Thyroid Dysfunction

Introduction

Substances in the environment, known as endocrine [ENdoh-krin] disruptors, can alter hormone function. Most research has focused on substances that affect reproductive [ree-pro-DUK-tiv] hormones. However, more than 100 natural and synthetic substances have effects on thyroid function. Because thyroid hormone is needed for the body to develop normally before birth and in early life, anything in the environment that may affect the thyroid is a major concern for pregnant women and infants.

Perchlorate

Perchlorate [per-KLOR-ate] is used in many things, such as rockets, fireworks, road flares, matches, and air bag systems. Some fertilizers contain perchlorate and low levels may also be found in the environment due to natural processes. Perchlorate is present in some drinking water in the United States and worldwide. It has also been found in foods such as lettuce and other produce, wheat, cows’ milk, wine, beer, and multivitamins. At high doses, perchlorate
can block iodine from the thyroid gland. Since iodine is needed to make thyroid hormone, thyroid hormone levels might be decreased with even low-level exposure.

Almost everyone in the United States is likely exposed to perchlorate. In one study, higher levels of perchlorate in the urine was associated with lower blood thyroid hormone levels. However, recent studies in pregnant women have shown no link between being exposed to perchlorate and having a change in thyroid hormone levels. Even though research is ongoing and the effects of low-level perchlorate on the thyroid remain unclear, the Environmental Protection Agency has recently decided to limit perchlorate levels in the US drinking water supply.

Thiocyanate and Cigarette Smoke

Thiocyanate [thigh-oh-SIGH-uh-nate] is a chemical that, like perchlorate, can block the thyroid from absorbing iodine. Thiocyanate is found in cigarette smoke and plant foods such as cassava, cabbage, turnips, broccoli, Brussels sprouts, and cauliflower. Large studies testing the effects of cigarette smoking on thyroid function have had varied results. However, it is known that women who smoke during pregnancy are more likely to give birth to babies with low thyroid hormone levels in their blood. Women in the first trimester of pregnancy have lower thyroid hormone levels when they are smokers vs. non-smokers. A recent study showed that cigarette smoking lowers the amount of iodine in breast milk. This may be related to the thiocyanate in The Thyroid and the Environment By Elizabeth N. Pearce, MD, MSc Dr. Pearce is Associate Professor of Medicine at Boston University School of Medicine. She received her medical degree from Harvard Medical School and a Master of Science in Epidemiology from Boston University School of Public Health. Dr. Pearce’s interests include the sufficiency of dietary iodine in the US, thyroid function in pregnancy and lactation, the thyroid effects of environmental perchlorate exposure and other potential endocrine disruptors, and the cardiovascular effects of subclinical thyroid dysfunction. EMPOWER MAGAZINE • Vol . 4, Issue 1 23 cigarette smoke. Diets high in thiocyanate can be part of the reason someone develops goiter (enlarged thyroid) in parts of the world where there is not enough iodine in the diet.

PCBs

In the past, PCBs were used as coolants and lubricants in transformers, capacitors, and other electrical equipment. Starting in the late 1960s there were concerns about the toxicity of PCBs and their ability to persist in the environment. Due to these concerns, production of PCBs was outlawed in the US in 1979. Although levels of PCBs have decreased, PCBs remain widespread in the environment and the food chain because their presence persists for years. The structure of PCBs is similar to that of thyroid hormone, and they are thought to alter the actions of thyroid hormone in body tissues. Babies exposed to PCBs before birth have lower intelligence. This might be because PCBs interfere with the way thyroid hormone helps the brain develop normally.

Bisphenol-A

Bisphenol [BISS-feh-nol]-A (BPA) is used in food containers, baby bottles, and reusable water bottles, and is found in linings of some metal food cans. It may leach from these containers into stored food and drink. Studies in rats have shown that BPA can block thyroid hormone actions, but this has not been clearly shown in humans.

