THINK THYROID: Your GP and Your Thyroid 1
What Should You Expect from Your Doctor?
Where Has All Our Iodine Gone?
Thyroid Disease at a Glance
Book Review: Ridha Arem’s The Thyroid Solution 4
Upcoming Meetings 4
Flyer Recommended Books 8
Newsletter of Thyroid Australia Volume 1 No 1 January 2000
Feature - Doctor-Patient Relationships
Editorial THINK THYROID
By Megan Stevens
I hope you had a wonderful Christ-
Your GP and Your Thyroid
mas and that you will have a healthy and By David Dammery
Thyroid Australia has had a good be- Dr. David Dammery, Chairman of Faculty of the Royal Australian Col-
ginning, and is growing slowly. Since our lege of General Practitioners, Victoria, spoke at Thyroid Australia’s first
inception in late June 1999 we have pro- public meeting on 20 November 1999. This is an edited transcript of his talk.
vided information to over 170 people
about their thyroid concerns, and now
have 30 members from all over Australia. I must first thank Thyroid Australia for asking me to be part of the meeting today. It
is a great pleasure for me to be here among you and to have the chance to represent
not only the Royal Australian College of General Practitioners but also the whole
We hope we will continue to meet your
needs. Please let us know how we can do discipline of General Practice.
so. My own first interest in thyroid disorders came from my mother. She did not
We have established contact with all instruct me, except by example. She was born in Queensland which, like Tasmania
the other thyroid support organisations and parts of Victoria, is a state where iodine deficiency is common and she had a
who are members of the Thyroid Federa- goitre. She later developed an overactive thyroid - thyrotoxicosis - when I was a
tion International, and others. These or- medical student, so I had the opportunity to observe at first hand the effects of the
ganisations have been most helpful, and thyroid hormones.
many of them have given us permission The subject given to me for this talk was “your thyroid and your GP”. I would like
to use their material. Our thanks go to all to turn this around and make it “your GP and your thyroid”. There are two reasons for
at the Thyroid Federation International, this. The first reason is that you may need to know more about general practice and
the Thyroid Foundation of Canada, the your GP before you can choose a GP who will help you to look after your thyroid.
Thyroid Foundation of America, the TED The second reason is that it gives me an excuse to put the GP first in my discussion.
Association (UK), the British Thyroid General practice is something of a catch-all as a discipline within medical prac-
Foundation, the National Graves’ Disease tice. The general practitioner is sometimes called a provider of “primary medical
Foundation (USA), the American Foun- care” and sometimes called a “family medicine practitioner”. The GP may even be
dation of Thyroid Patients, Associazione called a “doctor of first contact”. Each of these names tells us something about the
Italiana Basedowiani e Tiroidei, Stor- nature of the discipline. General practice covers the whole range of medical care and
Stockholms Sköldkörtelförening, is often defined as providing “continuing, comprehensive, whole-person care”. So,
Schilddrüsen-Liga Deutschland, arising from this definition, we GPs are doctors who see you when you are first ill,
Thyreoidea Landsforeningen (Denmark), who begin to make the diagnosis of your illness, who continue to look after you
and Mary Shomon (the thyroid guide at throughout your illnesses and who provide ongoing explanation and support to you
About.com). the patient and to your family.
Our thanks too to the doctors in Aus- What is it then that you, as patients or the associates of those who are patients with
tralia who have helped us in so many thyroid problems should look for in your family doctor? What makes the ideal GP?
ways. Thanks for your support. We GPs come in all sizes, shapes and flavours. There is a model available to suit
all tastes and expectations. It is up to you to shop around until you find what suits you
Cleo magazine then, if you are smart, “if you’re on a good thing, stick to it”. For myself, the ideal GP
Some of our readers might have is a person with whom you, the patient, feel comfortable. He or she should be a
caught the November 1999 issue of Cleo person whom you can trust, whom you can talk to and who will give you the care that
magazine, and the article on page 59 en- you need and want.
titled “Feel less than groovy? Think Thy- The ideal GP, then, is a good diagnostician, a good carer and a good communica-
roid.” We received a number of calls in tor. Although each of us will have our own priority, to me communication is often the
response to this article, and hope that we most important of these three criteria. I sometimes suggest that we GPs speak two
have helped those who called. languages - the language of the specialist, which is the language of medicine, and the
language of the patient, which is our normal everyday English. The good GP can help
Continued Page 8 Continued Page 2
THINK THYROID: Your GP and Your Thyroid from Page 1
the patient communicate with the special- is more active on the metabolism while for an ultrasound examination of the thy-
ist - in the case of the thyroid this will be T4 is more active in the biofeedback regu- roid and for the hormone tests on the
the endocrinologist or the surgeon - both lation of the thyroid gland. That is why blood. These will tell me quickly if the
of whom can use some pretty big words we can use TSH levels as the screening goitre is nodular and whether the thyroid
with a highly esoteric meaning. Even a test for thyroid diseases. A high TSH in- is overactive, underactive or “just right”.
