 and welcome to the latest edition of Tell Health in Hawaii. I'm Vikram Acharya. I'm the Chief Executive Officer of Cloudwa Health, an all-virtual telemedicine organization based in Hawaii. January was Thyroid Awareness Month. We have a great show for you today. Dr. James Hennessy, a new chronologist at Beth Israel Deaconess Medical Center in Boston, is going to be speaking to us about the thyroid, what it does, how to take good care of it, and life as a physician. Enjoy the show. Mahalo. Aloha. Dr. Hennessy, how are you today? I'm fine. Thanks for asking. Good to have you on the show. Good to have you on the show. To get things started, tell us a little bit about yourself. You're a physician. You're an endocrinologist. You work at Beth Israel Deaconess Medical Center, which is affiliated with Harvard Medical School. What is an endocrinologist and how did you get to this point in your career? What is an endocrinologist? An endocrinologist deals with internal hormones. Your classic endocrinologist is taking care of a lot of diabetes patients, but most endocrinologists are also very interested in other kinds of endocrine problems, such as thyroid problems, adrenal problems, pituitary problems, and bone metabolism problems. I took an off-ramp from general endocrinology several years ago while I was at Walter Reed Army Medical Center, and I became a thyroidologist. It's been quite a ride ever since then. After 26 years in the military, I finally retired, and then I moved to Boston. It's been nice, but that period of time gave me a lot of experience in the world of thyroidology, and I've been involved with the American Thyroid Association and the American Association of Clinical and Chronologist Thyroid sections, and I really enjoy my job at Israel Deaconess. I spent my morning doing these on thyroid nodules, and I'll be spending our afternoon dealing with metabolic problems from thyroid, so it's very rewarding. Yeah, that's interesting. For our audience, your specialty is the thyroid. January was Thyroid Awareness Month. Where is the thyroid on the body? What does it do? Can you give us a little one-on-one on this subject? Sure. I can give an anecdote. By the time they were two, all three of my sons could say, that's where my thyroid is, Daddy. They were budding endocrinologists, but they've never done that. If I were to give you a useful introduction to the thyroid, perhaps Dr. Google helps us out a little bit with all kinds of terms that you can explain to your patients. For example, the thyroid is a small butterfly-shaped endocrine gland. It makes thyroid hormones, which are secreted into the blood and go to every tissue. The thyroid hormone helps the body use energy, stay warm, keeps the brain hard and muscles and other organs working as they should be working. If the thyroid is working appropriately, you don't even know that it's functioning. It's when it is dysfunctional that it starts to cause problems. How do you know that it's starting to become dysfunctional with thyroid? Well, that's an interesting question. There's essentially two different forms of dysfunction, and then there's anatomic abnormalities. The anatomic abnormalities will get out of way very quickly. The thyroid can develop nodules or lumps, and those nodules are 90 plus percent of the time just benign nodules with no particular clinical consequence. However, because 10 percent or less actually represent malignancies in the thyroid, we take thyroid nodules very yearly. We intervene as quickly as reasonable to try to help the patient understand whether they have a big problem or just a small cosmetic problem in their thyroid. As far as functional problems, the thyroid can either overproduce thyroid hormone, and that leads to the process that's known as thyrotoxicosis, or the thyroid can be deficient in its ability to put out thyroid hormone, and that leads to the process called hypothyroidism. Both of these have their own fairly non-specific symptoms, and it's usually now coming into focus that we order thyroid function tests when we suspect a thyroid abnormality. But I would take it one step further and say, I order thyroid function tests to rule out thyroid disease. When people have very non-specific symptoms, like many people my age, for example, I have thyroid function test done just to be sure that it's not something significant with my thyroid, and then my primary care doctor has a big chore to figure out why I'm complaining of those things once he knows that my thyroid is functioning correctly. Overactivity in the thyroid might result in people feeling, at least initially, overly energized, but when that's chronic, that can also lead to fatigue. Not infrequently, people with an overactive thyroid may very well develop a greasing heartbeat, and that can be perceived as palpitations or anxiety. Again, the longer it goes on, perhaps the bigger the problems become, because thyrotoxicosis, if persistent, and especially in older people, can lead to tachycardia, atrial fibrillation, and then all the consequences of atrial fibrillation. Then on the other hand, it increases bone turnover and leads to bone loss, so we can see significant further bone loss in postmenopausal women, and thyrotoxic men who might have persistent thyrotoxicosis can have very low bone densities. Of course, both of those result in fractures. An overactive thyroid is not a good thing to have, because it should be corrected, because overactivity in the thyroid, if left alone, can actually be fatal. The far more frequently encountered problem with thyroid function is hypothyroidism. Here we've got a subtle story going on. Everyone thinks that when they were in medical school, they read that hypothyroidism is extremely common, and 10% of the population has it, and it responds immediately to replacement