 Well, hello, everybody. Welcome to another episode of Dr. Jill Live. You may notice we're rebranding. We have a new name. So as this comes out, the new name is called Resiliency Radio, Hope Health and Healing with Dr. Jill. So either way, wherever you hear this on iTunes Stitcher, please stop, leave a review if you like. Our guest today is very special guest. I'm super excited to learn from her. Let me give you a brief introduction and then we'll dive in. Dr. Angela Massa is a triple board certified endocrinology diabetes, metabolism, internal medicine and anti-aging and regenerative medicine. Her broad medical background includes significant research in both basic clinical realms of endocrinology, basic end clinical realms of endocrinology. She's the founder of the Metabolic Center of Wellness in Florida, where she spends a great majority of her time caring for persons with autoimmune thyroid disease, thyroid nodules, thyroid cancer. She's currently the only physician in central Florida performing radio frequency ablation. That's one of the main things we're gonna talk about today, I cannot wait to dive into this. A non-surgical option for some thyroid nodules, highly regarded for her individualized approach to patient care. Dr. Massa empowers each patient to achieve their unique goals by providing education, lifestyle management and support. She believes that hormonal changes that happen in women and men as they age play a huge part in their overall health, longevity and quality of life. And she has a passion for helping her patients achieve metabolic and hormonal balance. Dr. Massa, so awesome to have you here. Thank you so much, Dr. Joe. Welcome and I'm so excited as you know and I know and our listeners know many, many, many people with thyroid issues. I think it might be one of the most prevalent, number one autoimmune diseases, right? But just dysfunction in general, I don't know of, I would say the majority of my patients have thyroid dysfunction versus not having it, right? It's becoming more and more common. Yeah, so let's talk a little. We talked a little about my audience. There's a lot of women, but then they also dragged their husbands over. So there's women and men. We just, I would guess, I would love to know your thoughts on statistics, but I think it's more common in women, especially the autoimmune version because we see more autoimmune in inversion. But what are you seeing as far as the landscape, even compared to maybe 10 or 20 years ago with thyroid issues and women in particular? Right, I would have to say, because I've been in practice, I don't wanna say completely how long. I've been in practice outside of fellowship since 2008. So that tells you. And I've been seeing more and more thyroid issues emerge. I don't know if we're looking a little more closely for them. That might be part of it, but they're becoming more and more prevalent. Whereas I would have to say the majority of my patient population, probably like you said with yours, all have some sort of underlying thyroid issue, if not just positive thyroid antibodies. I think there's a lot to it. I think, like I mentioned, probably we're looking for it a little bit more, screening a little bit better, maybe looking and digging into labs a little bit more, at least in the integrative and functional community, which I think we're really good at doing that. But I think we're exposed to so many things that influence underlying inflammation, because that's the key thing, right? It's inflammation is the root of all evil. And the virus is so, so sensitive to inflammation. So whether it's toxins we're exposed to in the environment, things that we're taking in in our diet, stress is a huge one. That's a big one. I'm sure you have to tackle that with your patients too. That's, I think that's one of the toughest ones, it's the inflammation associated with stress, to put on top of it other medications. It's just a lot of things that we're exposed to, that the poor thyroid is just trying to do its thing and it's super sensitive. So I love that part, because I feel that's exactly what I'm seeing as well. I think of this as like the little sentinel organ, right? Like it's a little, you know, they're like saying, hey, what's that happening? I mean, obviously it regulates metabolism. We can talk about like what's an ideal thyroid function do, but interestingly, my own history, I had 25 year old in med school breast cancer and my sister, I don't always talk a lot about her, but she at 28, so three years after when I was diagnosed with cancer was diagnosed with thyroid cancer. So we have two women, two girls in their 20s in the same environment and in genetics too, that had endocrine related cancers, one in the breast, one is a thyroid. And my mind was always like, oh, that was related. Number one, the genetics, we probably had poor detoxification and maybe issues there, but environment plays a huge role, right? And we both grew up on a farm. There was all kinds of organophosphates and chemicals and many people may not know the fact that these chemicals in our environment like pesticides, herbicides, roundup, phthalates, parabens have a huge effect on this little gland, don't they? Right, exactly. And I mean, they can impact every single step of the way our thyroid makes thyroid hormone. So from the way it takes up iodine, not to mention