relatively simple word like “hormone” can dicates a low level of thyroid activity and It is from this point that the road begins
to fork. Any further tests are dependent
on the results of the first round of tests.
Nodular goitres, especially those that
are overactive, require an isotope scan.
In this test, radioactive iodine is given and
the thyroid is looked at using a nuclear
scanner to look for “hot spots” in the thy-
roid. These are areas of increased isotope
uptake indicating overactive nodules in
the goitre. Similarly, “cold spots” are ar-
eas of reduced uptake that are
underactive. Thyroid cancer may produce
both hot and cold areas.
There are clearly about six or eight
combinations that can occur. The deci-
sion on further investigation and treat-
ment will then depend on which combi-
nation comes up. I shall not elaborate the
various combinations at this stage.
Dr Dammery with the Thyroid Australia committee Hypothyroidism is characterised
Kay Horley. Karen Latimer, Alun Stevens, Megan Stevens, Dr David clinically by a reduced metabolism. This
Dammery, Christopher McDermott, Colleen Dean
condition is sometimes called myxo-
be readily misinterpreted. Thyroxine is a vice-versa. So, if you have a goitre and a edema but that term really describes the
hormone; the use of thyroxine is a form normal TSH, we would say that you have false swelling of the tissues due to the
of hormone replacement therapy - as is the normal thyroid activity or are “euthy- laying down of various infiltrates into the
use of insulin in diabetes. However, we roid”. Likewise, high TSH and low lev- skin leading to a puffy appearance of the
do not usually think of HRT in that way. els of T3 and T4 indicate underactive thy- face and swelling of other parts of the
Your GP can give you that sort of expla- roid or hypothyroidism. The reverse pic- body. The clinical picture of hypothy-
nation as well as monitor the progress of ture is true of an overactive thyroid; a con- roidism is often quite slow to develop.
your condition. dition also called hyperthyroidism or thy- All of us GP’s have had the embarrass-
rotoxicosis. ment of a patient whom we have known
for years developing hypothyroidism
I hardly need tell you what the thyroid Thyroid Disorders
without us being aware of the changes. I
gland is and what it does. You probably There are properly speaking only four
certainly can recall a couple of instances
know it even better than I do. It is a gland conditions of the thyroid that may result
of this. The doctor often misses the gen-
in the neck that acts as the metabolic regu- in thyroid disease. They are simple goi-
eral slowing down of the patient, and their
lator - a sort of energy traffic cop. What tre, cancer, and both overactive and
apparent depression is blamed on psycho-
you may be less certain of is the three underactive thyroid disorders. We screen
logical factors. (Sometimes it seems as if
things that we use to measure thyroid func- for thyroid disorders by the use of TSH
a GP who doesn’t know you can actually
tion. They are called the TSH, T3 and T4. estimations. If the TSH is abnormal, we
pick up hypothyroidism better than the
The thyroid stimulating hormone or proceed to measure T3 and T4. If some-
GP who does know you.)
TSH is the regulating hormone put out by one presents with goitre, the thyroid ul-
It is for this reason, at least, that I am
the pituitary gland at the base of the brain. trasound is my next line of approach.
a strong advocate of regular thyroid
T3 is tri-iodothyronine, a three-iodine pro- Goitre is the name given to any en-
screening, especially where depression
tein complex. T4 is thyroxine, a four-io- largement of the thyroid gland, whatever
does not quite seem to fit the pattern or is
dine protein complex that is the classical the cause. This enlargement of the gland
slow to resolve.
thyroid hormone. Incidentally, it is the T3 may be nodular or just vague and diffuse.
