Health estimates that more than 12 million Americans have thyroid disease, many of whom don’t even realize it. Thyroid patients insist that current treatment standards leave too many patients suffering from a lack of diagnosis or ineffective treatment. Both patient populations are left with a diminished quality of life, yet there are few doctors willing to step outside of the current guidelines. In an effort to change this situation a team of patients created ThyroidChange, a nonprofit organization dedicated to improving the treatment of thyroid disease.

What is Thyroid Dysfunction?

The thyroid is a gland in your body which is located at the base of your neck. Go ahead, touch it! Just above your collar bone and just below your “Adam’s apple.” This gland is shaped like a butterfly with two lobes which stretch around your trachea – hence its nickname the butterfly gland. This gland is key to your body’s metabolism. The hormones it secretes kick-start the energy in every cell of your body like a spark plug in your engine or flint to a match. Without appropriate amounts of thyroid hormones, whether too high or too low, the function of your body is greatly impacted. There are over 300 symptoms of insufficient thyroid hormone and they represent dysfunction in every major organ. Thyroid dysfunction is so common that you or someone you know is probably impacted or will be in the future.

Thyroid hormone is a broad term. The thyroid secretes many hormones, but the two most important for this conversation are thyroxine (T4) and triiodothyronine (T3). The pituitary gland located in your brain senses the level of hormones in that area of your brain, and sends out thyroid stimulating hormone (TSH) which excites your thyroid and causes it to release hormones. T3 is used immediately by various cells and T4 is called the storage hormone because it cannot be used by the cells. It is stored to later be converted to the useable and valuable T3. When a patient does not have sufficient levels of T3 in their blood stream, physicians expect a patient’s TSH level to increase, demonstrating the demand for more hormone by the pituitary gland. If a patient’s thyroid is producing too many hormones, the TSH lab value should decrease to tell it to “decelerate” its production.

An individual whose thyroid gland makes too much thyroid hormone is hyperthyroid. Some patients are rendered hyperthyroid due to an autoimmune disease called Graves’. One can also have cancer of the thyroid gland. Treatments for these can vary, but inevitably it leads to a lifetime of hypothyroidism.

One who has insufficient T3 available to their cells is called hypothyroid. The leading cause of insufficient thyroid hormone is the autoimmune disease, Hashimoto’s Thyroiditis. This disease causes one’s own body attacks their thyroid gland making it inefficient.

What is the Current Treatment standard? Why is it Flawed?

The flawed TSH test is used to diagnose and treat individuals. A physician will run the TSH and if the value is above a particular threshold, the physician will declare a patient hypothyroid. The physician will usually prescribe levothyroxine which is synthetic T4. The dosage will be determined by the TSH lab value. Once it hits a number determined by the physician, the patient will be determined as “euthyroid” or “good as new.”

How many disorders are you aware of that have one lab test and one prescribed treatment? Even though there is research demonstrating that the TSH lab test is flawed and that there are alternative treatments to effectively treat thyroid disease, thyroid patients have difficulty accessing these research-proven methods. We have not even begun to discuss that a majority of hypothyroidism is caused by an autoimmune disease that is seen as insignificant and is not necessarily tested for when a patient is being treated for the resulting hormone imbalance.

What is the Change Being Sought by Thyroid Patients?

One can plainly see that current treatments are solely based on T4 substitution and the ability of an individual’s body to convert the prescribed hormone to the active hormone T3. Patient experience shows that if a patient continues to complain about lingering symptoms, physicians focus on current guidelines which promote the flawed TSH lab value instead of drawing additional labs. This further testing may well demonstrate that a patient is lacking the necessary T3 to function properly, but as so few physicians are willing to perform this, many patients continue to suffer.

In a person with low Free T3, raising T4 doses will not alleviate symptoms. These patients are often prescribed drugs such as antidepressants and cholesterol-lowering drugs to mask the symptoms of insufficient T3. (If you are on one of these medications, have you had your thyroid tested? If you are on thyroid medication, have you had your Free T3 tested?). Adding medications increases side effects and does not restore balance to the patient’s hormones. Simple blood tests can demonstrate to a physician why symptoms persist after the employment of current treatment guidelines. Tests such as Free T4 and Free T3 can indicate how much Free and useable T4 and T3 are in a person’s bloodstream. These tests in combination with antibody testing can help to shed light on a patient’s persistent symptoms.