how our gut is taking up our micronutrients, that's a whole nother ball game with selenium, but it affects how our iodine is taken up, it affects how the thyroid peroxidase, the enzyme that incorporates iodine, affects how it's released into our system, how it's converted, T4 is converted to T3. Every step of the way can be influenced some way by these toxins. Yeah, so one in particular you mentioned, obviously tyrosine and iodine are used to make T3 and T4 and then selenium. What are some of the core nutrients that people if they're maybe not getting in their diet could have thyroid dysfunction just based on nutrient deficiencies? Yeah, iodine is number one, but it's the trickiest one, because I don't want everyone to go out and start taking iodine, because there is a narrow window for iodine. So too much can shut down the thyroid or cause too much thyroid hormone, like go into overdrive, especially if you have underlying autoimmune thyroid that may or may not be diagnosed. And if you don't have enough, you just don't have the raw material to make thyroid harm. So the supplements, the over-the-counter iodine supplements are like my pet peeve, because I have everyone come in when I see them for the first time, bringing all your supplements and darn it if there isn't a thyroid supplement with a ton of iodine. So I just check those levels right away. And that's what I would recommend people do before starting anything as far as iodine. My number two would be selenium. Selenium is so, so, so important. The thyroid is dependent upon selenium, not only to make thyroid hormone, but it protects the thyroid from kind of everything we're exposed to. It's kind of like the great protector. Not to mention like with Hashimoto thyroid, it helps bring down antibodies, but you can't go wrong with selenium. And you don't have to check selenium. You're not gonna become toxic on selenium, 200 micrograms a day or two Brazil nuts, you're good. Iron is the other one. That's kind of my third one, because especially women, how often are women bound to have low iron? And we, how often do we even check if we're not thinking of it? If they're not endemic already, we're not checking for iron. So iron is so important for the enzyme within the thyroid that thyroproxidase to work better. It's a heme protein enzyme. So we don't have iron. We can't make thyroid hormone. And so especially women, even if you're not anemic, I would say get your iron checked at least once. Yeah, great. It's actually replacing those micronutrients to be the difference between just being put on thyroid, hormone replacement and not. So if you replace the micronutrients that the thyroid needs, it can work usually, if there's not something else going on, and depending upon where we're at. I love that, because I would agree like often, like you and I are probably checking, let's talk about labs in just a moment, but we're probably checking antibodies at the very least. And I see still a normal TSH and free T3 and free T4. Usually the first thing I'll think of is let's try selenium and see if we can get those to end gluten-free diet or something like that. Yeah. Oh yeah, definitely. Low clavatory gluten-free diet. This is what I'm saying. So if you saw just thyroid antibodies in the docs, like, okay, everything's normal, which we know may or may not be true. What would you do as a first step before you do any thyroid replacement if TSH, T4, T3 are pretty normal and the thyroid antibodies are up? I would actually just replace the micronutrients and remove any sort of inflammatory. So the diet we can control, we can't control everything else, but the diet we can. And I'm at a little bit of a luxury too, because I have a thyroid ultrasound in my office. If I put my thyroid ultrasound probe over the thyroid and I see long-term changes, that makes me a little more suspicious because that tells me I don't got a lot of time. So I'm gonna monitor that person a little bit more closely, especially if they're kind of in that not optimal thyroid range. But if I didn't have that luxury, I would go for the micronutrients and the low-inflammatory gluten-free diet. And then reach out to them six to eight weeks. What do you have to lose? I totally agree, because often you'll see those either go down. I mean, in the traditional sense, our conventional training says autoimmunity is irreversible, right? And you and I both know that with the right circumstances, we can see like, I always tell my story 20 years ago with Crohn's disease, I don't have it anymore. And that's like unheard of in the conventional medicine because the truth is when we give the right nutrients, when we reverse the inflammation, it's not all cases, but sometimes we'll see these cases of thyroid where they're early and the thyroid hasn't really been damaged and you can actually reverse or decrease those antibodies, right? Exactly, exactly. And I get into this kind of a little bit of a debate with some of my traditional endocrinology friends where they'll say, there's no need to check the antibodies once they've been checked, they're there. So there's nothing you can do about it. And then that's when people end up on leave with the rocks and for the rest of their lives and they never get taken off of them. So they don't have to put someone on medication, I'd rather not. Absolutely. So let's talk briefly about