Hypothyroidism may follow thyroid
that is the more metabolically active hor- Many patients come to me with a swell-
surgery or radiotherapy but in many cases
mone. It is largely made from the T4 in ing of the thyroid gland. The swelling is
it is due to Hashimoto’s autoimmune thy-
the cells of the body, not in the thyroid usually not painful and they are often
roiditis. In these circumstances, the in-
gland itself. In turn the levels of T3 and aware of it only because of the appear-
vestigations include the assessment of
T4 control the level of TSH by a biofeed- ance, or because of a tight feeling in their
thyroid antibodies. Antibodies may form
back mechanism. The more T3 and T4 neck. How do I test and investigate such
to both the thyroid microsomes or to thy-
there is, the less TSH there will be. The a swelling?
less T3 and T4, the more TSH there is. T3 The first things that I do are to arrange Continued Page 7
2 Thyroid Flyer Volume 1 Number 1 January 2000 Thyroid Australia
Where Has All Our Iodine Gone?
The possible re-ermergence of iodine deficiency in Australia needs to be investigated in
national surveys (Editorial - Medical Journal of Australia)
By Creswell J Eastman, AM
M ost countries in the world, includ
ing Australia, are signatories to the
United Nations-sponsored “Declaration
easily recognised and best-known conse-
quence of iodine deficiency, it is probably
the least important. At critical periods in
Why is our iodine intake de-
creasing in Australia?
Gunton and colleagues implicate a
for the Survival, Protection and Devel- fetal development and in early childhood, combination of factors. Firstly, for over
opment of Children”, which states that biochemical hypothyroidism, due to io- three decades, we have been dependent
“every child has the right to an adequate dine deficiency, results in a wide range of on iodine in milk contaminated by clean-
supply of iodine to ensure its normal de- devastating and irreversible effects now ing solutions used in the dairy industry;
velopment”.1 One teaspoon of iodine is known as iodine-deficiency disorders.5 these solutions are gradually being re-
all a person requires in a lifetime, yet io- More recently, we have come to appreci- placed by others which leave less iodine
dine deficiency at critical stages of de- ate that there is a general diminution in in milk. Secondly, we seem to be using
velopment in fetal life and early child- intelligence in iodine-deficient communi- less iodised salt, through a combination
hood remains the world’s single most ties such that iodine deficiency is consid- of purchasing uniodised salt for domes-
important and preventable cause of men- ered to be the commonest cause of pre- tic consumption, probably decreasing
tal retardation.2 ventable intellectual disability worldwide.2 our salt consumption, and consuming
For the past three to four decades io- Further, there is now very good evidence most of our salt in processed foods,
dine deficiency has not been of signifi- that a small decrease in serum free thy- which, as far as we can ascertain, is
cant concern in Australia (except in Tas- roxine level during pregnancy, either be- uniodised. The problem is not unique to
mania); it was considered largely a prob- cause of iodine deficiency or thyroid dis- Australia, as similar downward trends
lem of developing countries. That is what ease, is an important risk factor for im- in iodine intake have recently been noted
we thought until Gunton and colleagues paired psychomotor development in in- in other developed countries such as the
give us a wake-up call with their article fants.6,7 The recent demonstration of in- United States10 and New Zealand.11
in this issue of the Journal.3 They found tellectual impairment in the children of
evidence of mild to moderate iodine de- American women who had mild hypothy- What actions should be taken in
ficiency in pregnant women, patients with roidism in pregnancy highlights the need response to these findings?
diabetes and a small group of volunteers for better detection and treatment of hy- Firstly, we need more information
attending a Sydney teaching hospital. In pothyroidism in early pregnancy, irrespec- through a national survey of urinary io-
their study, median urinary iodine con- tive of its cause.8 dine excretion and goitre rates to deter-
centrations ranged from 64 µg/L in the Tasmania is the only Australian State mine the status of iodine nutrition
volunteers to 104 µg/L in pregnant where regular surveillance of iodine nu- throughout Australia. Secondly, we need
women. The World Health Organization’s trition is undertaken and records are main- to educate the population and healthcare
standard for iodine-deficiency disorders tained. Other data are available from the providers about the insidious and harm-
in population surveys recommends that Australian Centre for Control of Iodine ful effects of iodine deficiency, espe-
a median urinary iodine concentration Deficiency Disorders (ACCIDD), located cially during pregnancy and early child-
above 100 µg/L is evidence against sig- at Westmead Hospital, which has per- hood. Finally, we must institute effec-
nificant iodine deficiency in that popula- formed sporadic surveys of urinary iodine tive and sustainable means of iodine