Triclosan

Triclosan [try-KLO-san] is an antibacterial [an-ti-bak-TEERee-ul] agent that is found in soaps, toothpastes, skin care products, plastics, and fabrics. At high doses in rats, triclosan decrease thyroid hormone levels. Lower-level triclosan
exposure has had varying effects on thyroid hormone actions in frogs. In the only human study, brushing teeth with a triclosan-containing toothpaste for two weeks raised blood triclosan levels, but did not alter thyroid function.

PBDEs

PBDEs have been used as flame retardants in plastics, foams, building materials, carpet, and upholstery. PBDEs are slowly released from these products into the environment. PBDEs have been detected in many foods. Exposure may also come from inhaling indoor air and contact with house dust. In animal studies, PBDE exposure causes low thyroid hormone levels. However, results of the few human studies, to date, have not shown consistent effects of PBDEs on the thyroid.

Isoflavones

Isoflavones [eye-so-FLAY-vones] are found naturally in soy products, peas, beans, nuts, grain products, coffee, and tea. Large doses can decrease thyroid hormone. Infants fed soy formula without enough iodine nutrition may develop low thyroid function. Since all infant formulas marketed in the US now contain iodine, this is not currently a problem. Recently 13 out of 14 studies of the effects of soy or isoflavones on thyroid function in healthy adults showed only a small decrease in thyroid hormones or no effects.

Sunscreens

Studies in rats have shown that ingredients in certain sunscreens may alter the body’s ability to process thyroid hormone. These sunscreen ingredients have been found in wastewater treatment plants, are known to build up in fish, and have been found in human milk. Sunscreens, cosmetics, and diet can expose a person to these thyroid hormone-altering ingredients. In one human study, one week of applying sunscreen with these ingredients to the entire body every day did not alter thyroid function.

Summary

Common environmental exposures such as cigarette smoke may affect thyroid function. People may be most vulnerable to these effects in early life, since thyroid hormone is needed for normal brain development. More studies are needed to better understand the risks.

Dr. Pearce is Associate Professor of Medicine at Boston
University School of Medicine. She received her medical degree from Harvard Medical School and a Master of Science in Epidemiology from Boston University School of Public Health. Dr. Pearce’s interests include the sufficiency of dietary iodine in the US, thyroid function in pregnancy and lactation, the thyroid effects of environmental perchlorate exposure and other potential endocrine disruptors, and the cardiovascular effects of subclinical thyroid dysfunction.

By Jeffrey I. Mechanick, MD, FACP, FACE, FACN, ECNU

Low thyroid function should be considered when someone complains of typical symptoms, such as fatigue, weight gain, constipation, and dry skin. But as you can imagine, these symptoms could also be due to many other causes. So a diagnosis of low thyroid function must always be made by your doctor and generally requires a “TSH” test (See link). The standard treatment for low thyroid function is levothyroxine [le-vo-thigh-ROX-een], a synthetic medicine that is basically the same as the thyroid hormone that your own thyroid gland produces.

From time to time, you may get advice about other ways to treat low thyroid function or hypothyroidism [hie-po-THIGH-roid-is-m]. The source could be the internet, a friend, or even a doctor or nurse. Besides making sure that you actually have low thyroid function, properly diagnosed by your doctor, you should be aware of some important points about the use of dietary supplements that are marketed or claimed to have thyroid-related actions. Bear in mind as you read this that there are no scientific studies showing that dietary supplements actually improve thyroid function in any significant and safe manner. As more research is done, some dietary supplements may show promise, but levothyroxine is still the proven, safe way to treat low thyroid function.

There are three broad types of dietary supplements that you may encounter regarding your thyroid.

Supplements that contain a lot of iodine

Kelp, a type of seaweed, contains a lot of iodine. Kelp may be suggested as a logical and natural way to boost the function of your thyroid. After all, thyroid hormone contains iodine so increasing the amount of iodine in your diet should be good for your thyroid, right? Unfortunately, this is not the case. In fact, a high level of iodine intake may reduce the amount of thyroid hormone secreted or released from your own thyroid gland.

Substances that are claimed to promote thyroid function

B-complex vitamins, garlic, ginger, gingko, licorice, L-tyrosine, magnesium, manganese, meadowsweet, oats, pineapple, potassium, saw palmetto, selenium, tiratricol (TRIAC), and valerian have all been claimed to improve thyroid function. The theory behind many of these claims is attractive and very interesting. However, there is not enough data to support using these substances instead of levothyroxine for the treatment of hypothyroidism or an underactive thyroid.