labs because you and I probably take a lot more than the average. Oh yeah. Just check TSH. Tell us a little bit about what, just the very basics, TSH reaching through and kind of what the panel labs would be and then why that might be important to look a little bit bigger than just the TSH. Yes. And it's the first time I'm seeing someone I order the most amount because I figure, I don't wanna like add things in later. I'd rather just check everything all at once. And I warn my patients to be prepared, go well hydrated to the lab because we don't have a lab here in our office. So just be prepared, they're gonna draw a lot of labs. So basic lab TSH, free T4, free T3, reverse T3. I'll check a random urine for iodine and creatinine. So ideally, there's no great lab tests for iodine. So probably the best would be a 24 hour urine collection for iodine, which it's a pain to do. Nobody likes doing that. So if you get a random urine with a random, random urine iodine with a random urine creatinine, you can kind of extrapolate out a 24 hour urine and then that tells you where you're at. So thyroid antibodies. So anti-TPO, it's a thyroglobulin antibody. Those are kind of my basics. Depending upon my suspicion and this history, that's where I'll kind of start with getting a complete iron panel of ferritin. I'll kind of go from there. If I'm suspecting something like f-steam bar, then I'm checking for reactivation. It kind of all depends upon the story I'm getting from the patient. Say they're having real issues with weight, then I'm adding in insulin levels and kind of going from there. But the basics when it comes to thyroid are those first group of labs. Fantastic, I couldn't agree more. I want to talk a little about TSH because the other thing we were talking about in med school is don't touch it until it's over 10, right? And I start to think about issues above three, but where's your, and I don't always treat depending on where they're at. Where would you say numbers for TSH should be ideally or when should we think about maybe there's an issue? Yeah, my goal is I shoot for like between one and two, two and a half, but three is reasonable too. Because when we actually now have data outside of when those rules for TSH and subclinical hypothyroidism were made, we now know that people have metabolic issues with the TSH that's above four at least, cardiac issues that can happen. We're already seeing homocysteine issues. I mean, there's things that are happening in that considered safe subclinical range that we have the luxury of this data now that we didn't have then, but we're unfortunately we're still going by that same guideline. Right, we're like 20 years behind the times, right? I know, it's my help. Yeah. But I mean, our goal is even as integrative doctors, we're trying to educate and kind of, we're ahead of the game on everyone. So it's our goal to really spread that information because if you're letting something happen, my big thing is I don't want something bad to happen to my patient when I had the foresight to know the potential to shift it. I agree. And when we're thinking integrative or functional medicine, we're on this trajectory always. I always say it's not like one day Tuesday, you're fine and Wednesday, you wake up with diabetes. There's never happens, right? So it's always we're like walking towards metabolic dysfunction or thyroid dysfunction. And so you and I are like, where are you at on that timeline, that trajectory? And if you're starting to walk in the wrong direction, we're like, hey, let's go this, let's go back. They would ever wait. You're closer like falling in the river if you're so close, so. Good, good, good. One last thing, and then we're gonna go into nodules, which is your area of expertise. I was gonna ask about symptoms. Just for the, again, people probably know this, but for those who are just listening, what might people feel if they're, Tuesday it's just starting to creep up or they're developing Hashimoto's? What are some of the basic symptoms that they would expect or that you maybe ask them for hypothyroid? Gotcha. Well, when I first started practicing, there were symptoms I was over to say, no, that's not thyroid, that's not thyroid. But now doing this for so long, I can kind of, depending upon the person, see how things that wouldn't make sense being thyroid actually are thyroid because thyroid affects pretty much every system or body. But probably the main ones are fatigue, just feeling zapped as far as energy. Brain fog's a big one. And I don't think we address that enough because our brain is so rich in thyroid receptors, especially as women, we kind of get, we kind of like just push through a lot. But if you feel like your brain is not firing, then get your thyroid checked, especially with Hashimoto's thyroidase. Feeling cold, in Florida, we don't have that so much. So I kind of always say, this is a loaded question, but are you feeling hot more than normal, more than normal? So that's kind of a tough one down here. Hair loss, changes in skin and hair, those are big ones. Having trouble losing weight, even though you're like, hey, I've not been veering off track with my meal plan, I've been exercising, I've been trying to get sleep, but I'm still tired in the morning, but I'm trying to get sleep. Those are kind of the big ones. If you look, I mean, if we