tion.4 Other population indicators of io- excretion levels in small samples of Aus- supplementation to our whole commu-
dine deficiency, including total goitre tralians for the past two decades. In 1992 nity through legislating for universal salt
rates in school-age children and serum we reported that the mean urinary iodine iodisation, so that all salt used for hu-
thyrotropin (TSH) levels in the newborn, excretion level in Sydney residents was man and animal consumption in Aus-
were not assessed in the Sydney study. 180 µg/L, and over 200 µg/L in Tasma- tralia is iodised. Iodising all edible salt
The data of Gunton and colleagues indi- nian children.9 Since then, our sporadic will cost less than 10 cents per person
cate that the pregnant women they tested surveys have shown a gradual but sus- annually. In the past this intervention has
are ingesting less than half the recom- tained decline in urinary iodine excretion been viewed as politically unacceptable,
mended iodine intake in pregnancy of 200 levels in Sydney residents. We recently but the debate was conducted with a
µg/day. Although this study was not a found similar results to those of Gunton view to eliminating endemic goitre with-
national survey, and the sample size was et al3 in a survey of primary schoolchil- out any real understanding of the often
small, the findings are alarming and raise dren from western Sydney who had a subtle, but devastating, consequences of
concern that a major public health prob- median urinary iodine concentration of impaired brain development. In the in-
lem may be developing in the Australian 84µg/L, and in 16% of whom the iodine terim, every effort should be made to
community which could put future gen- concentration was less than 100 µg/L. Fur- ensure every pregnant woman ingests an
erations at risk of iodine-deficiency dis- ther, unpublished results we obtained in adequate amount of iodine to ensure her
orders. healthy pregnant women were also very unborn child experiences normal men-
The key factor in the genesis of io- similar to those of Gunton et al, indicat- tal development. Until we have educated
dine-deficiency disorders is decreased ing that widespread mild iodine deficiency the population as a whole about the risks
production of thyroxine from the thyroid threatens to affect the most vulnerable in
gland. While endemic goitre is the most our community. Continued Page 4
Thyroid Australia Thyroid Flyer Volume 1 Number 1 January 2000 3
Thyroid Disease at a Glance
T hyroid disease has many faces, yet
all of its symptoms originate with
trouble in the thyroid gland. The thyroid
Hypothyroidism - occurs when the
thyroid gland is underactive and produces
insufficient thyroid hormone. It is the
able for hyperthyroidism, including anti-
thyroid drugs, radioiodine treatment, and
surgery. All are effective, though no one
gland is a small, butterfly-shaped gland most common thyroid disorder, occurring treatment ever results in a complete cure.
weighing only an ounce. But it is also more frequently in women than in men. Thyroid cancer - fortunately, is ex-
command central for many organs in the Hypothyroidism affects 6%-10% of tremely rare, accounting for less than 1%
body, including the heart, brain, and liver. women over the age of 65. of all cancers. Total or partial thyroidec-
The thyroid gland also regulates metabo- Treatment for hypothyroidism is tomy is the only treatment option. If the
lism and cell growth. straightforward. Synthetic levothyroxine cancer has spread to the lymph nodes,
The thyroid gland secretes two major (LT4) is a safe and effective thyroid hor- these must also be removed.
hormones, T4 (thyroxine) and T3 mone replacement therapy. In fact, it is Nodules - about 5% of the popula-
(triiodothyronine). These hormones travel one of the top three most commonly pre- tion have 'bumps' on the thyroid gland
to the organs of the body via the blood- scribed drugs in North America. known as nodules. They are more com-
stream. When all systems are go, Thy- Hyperthyroidism - is a less common mon in women than in men and are prob-
roid Stimulating Hormone (TSH) is re- disorder affecting approximately 2% of ably caused by low T3 and T4. Provided
leased by the pituitary gland, which trig- women and .02% of men. It occurs when they are solitary, nodules have just a 5%-
gers the production of T3 and T4. the thyroid gland is overproductive. The 10% chance of being malignant.
When T3 and T4 are at the appropri- elevated T3 and T4 levels can have a dra-
ate levels, TSH will level off as it should. matic impact on body functions, speed- Originally published by the Thyroid Founda-
However, if there is too little T4 and T3, ing up metabolism by 60%-100%. Pa- tion of Canada, Thyrobulletin, Volume 20,
TSH will be elevated. If there is too much tients with hyperthyroidism have some- Number 3, Autumn 1999.
T4 and T3, TSH will be suppressed. In times been described as being anxious to Republished with permission.
this way, TSH is a marker of thyroid func- a point of not making sense.
tion and thyroid hormone levels. There are a range of treatments avail-
What Should You Expect From Your Doctor?
What Should Your Doctor Expect From You?
By Elliot G. Levy, M.D.