with thyroid hormone. I read the same chapters in the textbooks, but I've been studying hypothyroidism for the past 25 to 30 years, and it turns out to be far more subtle than that. The first thing we have to keep in mind is what's a normal TSH? Now let's remember what the thyroid stimulating hormone does. It comes from the pituitary under stimulation from the hypothalamus, and it circulates throughout the body to go to the thyroid and then stimulate the thyroid to put out thyroxin and triiotyrinine or T3. Now the thyroid produces these two hormones in about a 17 to 1 ratio, so it's almost exclusively T4 coming out of the thyroid. That's the thyroxin. If thyroid hormone levels are insufficient, then the patients with overt hypothyroidism develops rather characteristics, but at the same time very nonspecific symptoms, like, oh, I'm feeling tired, or I'm feeling cold, or I'm feeling constipated, or I'm just not feeling the kind of get up and go that I'd like to have, and I'm feeling a little bit depressed. Well, in overt hypothyroidism, if indeed those symptoms are present and the patient is significantly hypothyroid, we can actually count on a very positive effect of replacing thyroid hormone and restoring normal thyroid function from that patient. On the other hand, here's another thing to think about. Several studies looking at normal aging have demonstrated that as we get older, our thyroid function tests change a bit as we go along, and this is seldom reflected in the normal ranges that you see coming from your clinical laboratories. One thing to remember is that as we age, our TSH levels start to creep up, and at the same time, our T3 levels circulating in the blood start to go down a bit, and they're about proportional to one. Now, it's been explained to me that that is nature's way of showing us that we're getting older, and when the T3 levels are coming down a bit, it's nature's way of saying, you know, your heart's getting a little bit older, it doesn't need all that stimulation, let's back off just a little bit so that everything remains in sync. So, the pattern that we see as people age is that the TSH goes up, the T3 levels go down a bit, and the thyroxin levels stay the same or even raise a little bit. So, this is not a disease process per se, this is normal aging, and the thyroid is not failing because the thyroxin, which is the primary hormone that comes from the thyroid, is not diminishing, but rather it's an adjustment to aging. So, the Europeans have looked at thyroid function tests as we age, and they've come up with a little bit of a simple algorithm. Their idea is, well, the laboratory says a normal TSH is 0.4 to 4.0, or somewhere in that area. But everyone who studies this recognizes the fact that a 70-year-old typically has TSHs in the four-and-a-half, five-and-a-half, six-range, and that's the 70-year-old, and the 80-year-olds a little bit more, and the 90-year-olds even higher. And these are perfectly functional, cognating older people who have a raft of other problems that are associated with their aging, like aches and pains and arthritis, and not being able to move quite as quickly as they previously done, and, oh yes, by the way, a little bit of constipation and feeling a little bit cooler when the air conditioning hasn't been changed at all. And so what the Europeans have proposed is, well, you know, anybody over 60 take whatever their age is and divide it by 10, and that should be probably the upper end of the TSH for them. So, 70-year-olds, those of us that study this, will accept the TSH upwards of about seven as being pretty much normal for a 70-year-old, and eight for an 80-year-old, and nine for a 90-year-old, etc. Now, several studies have actually been done looking at older people and trying to correlate their symptoms with their TSH levels, and it was perfect. They were unable to correlate symptoms with these raising TSH levels, because indeed, if you adjust for the age, you'll see that these are actually fairly normal TSH levels and not a reason to hit the 9-1-1 button, so to speak. Now, this has caused a bit of a problem, and I recall in medical school, as you probably do also, that the idea was, oh, hypothyroidism very common, upwards of 10 to 12 percent of the population will develop it, and the older you are, the more likely you are to be hypothyroid. Well, that's using a TSH of 4.0 as the upper limit of normal, but as I just said, normal aging does lead to a creeping up of the TSH levels, and so most likely over the years, we've been overdiagnosing hypothyroidism in the older people, because they have some non-specific symptoms. Someone orders a TSH, it looks a little bit higher than the laboratory says is normal, and therefore they jump to the conclusion that it's actually hypothyroidism. So a large group of people got together and said, well, let's take a look at these older people who have these mildly elevated TSHs, and let's see what treating them actually does for their non-specific symptoms. And lo and behold, for symptoms, it did absolutely nothing. So we go back to the rubric, I listen to my patients or you listen to your patients as a primary care doctor, and you say, oh, that could be hypothyroidism. Let me get some thyroid function tests. Well, to diagnose hypothyroidism, you'd look at a TSH and probably a free T4, not the T3 level. Let me emphasize that. For hypothyroidism, do not measure a T3 level. And then when the results come back, if the TSH is two, and they have these non-specific symptoms, you're going to be saying, oh my goodness, I've got some work to do to try to figure out why this patient has these symptoms. On the other hand, if you don't realize that you're misinterpreting the TSH, and you're starting them on thyroid hormone when they have symptoms that are not due to