As per the current guidelines in the treatment of hypothyroidism, based on TSH testing most patients are sufficiently relieved of their symptoms by T4-only treatment. Those who are not in the majority are left to struggle for a doctor willing to listen and run extended lab tests. Complicating this further, many doctors and patients are not only unaware of additional lab work, but also of the many treatment options that one can use to treat thyroid disease.

Levothyroxine or synthetic T4 will restore health in some patients. There are also various T3-containing treatment options such as natural thyroid extract and synthetic T3 which can be used to supplement or substitute T4 treatment. Each patient is unique. We need to make sure that each patient has access to the treatment approach to best restore his or her health. ThyroidChange is about patients advocating for other patients.

Who is ThyroidChange?

ThyroidChange is a nonprofit organization advocating for the use of extended lab testing (Free T4, Free T3, TSH, Reverse T3 and thyroid antibodies) and access to various treatment options to suit the individual patient. We host a petition to appeal for such changes and this has garnered more than 16,000 signatures worldwide, demonstrating that there is indeed a genuine need for change in thyroid treatment. Our community unites patient advocacy groups in an effort to gain better care for thyroid patients and to raise awareness of this widespread problem. ThyroidChange also aims to work with medical oversight agencies in order to create a unified standard of care for thyroid patients to increase patient access to effective, modern treatment.

Please help this effort by visiting www.ThyroidChange.org to sign the petition and unite for better thyroid care, or contact ThyroidChange to discuss how you can support this initiative.

Personal Story: My Thyroid Cancer

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I am a Professor of Economics at Vanderbilt University, VU. I teach and do research. My life is my work and my family. Inside me there is Myrna Holtz, a kid from very humble beginnings on a small farm in rural Alberta, a nerd who loved math puzzles and books but had few of either. Through my own research and through helping others with theirs, I want to contribute to our ability to understand social and economic interaction. I want to be close to my family and now to increase awareness of thyroid cancer and its potential effects. Here is my story.

Some History

In 2008 and 2009 I felt fatigued.  My home treadmill rested, unused. In September 2009, my VUMC (VU Med Center) physician palpated my thyroid and detected no problem. Two months later, after a quick swipe of my throat, my gynecologist found that my thyroid was enlarged. We both notified my VUMC physician. He responded (recorded on a VUMC web interface for patients) with, effectively, “See you when you next come in.” I thought, “Oh, that’s good, no problem then. Maybe I had a cold.” But as time progressed, I pressed and pressed again for an appointment with my physician. Finally, in mid-May 2010, after five and a half months, I had an appointment. When my VUMC physician palpated my thyroid, he immediately detected the enlargement and ordered an ultrasound, which I had the same day.

Too Busy to Call: Hearing about my Thyroid Cancer from a Stranger

A few days later, out of the blue, some unknown person phoned to schedule an appointment for me with an endocrinologist and to advise me that I would probably need surgery. What! How could something treated so casually by my VUMC physician be serious? Was it really? If so, why had my physician not seen me sooner? Why had he himself not called? Maybe it was only another surgery opportunity.

My former VU physician always called me “Myrna”. I called him “Dr. Hock”. A trusting patient is like a small child who places her hand in the hand of a benevolent, caring adult. The asymmetry in use of titles reflects this relationship of trust and confidence; the patient wants to be confident that the physician is competent, knowledgeable, and will take care of her. But maybe the asymmetry is designed to keep the physician in a position of unquestioned superiority, above the patient. I started to call my former VUMC physician “Rich”. And he switched, immediately, to “Professor Wooders”. It was almost funny.

With all confidence in VUMC gone – this was the most disturbing but not my first negative experience – I searched for a specialist on the internet and in September 2010 saw Dr. Erik Alexander, at Brigham and Women’s (B&W) in Boston. Erik advised me to have a thyroidectomy and also recommended a surgeon, Dr. Francis Moore, also of B&W. Dr. Moore interviewed me on November 10th, 2010, and I had a total thyroidectomy on November 11th. 2010

The Diagnosis: Thyroid Cancer

B&W Pathology reported a tall cell papillary thyroid cancer with extrathyroidal extension (minimal). Not good. Tall cell thyroid cancer has an estimated mortality rate about 16 times that of papillary cancer generally. At least one study proposes that tall cell thyroid cancer can become anaplastic cancer, which is extremely aggressive. “Extrathyrodial extension” means that the cancer has extended beyond the thyroid capsule. With extrathyroidal extension, for individuals over forty-five thyroid cancer becomes Stage III. Whether the extrathyroidal extension occurred during VUMC’s delay is unknown, but I believe it is likely; my VUMC physician was unable to detect the enlargement of my thyroid in September 2009, but detected it immediately in May 2010.  I complained to VUMC.