Animal-derived thyroid extracts or desiccated [DESS-ih-KATE-ed ] thyroid

Desiccated thyroid has been used to treat hypothyroidism for many years, but is rarely taken anymore. Most people switched to levothyroxine by the end of the 1970s. People may also seek out thyroid extract as a treatment for low thyroid function because they prefer “natural” treatments. Though this type of treatment still works by replacing the missing thyroid hormone from the body, it does not provide levels that are either as consistent or easy to monitor as levothyroxine does. In fact, if you search the internet for controlled clinical trials involving low thyroid hormone treatment, you will find a lot of strong evidence for levothyroxine and virtually none for thyroid extract.

So, when it comes to the treatment of any medical condition and specifically an underactive thyroid, the safest and most effective treatments should be used. Remember these key points:

• If you suspect that you have low thyroid function, see your doctor.
• If you truly have low thyroid function, levothyroxine should be used.
• At the present time, there is no proven role for the use of dietary supplements to boost thyroid function.
• If there is any doubt or question about an accurate diagnosis or best treatment for low thyroid function, consult an endocrinologist [en-doh-cri-NA-lo-jist].

Dr. Mechanick is Clinical Professor of Medicine and Director of Metabolic Support in the Division of Endocrinology, Diabetes, and Bone Disease at Mount Sinai School of Medicine in New York City. He has authored over 170 publications in endocrinology and nutrition and edited/authored five books in the fields of diabetes, nutrition, thyroid, and metabolic bone disease. Dr. Mechanick is in private practice in endocrinology and metabolic/nutrition support in New York. He currently serves as Vice President and Treasurer of the American Association of Clinical Endocrinologists (AACE).

A Dentist Appointment I’ll Never Forget: A Patient Story
By Karen A. Avitabile

My dentist saved my life. Yes, my dentist.

During a routine six-month cleaning, my dentist checked my neck and under my tongue. This was not foreign to me. He explained years earlier cancers of the throat, tongue and jaw were on the rise, and it is his job to make sure everything is normal with each patient.

While feeling my neck, he noticed a lump on the right side. “It may be a swollen gland, but if it doesn’t go away in a few weeks visit your medical doctor,” he said.

Nearing age 40, I led a busy life. In addition to my full-time job as a travel editor with AAA, I had just returned to college to pursue a second degree and volunteered in my community. I exercised regularly and watched my diet.

I never had a swollen gland, but I didn’t think it was something that was going to slow me down – I couldn’t see the lump, it didn’t bother me and I felt perfectly fine.

A week later, I visited my gynecologist for my annual exam. I told him what the dentist said and asked him to check my neck for a swollen gland.

“Swollen gland?” he said. “That’s your thyroid and you should see your regular doctor.”

OK, maybe there was something wrong with my thyroid, I thought. So if I have to take medication, it wasn’t the end of the world.

I went to my general practitioner the next day. He scheduled blood work and an ultrasound to “see what’s going on.”
Results of the blood work didn’t show any problems with my thyroid but the ultrasound showed a three-centimeter lump leaning on the right side of my thyroid. I was referred to a surgeon to discuss options.

“You’ve got this large lump which will never go away,” the surgeon said. “In fact, it will probably get bigger. We can biopsy it to ensure it is not cancer, or just keep an eye on it. It’s your call.”

“Is a biopsy going to tell us 100 percent if I have cancer?” I asked.

“Nope. Ninety-five percent,” he said.

That 5 percent gray area was all I needed to hear to make my decision -- I wanted to have the lump removed. This also meant removing the right side of the thyroid. In my mind, there was no way around it. I wasn’t willing to take a chance with my life.

Prior to the surgery, my father was diagnosed with Lou Gehrig’s Disease, a progressive neurodegenerative disease which causes patients to become paralyzed and leads to death. He was one in 50,000 people annually diagnosed with this debilitating disease.