again look back in the literature, hoarseness is always listed. I don't see that as much anymore. You actually have to be pretty far along to have a lot of hoarseness, but probably fatigue, weight gain, brain fog, and skin and hair changes are the big ones. Hey everybody, I just stopped by to let you know that my new book, Unexpected, Finding Resilience Through Functional Medicine, Science and Faith, is now available for order wherever you purchase books. In this book, I share my own journey of overcoming life-threatening illness and the tools and tips and tricks and hope and resilience I found along the way. This book includes practical advice for things like cancer and Crohn's disease and other autoimmune conditions, infections like Lyme or Epstein Bar and mold and biotoxin-related illness. What I really hope is that as you read this book, you find transformational wisdom for health and healing. If you wanna get your own copy, stop by readunexpected.com. There you can also collect your free bonuses. So grab your copy today and begin your own transformational journey through functional medicine in finding resilience. I totally agree, I see, and we see those a lot. Okay, let's shift to nodules. Let's talk for a space like what causes a nodule? What might someone notice anything more different or specific with labs or what you'd see clinically? And then we can talk about some options for treatment. Yeah, so nodules are really, really very, very common. If we ultrasound everybody that walks down the block, that one in three persons sometime in their life is gonna show up with something. So they kind of put it in perspective how common they are. You may not have any symptoms at all. Lots of times I have patients sent to me for thyroid biopsies where they were found accidentally for imaging for other things. Like they went in for imaging of their neck and they found they were found to have a thyroid nodule and chest x-rays somehow a substernal goiter showed up. So, but some people may feel a little lump on their neck or their doctor may feel it or a close love one may see it, but we see that sometimes too. Now as far as what causes them, that is a great question because we actually used to think, oh, this must have been iodine related sometime. And it could have been. I mean, the thyroid is so sensitive to iodine, but what we're finding more and more is we're seeing an increasing rate of nodules in the setting of inflammation. Again, the core thyroid is getting hit hard with inflammation. We see a lot more in obesity and insulin resistance now. So all my thyroid cancer, which cancer is what we wanna not miss with thyroid nodules. All of my recent thyroid cancers have been in the setting of insulin resistance and diabetes and obesity. So the thyroid is so exquisitely sensitive to it. Most nodules are benign. So we have certain criteria where we look at them a little more closely as far as biopsy to make sure that they're not cancer. And most nodules don't cause the problem at all. Some of them can grow depending upon what they're made of. If they're more fluid, they're more solid, they're more vascular and that can become a problem. So it can cause compressive symptoms because your thyroid sits right on your trachea. So you might have trouble breathing if your nodules giving you grief. You might have trouble swallowing because your esophagus runs right along the left side of the trachea. Some people have trouble just coughing. That's when we see hoarseness of voice because recurrent laryngeal neurofronts are behind the thyroid. So, but again, most nodules don't cause anyone any problems and we follow them and it's not an issue. But the ones that are up until recently within the past few years, our only option was surgery for a lot of them. Now there are nodules that make too much thyroid hormones. So those are what's called toxic nodules or overactive nodules. So those folks have symptoms as far as feeling overactive. So the exact opposite of what we're talking about is they take both iris and so they're gonna feel anxious, sweaty, trouble sleeping, shaky. They can, toxic nodules can be very symptomatic and very life-disturbing for some. Yeah, I've seen that. Both of them. Other than surgery, we have medicine up until recently. Excellent, so that's a great overview. So I know there's, we don't have to go into detailed radiology confirmation, but what are some of the basics as far as maybe size? Like when you think, okay, we can follow this every six months and it's probably benign. What's like, is there a few criteria that people might know about or can hear from their doctors of what would lead you to believe it's benign versus more serious? Yeah, so no size in particular we can say, because lots of times when we find nodules, we don't know how quickly they got to that point in time. So they may have grown very quickly to be one and a half centimeters or they may have been one and a half centimeters is kind of our go-to for biopsy. So making sure they're not cancer. And one and a half centimeters is pretty small. It's like the tip and a half of your finger. So most people don't feel them. So if we biopsy a one and a half centimeter nodule and it's benign, I usually say you repeat it again, ultrasound in six months. If that's stable, then maybe one year, every one to two years. So you look at the rate of