hypothyroidism, that's sort of the wrong treatment though, isn't it? So if I treat the wrong disease, would I really expect it to get better? Well, no, probably not. So we treat people with thyroid hormone who are 80 years old because they have a TSH of six and a half. They continue to complain about the exact same things. And if we're very careful, we don't make them thyrotoxic even though in that age range, we've got about a 12-fold increased risk of causing thyrotoxicosis. I refer to that as iatrogenic thyrotoxicosis, and only the doctors in the room feel guilty about that. So the symptoms don't go away. And it's because people with such mild elevations in TSH, which are probably physiologic, don't have hypothyroidism, and that's why they don't respond to thyroid hormone treatments. On the other hand, if you look at parameters like cholesterol and cardiac function and a few other parameters that are associated with mild hypothyroidism, there is some improvement in them. But not a miraculous improvement in them. So that's the basics on the overactive thyroid and the underactive thyroid. Let me reiterate that the way to make a diagnosis of hypothyroidism is first to think about hypothyroidism. It is not recommended that that be a piece of your yearly blood work that you get on patients. And the U.S. Preventative Services Task Force has not recommended evaluation of thyroid function as in asymptomatic people. And when I say asymptomatic people, I know how many aches and pains I have. And so technically, I guess I'm not asymptomatic, but this is what I'm saying. Don't add it to your annual blood work. Cholesterol, yes, of course, and other such things, but thyroid function testing is not something that's going to be helpful. And the U.S. Preventative Services Task Force concluded that when they looked at the data about people feeling better with mild elevations in TSH, and they concluded that it played no role. Now, if you're thinking about depression, if you're thinking about fatigue and other kinds of symptoms, or cognitive decline, for example, that also has not been associated in large meta-analyses with thyroid function for the most part, and especially not with subclinical hypothyroidism. So getting thyroid function tests, if someone says they forgot their sponsor's name or middle initial or something, and then finding a TSH or six, first of all, that's probably physiologic. And secondly, it's not likely to respond to thyroid hormones, so did you really want to know that? The more serious problem is the thyrotoxicosis, and we should probably spend a little bit more time on that because that can really cause some big problems. And to miss the diagnosis of thyrotoxicosis is a missed opportunity. Once you think you're dealing with a thyrotoxic patient, you want to do thyroid function tests, and there you're going to find their TSH level is suppressed, frequently suppressed to undetectable. Their T4 levels will be elevated, and their T3 levels will also be elevated. So the indication for measuring a T3 level is when you're working on a thyrotoxic patient. Then we have to decide once we've established the fact that it's thyrotoxicosis, is this endogenous hyperthyroidism, or is this some other form of thyrotoxicosis that's not being driven by an overproduction of thyroid hormone? So one of the tests that we frequently do, as long as the patient doesn't have overt ophthalmopathy, which would be consistent with the presence of grieves that see us, for example, is to do a radioactive iodine uptake test while the patient is thyrotoxic. And that divides the patients into two large groups, those with hyperthyroidism, where the uptake of iodine is going to be substantial. And remember, if the TSH is undetectable, you would expect the uptake of iodine to be zero, because as you'll recall, TSH stimulates the uptake of iodine into the thyroid. But if the uptake is substantial 10%, 15%, 25%, then that's consistent with thyroid autonomy, and that can take several different forms. Graves disease is probably the most frequently encountered one, and that's caused by stimulating immunoglobulins that interact with the TSH receptor. Another form of thyroid autonomy is atoxic, either uninodular or multinodular goiter. And when you do the radioactive iodine uptake and scan, you'll see bright little nodules in the thyroid, taking up plenty of iodine and overproducing thyroid. Now, there's two other forms that I would mention to you, but you'll probably never run into them. One is a pregnancy-induced thyrotoxicosis. And when HCG levels are very, very high, they will interact with the TSH receptors in the thyroid, and they can cause thyrotoxicosis in a pregnant woman. It can also happen in men if they have a choriocarcinoma or some sort of other thing that produces HCG. Men can also have HCG-positive thyrotoxicosis, which is actually a hyperthyroidism because the thyroid itself is being stimulated. And finally, there's a very, very rare cause, which is a TSH, a secreting tumor from the pituitary, which I believe I've seen one so far in my thyroidology career. The other side of the spectrum has very low uptakes, and that would be patients with thyroiditis. That would be patients who've been taking excessive amounts of exogenous thyroid hormone. That would be patients who are producing thyroid hormone ectopically, like in an ovary. Remember stroma ovary? And then finally, there's one that's kind of an artifact. If you are exposed to large amounts of iodine and you have Graves disease, your radioactive iodine uptake will be suppressed. And so if there's a history of intravenous iodine contrast, then that can cause that artifact. But it's an opportunity to go through a differential diagnosis because the treatment of just about each and every one of those entities that