I remember thinking those were crazy odds and certainly didn’t think I would be one of the over 35,000 people diagnosed with thyroid cancer each year.

Some family and friends thought I was crazy for going through with the surgery. “Why don’t you just get it biopsied each year? Why would you want to remove most of a vital organ if you don’t have to?” some asked.

The answer was simple – because I refused to gamble my life away.
The morning of the surgery, the doctor explained that it would take about 90 minutes to remove the right lobe of my thyroid. He added that they would be testing the right lobe for cancer. He asked if he could remove the whole thyroid if that was the case. I granted my permission.

The clock on the wall was the first thing I saw in the recovery room when I woke up. I quickly did the math. More than three hours had passed. I knew this was a bad sign.

My fears were confirmed when my doctor entered the room.

“You had cancer,” he said. “We had to remove your entire thyroid.”

When I arrived in my hospital room, I tried to compose myself before facing my family. “In a few minutes,” I repeated to a nurse who kept coming in to tell me my family was waiting to see me.

Like me, my family knew something was wrong based on the length of time the surgery took. My doctor gave them the news before they came in to see me.

No one, especially me, could believe this had happened to me.

The next morning, the nurse came in to give me my first dose of levothyroxine – a thyroid replacement medication that I would have to take daily for the rest of my life.

I was not looking forward to what lie ahead, who would? In addition to my daily medication, I would have to undergo radioactive iodine therapy, ultrasounds and ongoing monitoring.

After a few days, the lab tests confirmed I had papillary thyroid cancer, one of the more common types, and I was expected to make a full recovery.
Within two months, I underwent radioactive iodine treatment – to ensure any remaining thyroid cells in my body would be destroyed – and another ultrasound. All tests came back negative for additional cancer.

Four years later, I remain cancer-free. I see my endocrinologist every three months, have an annual ultrasound examination and ingest a small amount of radioactive iodine each year as a precaution. My endocrinologist monitors my TSH (thyroid stimulating hormone) levels. If they are either too high or too low, he may choose to increase or decrease my dose of levothyroxine. He also organizes my ultrasounds and radioactive iodine treatments.

Other than that, I’m back to living the life I’m used to. I graduated from college for the second time in May 2009, still volunteer in the community, exercise and continue to travel the globe as part of my work at AAA. Of course, my levothyroxine is the first thing I pack now.

When you first hear the word “cancer,” the natural response is fear. As I have come to learn firsthand, however, thyroid cancer is very treatable and manageable.

I may be one in 25,000 people to be diagnosed with thyroid cancer, but I still consider myself lucky in many regards.

And I thank my dentist every time I see him.

Editor's note
We were delighted to receive Ms. Avitabile’s unsolicited contribution to our magazine. Previously, endocrinologists belonging to AACE submitted all magazine pieces featuring patients.

Ms. A’s decision to undergo surgery regardless of the result of a biopsy based on her wishes to eliminate uncertainty is a well-accepted basis for having surgery. Although a fine needle aspiration may be inconclusive, it is standard practice to do one before surgery. In some cases, in addition to establishing whether or not to remove both sides of the thyroid, it could lead to further preoperative evaluation in order to determine whether even more extensive surgery such as lymph node removal will be required (see sections on thyroid cancer). While her family and friends advised her to “get it biopsied each year”, yearly biopsies are not necessary when a nodule appears to be benign and is not growing. Lastly, although yearly ultrasounds are routinely done for several years after papillary thyroid cancer is diagnosed, most cases do not require yearly radioactive iodine imaging.

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Hypothyroidism in Women
By Dr. Daniel Einhorn

Could it be my thyroid? This is one of the most commonly asked questions by women, especially to a clinical endocrinologist like me. The “it” usually refers to weight gain, fatigue, mood disturbance, sleep disturbance, hot or cold intolerance, and any one of dozens of similar concerns. Since the answer has to include that “it might be,” many thyroid tests are done even when the likelihood of thyroid disease is small. Since puberty, pregnancy, and menopause may cause identical symptoms to thyroid disease, those are the most common times women present with these symptoms. When thyroid disease does turn out to be the diagnosis, everybody is happy because the treatment is very satisfying, safe, and inexpensive.