growth basically, right? The rate of growth and time for that, which makes sense. I kind of have like a baseline. I always like to have a baseline. Now, there are sonographic changes on an ultrasound that make us a little bit more concerned. Nodules that are a little more vascular means we got to look at them a little more closely, especially if they have vascularity in the middle of the nodule, that's a little bit more concerning for cancer or cancer is growth. And we look for also, you might hear something about micro-classifications. Nodules that have micro-classifications make us a little more concerned. So we follow them a little more closely. And nodules have just, sometimes they just have weird borders and they just look, I don't like the look of it. Then I just say, you know what I feel better just following a little more closely. That makes sense. And again, you're actually able to do that when you want to because you have to. Awesome, that makes so much sense. So people can kind of, so okay, so say we've decided they're likely benign, there's a very slow rate of growth. You're really confident that you're not dealing with a cancer. Let's talk about radio frequency ablation because that's something that you do, that's really unique and that's incredibly powerful because there's not a lot of docs out there that are doing this, is that correct? Yeah, yeah. It's becoming more accepted and we're trying to get more education out there because still people are unfortunately needlessly having their thyroid taken out every day. And we talked about all the things that the thyroid does. And if we're doing surgery to take out a thyroid nodule that's benign or not causing any problems and we've just traded one problem for another, basically we haven't really solved anything. Yet someone that's gonna be on thyroid hormone replacement for the rest of their life. So radio frequency ablation, you might have heard it in terms of other tissues like it's been used for years for small tumors of like prostate, liver, lung, even in the cardiac world for heart disease. Yeah, it's the ectopic beats and stuff, right? Yeah, yeah. So back in 2002, it was first used in South Korea for benign thyroid nodules. So and all across the globe, had this had been accepted for a treatment option for benign nodules, that includes overactive nodules. But it wasn't improved in the US until the end of 2018. So I got trained right on board and I was like, I took care of so many people that had their thyroid taken out and we're having trouble getting their thyroid levels on track for so many years. I was like, this is a no-brainer. So it's done in the office, you don't have to have surgery, you don't end up with a scar, it's effective, it's safe, there's not complications like you're associated with surgery. So it's just really, I kind of look at it as an honor to be able to offer this service to people in the area. And we've had people come from all over the country for this procedure that are, they wanna look for other options other than surgery. I believe it, I was so excited to talk to you because I think people, the more I can help you get the word out, the better because this is such a fan of what happened, what happens in medicine. I mean, I'm a cancer survivor, so I know this well. We cut and we burn and we treat and there's nothing wrong. It saved my life, but I look back and in relation to what you're talking about, the chemotherapy, the radiation, the surgeries that I had, the cancer was easy. I was through that in about nine months and I've never had it again. But the last 20 years, what I've dealt with is the side effects of the treatments, right? Which is what you're doing. No regrets, I would do the same thing again. However, I realized how toxic a lot of those things are and that's how our system works. And again, it saves lives, but it's very relevant to thyroid because I think the historical bent has been to take it out, remove it if there's any. And most people are going to, I mean, there's great surgeons out there. I love my surgeon colleagues, but if you're going for an option to someone who that's what they do is surgery, then. Yeah, that's the option to help you, right? The recommendation. But, you know, I think getting the word out more, we actually have more surgeon colleagues that are doing RFA as well. So, because they realize it too. Yeah, are you teaching or talking more about this sort of like a podcast episode? Are you able to? Yeah, I'm trying. I'm actually at A4M, I presented on RFA. I'm trying to do more, just more local education, just getting the word out there. We have episodes on YouTube channel, things like that. But I have to say, RFA has been very patient driven. The patients that have referred themselves to me, they sought out this treatment. It wasn't like the recommendation of their doctor. So, I think especially in the integrative community, we have to be aware of it as an option to really say, okay, here you go. This might be a way for you to save your thyroid and not have to go through surgery. That makes so much sense. That's again, why I'm so excited to talk to you because it's for me too. I'm like, oh my goodness, this is such a needed option. I don't know that there's anybody in my area doing it, but so is there any times when you like would do an ablation and it either recurs or is