I just mentioned to you is very different. Your work as really specializing around the thyroid, how does telehealth integrate with this? Are you able to do more with telehealth? I know we're talking about a very detailed subject here. Yes, and I'll share with you a couple of anecdotes during the height of the pandemic when I was forbidden to go into the office. Can you imagine that a medical administrator telling doctors not to come into the office? But when I was forbidden to come into the office, we set up a telehealth network, of course. And I diagnosed no less than four patients with thyroid toxicosis, three of whom turned out to have Graves disease, and one of whom turned out to have subacute thyroiditis. And I managed all four of them just by laboratory work, as well as discussion via telemedicine. So I am in favor of telehealth, and I really feel that it was a tool that I could use to keep me in touch with my patients. And indeed, I met a fellow last month who said, well, I've been seeing you for three years, but this is the first time you're ever going to feel my thyroid, because I had started that story on telehealth, managed him to use thyroidism, and he was finally following up, and we were finally able to meet face to face. So I think telehealth plays a big role. You listen, you hear what the symptoms are, you order the laboratory evaluation, and you follow through in exactly the same manner. And don't forget, I even did diagnose several thyroid cancers during the pandemic with people who were discovered to have thyroid nodules. We just went through the process of getting an ultrasound rather than putting my fingers on their thyroid. And then we took it from there with a biopsy of their thyroid nodules. And our was so happy to have something to do. That is incredibly interesting. So for three years, you were managing this patient virtually, and you never actually touched him. Never touched him. Wow. And he turned out okay. Now, are you still doing a lot of telemedicine now, or has it shifted more back to the in-person for you? It's shifting back to in-person for several reasons. I think I mentioned to you previously that in New England, we're now restricted to only patients in Massachusetts to do telemedicine with. We were going across borders into New Hampshire and Maine and Vermont, and Rhode Island, and Connecticut too, actually. But at this point in time, all of those connections are set by the insurance companies. And at this point in time, our administrators have discovered that it's in their best interest to have the patients coming back and utilizing their facilities. And so they're discouraging the use of telemedicine. But if I've got an older patient in a wheelchair that really has problems getting in, then I can agree to have them do telemedicine. And as long as the visiting nurse can draw the blood, I can typically manage their thyroid dysfunction just as readily as I could if they made the effort to get into the office. So we're still doing some, but far less than previous. I'll share with you another anecdote. We have a fellowship in the endocrinology and our institution. And during the height of the pandemic, even the fellows were being forbidden to go into the hospital and see patients. So they were doing outpatient clinics with me on a separate link. It would be sort of like the two pictures I'm looking at right here with the patient in between. And I'd be sitting in on the fellows visits with their routine clinic patients. And they do five or six patients on an afternoon. And I'd simply be there with them and we could discuss the cases and the patients knew that they had double coverage. They had a nice bright young person very interested in them and then someone who somehow stayed awake throughout the entire visit and made what sounded like wise comments in the end. So we even taught via telemedicine. For our non-clinicians, non-positions who might be watching this and around the thyroid, thank you for all this very helpful information. What advice would you give them if they're concerned about their thyroid or if they have questions about it? Well, I would give them a website and this is a website that I would recommend. It's called thyroid.org. There is a wealth of information on the thyroid.org website. I do not recommend just random websites because I'm never sure exactly what's going to be presented or why they're presenting it that way. But I would say thyroid.org is a good place to look for information. Otherwise, when you're talking to your primary care doctor, you can ask, is it my thyroid? And they can measure thyroid function tests. And remember, if you're my age, you're going to have to make an adjustment as to what the expected range for TSH is. As we get older, it goes up a bit with no negative effects on our physical well-being. And let's make sure that we don't over-diagnose thyroid disease. But that's why we measure thyroid function tests to rule out thyroid disease so that if the thyroid function is reasonable and normal, primary care doctor can move on and actually figure out what is causing it. Dr. Hennessy, thank you so much for breaking down all this comprehensive information about the thyroid. I know this is a very specific subject. And we just finished Thyroid Awareness Month and just really appreciate you breaking down all this valuable information for patients, telehealth, clinicians. It's very appreciative of your time and very comprehensive. Thank you. Well, thank you for your invitation. That was just a pleasure. Thank you so much for watching Think Tech Hawaii. If you like what we do, please like us and click the subscribe button on YouTube and the follow button on Vimeo. You can also follow us on Facebook, Instagram, and LinkedIn, and donate to us at thinktechhawaii.com. Mahalo.