Most thyroid disease is autoimmune in nature, so it is not surprising that women have it 8 to 12 times more commonly than men. Most common of all is under active, or hypothyroidism, which affects between 12-30 million Americans, depending on how you define it. Symptoms include all those listed above, plus physical signs such as dry skin, hair, and nails, puffiness of hands and face, and, often, diffuse enlargement of the thyroid gland. Diagnosis must be made by lab test, however, since there are no diagnostic clinical features.

Elevation of thyroid stimulating hormone (TSH) is the diagnostic hallmark of hypothyroidism. Controversy exists over what level of TSH should be considered high. Traditionally, the range of normal has been .350 to 5.500. However, some endocrinologists believe that any TSH above 3, in the presence of suggestive symptoms and signs or evidence of autoimmunity, should be considered possibly hypothyroid. Levels above 10 should be treated even in the absence of symptoms or signs because hypothyroidism can adversely impact blood pressure, cholesterol, and other cardiovascular risk factors. The elderly have higher TSHs and pregnant women have lower TSHs, often below 1 in the first trimester and below 2.5 throughout the pregnancy.

There is some value to knowing whether you have the most common form of hypothyroidism, Hashimoto’s Disease, since that is highly inheritable, especially among the females in the family. Named after Dr. Hakaru Hashimoto, it is diagnosed by the presence of antibodies to components of the thyroid, anti-TPO and anti-microsomal antibodies. Often these make the gland hard rubbery and enlarged, sometimes with nodularity that can be mistaken for malignancy. This, like virtually all forms of hypothyroidism, is permanent. An exception is post-partum hypothyroidism, which can be temporary.

As with postmenopausal hormone replacement therapy, there is a lot of art, as well as science, to thyroid replacement therapy. Generally L-thyroxine or T4 (brand names Synthroid Levoxyl or Levothroid) is recommended at the lowest dose where the woman feels optimal and has a normal TSH, generally in the 1-2 range. Generics are very inexpensive and are fine for the majority of women. The brand may be worthwhile in especially sensitive women for whom variability in the bioavailability of generics is an issue. Always important is remembering to take the L-thyroxine first thing in the morning on an empty stomach and to wait at least a half hour before putting anything else in the stomach, including vitamins, iron, calcium, food, etc., since so many things can interfere with the absorption of thyroid.

“Most thyroid disease is autoimmune in nature, so it is not surprising that women have it 8 to 12 times more commonly than men. Most common of all is under active, or hypothyroidism, which affects between 12-30 million Americans, depending on how you define it.”

Not recommended are forms of thyroid replacement that contain T3, such as dessicated thyroid (e.g., Armour) or are pure T3 (Cytomel). This bypasses the body’s highly regulated T4 to T3 conversion, wherein just so much of T4 is converted depending on the body’s needs at the time. Complications of over-replacement are more likely with T3, including cardiac dysrhythmias, anxiety, bone loss, etc. As with most everything in medicine, there are exceptions, and some women have unequivocal benefit from T3.

Titrating the dose of thyroid is an art. There is a difference between being somewhere on the normal range and being at the optimal point on that range. I often give women at least a few different doses to try for several weeks each to see if they can tell which feels “right.” It is remarkable how much difference a small adjustment of thyroid hormone can make.

Three special circumstances are worth noting. In pre-pregnant and pregnant women, only T4 should be used because the fetus cannot use T3 and is dependent on T4 to T3 conversion for normal growth and development during the first critical 12-14 weeks of pregnancy. During pregnancy, thyroid requirements may go up dramatically, and so thyroid levels should be followed closely in each trimester. In some patient populations such as the elderly and those with heart or bone problems, high-normal TSH levels in the mid to upper range of normal may be advisable.

Thyroid levels should be rechecked and the history and exam be reviewed at least annually since everyone changes over time. More frequent evaluations are reasonable during times of more rapid change, such as in menopause.

In the end, it should be clear for each woman that she is at her optimal level for thyroid hormone replacement. If related symptoms exist, they can be addressed by other, non-thyroid, means, and the thyroid part of the equation can be put to rest.