Post-Surgery Treatment

My treatment involved thyroid hormone withdrawal to raise my TSH (thyroid stimulating hormone) and a low-iodine diet lasting some weeks followed by ablation with radioactive iodine (RAI).  “Glowies” are not allowed to fly so I had the RAI at VUMC. The endocrinologist at VUMC referred me to his nurse for instructions for the procedure.  I was not following the VUMC standard procedure of injection of Thyrogen (a form of TSH) to raise TSH but instead hormone withdrawal. The instructions for my procedure were somewhat garbled. I sought and obtained clarification, but still it was anxiety-provoking.

In January 2011, three men in hospital garb brought my RAI pill into a small, cold room at VUMC where I had been waiting on a small, cold hard chair. Might they be like three co-authors, each of whom relies on the other two to catch any mistakes? Might something else have been garbled? But I was at VUMC to swallow the pill so I swallowed the pill.

A few days after swallowing the pill, standard procedure is to have a whole body scan to see where the RAI was soaked up. I lie in a cold machine in a cold room, while in the adjoining small room with a glass window and open door several hospital personal watched monitors, laughed and giggled. Was it funny? Most important, though, the RAI was soaked up where it was supposed to be – in the thyroid bed.

Surgery and Treatment Side Effects: Hyperthyoidism

After my surgery I had a sore throat. But the frequent sensation of clutching around my neck, the heaviness in my chest, my sometimes racing heart, and extreme fatigue seemed to only get worse. Last year, 2011, was a very bad year. I had MRIs, electrocardiograms, nuclear stress electrocardiograms, nuclear perfusion tests, CT scans with contrast, and blood tests for everything. But no explanations of my symptoms were offered. The symptoms intensified.

It now seems that I was suffering effects of hyperthyroidism.  To suppress the activity of any remaining thyroid cells, thyroid cancer patients are prescribed high levels of levothyroxine (thyroid hormone). Individuals react differently to hyperthyroidism. I had multiple symptoms – fatigue, anxiety, palpitations, and an atrial fibrillation. (At the time of my atrial fibrillation I was in Sydney. My wonderful daughter-in-law came to the hospital. I was so glad that she was there to keep watch.  By the way, there everyone – doctors, paramedics, nurses – called each other by their first names. I was “Mrs. Wooders”.)    It might have helped to know that my symptoms were those of hyperthyroidism, not of the return of cancer. See http://www.myrnacatharsis.com/what-it-is-like/ for more of the story.

All Clear

My first post-thyroidectomy exam was on August 20th, 2011 at B&W. There was no observable evidence of cancer. It was wonderful. The sun shone, the trees glistened, the streets of Boston were filled with happy, smiling people.

Last March we reduced my levothyroxine. And, as time passes, it becomes less and less likely that I will have any recurrence. Back in rural Alberta, I had learned to “never let them see you cry” so I tried to keep my thyroid cancer private. This spring I decided to go public; I let my colleagues in VU Economics know in an email and via my website: Myrna’s Catharsis. I found the Thyca website (Thyroid Cancer Survivors Association) and learned that my experience with extreme hyperthyroidism had been shared by others.  See: What it is Like.)

In the spring of 2012, my tests looked very fine. My treadmill squawked a bit with its first use this summer, but now runs smoothly! Except for emotional scarring, I feel back to normal. If I have to increase my levothyroxine again, I will recognize symptoms of hyperthyroidism. If I have a recurrence, I think that it will not be for some years; I am hoping for forty. It may be useful for other thyroid cancer patients to know the symptoms that may occur as a result of their treatment, for persons in positions of power over others to better understand that thyroid cancer survivors may be hyper (or hypo) thyroid. And for physicians to recognize that not all thyroid cancers are slow growing so a patient with an enlarged thyroid should not be ignored.

Some fantastic reference books that I found along my journey:

Kenneth Ain,  A specialist in thyroid cancer, author, with Sara Rosenthal, of The Complete Thyroid Handbook, which includes a discussion of various levels of care, including “standard community care” – what one might expect of their local GP.

Another excellent, more technical and specialized book is Thyroid Cancer: A Patient’s Guide By D. Van Nostrand, G. Bloom, L. Wartofsky

This article was posted previously on ThyroidChange and re-posted with permission.

From Myrna Wooders (www.myrnacatharsis.com)