there a small percentage of failures or what you need to do with another treatment or tell us kind of like a spectrum of successes and never need treatment again versus maybe something else happening. Right, so larger nodules, we can only ablate so long. We want to keep things as safe as possible. But we're doing some very, very large nodules, like 65 milliliter nodules where I can only do the procedure for so long because patients awake, we're monitoring their voice just for the sake of time. And it can be a lot after a while. So those are patients that I say, you know what? We can shrink it. Our goal would be to get it 70 to 80%. But if we can at least make a difference in how you're feeling, it's not causing as compression issues. It's still gonna be there. You probably need another treatment to get more decrease in volume. So those are cases where you have to be really up front with people. The other case is these overactive nodules. So these overactive nodules are very, very vascular. And when they're more than maybe 10 or 12 milliliters in size, I mean, that's not that large of a nodule. I mean, that's like two by three. They oftentimes need another treatment because this is a vascular treatment. I have to repeat it usually. Is it done in low-risk cancers? Can you actually treat a low-risk thyroid cancer too? Yeah, so this is kind of an exciting thing for RFA within the past year or so. So very small cancers are called micropapillary cancers. So those are the most common types of cancers. Micropapillary means they're probably around one and a half centimeters. The chance of micropapillary growing over time is very, very low. So even the American Thyroid Society even realized that, these cancers grow so slow, do they ever become a problem? So then we gave the treatment option of just observation. So you're telling a patient, all right, you can either have your thyroid taken out or we can just watch it every six to 12 months. The observation part is very anxiety producing for a lot of people because they're like, I'm just gonna watch the cancer that's in my throat and we're not gonna do anything. So now we can offer RFA for that. And the treatment, the results are great. So it takes, again, we have to follow it over time. We still follow it closely, but at least it's something that the patient feels that they're doing something for the cancer. They're not just watching it because lots of time when we look over time with the observation data, patients end up having the surgery anyway because they were so anxious about the cancer. Wow, amazing, so needed this information. Is there anything else on the horizon that may not be standard yet but that you've seen that has any other future things that you're looking at are seen besides this actual maybe treatment of cancer? Well, there's some different therapies that are as far as non-surgical options that are kind of coming up on the radar for different types of cancers, but we just don't have enough data to say the safety long-term, but there is a lot coming up. And it makes sense because thyroid, a lot of them are not super aggressive. And maybe I'm saying that wrong, but I would say in general, that's versus like a pancreatic cancer, right? Or one of these- Oh, yeah, they're very slow growing. There's a couple that are fast growing, but those are very rare. Which is nice, because then there are other options as we go. So how exciting. Well, thank you so much for your information. Tell us a little bit more about what other places people can find you, where's your website, any other podcasts. Sure. Thank you. Well, I actually have a book coming up called I'm Fyrotalk, an integrative guide to optimal thyroid health. So hopefully within the next week or so. We'll have a master's soon. Wonderful. Yeah. We won't be able to, when this podcast comes out, it probably will be available. We'll make sure and link, if you're listening wherever you're listening, look at the show notes because I will link to wherever you can buy the book or pre-order. Are they able to pre-order now? Oh, yes, they are. This was a kind of a, something I never thought I would do, but when COVID hit, I had a little more time. So this has kind of been a work in progress since then. So I'm so happy for it to be out. And there's going to be a master class that kind of goes along with it shortly thereafter because I realized that lots of people don't have access to endocrinologists. They don't have access to the information that you and I have that we can spread. So that's the master class. We have a podcast called, Thyroid Talk with Dr. Angela Mazza on all the streaming channel. And Dr. Jill, I would love if you would be a guest on our podcast. Of course I would love, we'll make it. And then finally, we have, our website is metaboliccenterforwellness.com and Facebook, Instagram, TikTok, although I don't dance. Me neither, I'm like, I'm not going to dance. Awesome, very good. Well, thank you again for your great information. Thank you, leader. Because it takes someone who's like cutting edge and like pushing the envelope a little to get to the places where we need to be with patients. But it's, when you're the pioneer, sometimes it's a little lonely out there. So thank you for being that pioneer in this field. Oh, and thank you for being so supportive and helping to spread the information.