Daniel Einhorn, MD, FACP, FACE, is President Elect of the American Association of Clinical Endocrinologists (AACE). He was the 2005 recipient of the Yank D. Coble, Jr., MD, Distinguished Service Award from the American College of Endocrinology (ACE). In 2006, he was elected Secretary of AACE. Dr. Einhorn was Co-Chair of the ACE Task Force and the Consensus Conference on the Insulin Resistance Syndrome. He is past Chair of the Clinical Research Committee, Membership Committee, and the AACE 3000 Campaign and has served six years on the Board of Directors of AACE. He is on the Board and Executive Committee of the California Chapter of AACE and has participated in regional AACE programs. He has presented at national AACE meetings for the past 10 years on subjects ranging from the evolving role of the clinical endocrinologist to clinical strategies, devices, and novel compounds. He has chaired and served on many AACE committees, including Strategic Planning, Nominating, and International.

He received his BA from Yale (Summa Cum Laude) and his MD from Tufts (Alpha Omega Alpha) before going on to training at the Beth Israel Hospital, Harvard Medical School. He did a residency in internal medicine, a year of psychiatry, and his Fellowship in endocrinology before going on to be an Instructor of Medicine at Harvar

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Battling Thyroid Cancer “DEE”

By Greg Willis

Talk about driven. Dee is the very definition of the word. She’s a hard-working, intelligent woman, thriving in the hustle and bustle of downtown Manhattan. Dee works as a consultant in corporate communications, and hasn’t slowed down much in the last ten years - despite battling thyroid cancer.

Ten years ago, she was an undergraduate about to attend Columbia University in New York. Before beginning the fall semester, she scheduled an appointment with the family doctor for an annual physical. Despite feeling fine, the doctor noticed something odd: A lump in her throat.

“The lump was quite insignificant,” Dee said. “In fact, it could only really be seen from the side. It came as a surprise that this could potentially be something worth worrying about.”

After she discovered the lump, Dee underwent surgery to have the “cyst” removed. During surgery, cancer was discovered.

“Looking back on it now, I should’ve requested a biopsy immediately after they noticed the lump in my throat,” she said. “But I was 24, and being a potential candidate for cancer never even crossed my mind for a second. It was surprising.”

Dee then underwent a complete thyroidectomy to remove all of the cancerous areas around her thyroid one month later. Her thyroidectomy was performed at Brigham and Women’s Hospital in Boston.

Since the diagnosis 10 years ago, she has undergone six additional surgeries related to the thyroid cancer. During that time, she continued her studies at Columbia University and then went on to get her Masters at the London School of Economics and Political Science. “It certainly made for hectic semesters,” Dee joked.

“My family was very supportive of my choices during that time,” she said. “They encouraged me to do whatever I wanted, but to make certain that I was receiving good care.”

And essentially that’s what she has continued to do. Her endocrinologist of 10 years, Dr. Jeffrey Garber of Harvard Vanguard Medical Associates, reports that although the cancer is not completely cured, she’s in great health and continues to live a normal and active lifestyle.

“I’ve been insistent that this won’t stop me,” Dee said. “And I haven’t let it.”

"Looking back on it now, I should've ordered a biopsy immediately after they noticed the lump in my throat," she said. "But I was 24, and being a potential candidate for cancer never even crossed my mind for a second. it was suprising."

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A knot in the Neck Kelly Forman

By Greg Willis

Kelly Forman is no stranger to adversity-- she cared for her mother as she lost a hard-fought battle to breast cancer in 2002. A year later, Forman was diagnosed with thyroid cancer.

It began after she saw a protrusion in her neck, mostly by coincidence. She noticed that when she wore jewelry around her neck, it rested differently than it used to. Concerned, she met with her physician to get some answers.

“At the time, I suspected it was lymphoma,” Forman said. “Although my doctor wasn’t convinced.”

So testing began. Her doctor ordered a blood test, which didn’t reveal anything out of the ordinary, ruling out lymphoma or a thyroid condition.

A couple of years passed and Forman forgot about her own troubles. She helped care for her mother, relocating from Florida to the mountains of North Carolina. She paid little attention to the knot in her neck.

During that time, the lump was still noticeable. But Forman “didn’t think it was anything too serious, and kind of just forgot about it.”

While meeting with her doctor in Boone, North Carolina, he noticed the lump and began to ask questions. “I told him that blood work was done, and everyone came to the consensus that the nodule was benign,” Forman said.

“No, this is a problem,” her doctor replied and ordered a biopsy.

On Christmas Eve in 2003, Forman received the official diagnosis -- she suffered from an aggressive case of papillary thyroid cancer.

“There weren’t words to describe how I felt at that moment,” Forman said. “It put a damper on the holidays that year, that’s for sure.”

Having lost her mother to cancer, Forman wasn’t taking any chances with her own health. “I commuted from North Carolina to New York City to get the best possible treatment I could find.”

After consulting with AACE endocrinologist Donald A. Bergman, MD, FACE, treatment began shortly thereafter. Since then, her battle with cancer has followed a more unconventional path than many thyroid cancer patients.

“I suffered three reoccurrences after the initial diagnosis,” Forman said. “Quite honestly, it was difficult at times.”

But she was determined not to let it get her down. For her, getting healthy again became “the central priority of my life.”

These days, Forman feels much better. Her cancer is currently in remission, and she maintains periodic appointments with Dr. Bergman.

She’s also quick to advise her friends that a “lump in the throat” may be much more than a “fashion faux pas” and may warrant attention from their physician.

“It’s such a subtle, little thing that can easily go unnoticed,” Forman said. “But if you suspect something may be wrong, get it checked.”

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Patient Stories Wiped Out Paloma Nunziata

By Sarah Senn

Living in New York City can be chaotic for anyone, but the constant motion of the city can be especially overwhelming for someone suffering from a thyroid dysfunction. Paloma Nunziata knows this first-hand.

Nunziata is a social worker living in Manhattan who was recently diagnosed with a thyroid disorder. Before her diagnosis, Nunziata was like many other New Yorkers. She commuted from her home in Manhattan to her job in the city. As a social worker, Nunziata visited clients’ houses across the city.

Work isn’t the only thing that keeps Nunziata busy. She enjoys snowboarding in upstate New York and traveling to exotic locations to surf. In May 2008, Nunziata traveled to Costa Rica to go surfing. The excursion was great, but Nunziata felt different than usual when she returned. Weeks after the trip, she was still tired and her bones and joints were abnormally achy.

“I was really sore, and I never stopped being sore,” Nunziata said.

At the beginning of September, thinking she had mononucleosis, Nunziata made an appointment to see her regular physician. After a series of blood tests, this doctor referred her to an endocrinologist. Nunziata was diagnosed with Graves’ disease, an autoimmune disease that is caused by an overactive thyroid and is more common among women. Graves’ disease causes the thyroid to produce an excessive amount of thyroid hormone, and it frequently results in hyperthyroidism. This disease is treatable, but its effects often disrupt daily routines.

“I was worried about not being able to be active and the treatments were daunting,” Nunziata said.

There are three common treatment options for hyperthyroid disorders - anti-thyroid medications, radioiodine therapy and surgery. Anti-thyroid drugs slow thyroid hormone production and are taken daily. Radioiodine therapy uses radioactive iodine to destroy the diseased thyroid gland and create a hypothyroid condition that can be more easily controlled with thyroid hormone replacement therapy.

Nunziata evaluated her options with her endocrinologist and decided to start anti-thyroid drug treatment. She began taking propylthiouracil (PTU) at the end of September. Nunziata has reacted very well to the anti-thyroid drugs.

“I was supposed to be on the medications for a year, but I’m already responding so well. It’s very surprising,” said Nunziata, “I feel 90 percent back to normal.”

Even though Nunziata has made a few adjustments to accommodate the effects of the disease, it hasn’t changed her outlook on life. She left her job that she commuted to across the city and found a position closer to home. This new job also allows her to be more sedentary, but still work as a therapist in the same capacity. With her disease under control, Nunziata can’t wait to travel back to Costa Rica, and she’s looking forward to seeing snow.

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