Y ou would think it is all quite simple.
The thyroid gland is a small organ,
located in the front of the neck. It is a
What should you expect from
shorter, and fewer tests are ordered. The
overhead of a medical practice is con-
stantly rising, yet doctors in most parts
Nowadays, the traditional role of "the
factory that is designed to produce one doctor" may seem different, especially to of the country are not able to raise fees
product - thyroid hormone. It usually those of you who remember the "good because of contracts with insurance com-
makes just the right amount of hormone ol' days of medicine," when your doctor panies or with Medicare. There is a ten-
to meet the body's needs. Occasionally it was your friend, took lots of time with dency for doctors to have to see more and
can make too much hormone. More of- you, got to know you and your entire fam- more patients each day to cover their of-
ten, it can produce too little hormone. It ily, took care of all aspects of your care, fice overhead. There is great pressure on
can grow lumps, some of which can con- saw you when you were sick in the hos- primary care doctors to "do everything"
tain thyroid tumors, including thyroid pital, maybe even came to your house for including, often, holding back early re-
cancer. a house call, and, certainly, never hesi- ferral to specialists.
It all sounds very simple, and so it tated to refer you to a specialist. Things In the area of thyroid disorders, this
seems, until you suddenly discover that are just not that way any more. fact is very evident. Often patients are
you or someone you know has a thyroid Whether it was caused by the rising referred very late in the course of their
problem. Then you realize that what cost of health insurance to employers, or illness and often with many inappropri-
sounds so simple at first actually can be the total cost of health care to the gov- ate (and expensive) tests having already
quite complicated and very confusing. ernment, or the influence of profit-driven been done. Who suffers the most when
The purpose of this article is not to "big business" into the health care indus- this style of medicine is continued? The
advise you what to do about any specific try, or some other cause, there is a very patient is always the victim.
area - there have been, and will continue different approach to health care today. Nowadays, I personally recommend
to be, informational articles in this publi- The influence of Managed Care has that the patient become her or his own
cation addressing all of these areas - but greatly changed the doctor-patient rela- advocate in her or his relationship with
to help you understand the nature of the tionship of years ago. Doctors are con- the physician. I hope to provide some tips
relationship between you the patient, and stantly scrutinized over how much they to improve this relationship to seek the
your doctor. are spending to evaluate a patient's ill-
ness and treatment. Hospital stays are Continued Page 6
Thyroid Australia Thyroid Flyer Volume 1 Number 1 January 2000 5
What Should You Expect From Your Doctor? from Page 5
ultimate endpoint of a satisfied and roidism, all thyroid lumps (nodules), all doctor's office or at the nuclear
healthy patient. pregnancy-related thyroid problems, all medicine facility of the medical
Patients deserve to know what is cases of thyroid tumors, and any time the center or diagnostic center
wrong with them and deserve to have all thyroid blood tests are confusing. Special- • Follow-up monthly (for first 6
of their questions answered in a prompt ists (i.e., endocrinologists or months) or until hypothyroidism is
manner. The word "doctor" is derived thyroidologists) should be able to do all discovered
from the Latin word "docere" or "to of the above. The specialist should have • Follow recommendations for hy-
teach". The primary role, therefore, of a the time and experience to answer all your pothyroidism, above
physician is to teach his or her patient questions, explain to your understanding • If anti-thyroid drugs are used, fol-
what is wrong and how to improve or fix even the most complicated thyroid prob- low-up every 1-2 months for the
the problem. lems, be able to arrange the best place for duration of the anti-thyroid drug
It is said that the three major com- your diagnostic tests, hospitalization, lab treatment
plaints that patients have about their doc- testing, and surgeon if you need thyroid
tors are that: surgery (within the limitations of your
• Initially to establish the diagnosis
1) My doctor is always late. insurance company). He or she should
• First follow-up in one to three
2) My doctor does not spend enough provide you with written material, recom- weeks to review the test results
time with me. mend support groups (like the TFA), in-
• If surgery is recommended, fol-
3) My doctor does not listen to me. form you about web sites (such as
low-up within one month after sur-
www.tsh.org), and make notes for you to
Perhaps you should anticipate these gery
explain to your family at home. You are
three areas and be prepared to deal with • If no surgery, and thyroid hormone
entitled to all of this.
them individually or change doctors if suppression is used, then follow-
In addition, I feel your doctor should
you cannot find one who meets these up visits every 3 to 6 months for
help you make decisions. You come to
needs. the first 3 years, then yearly there-
your doctor to understand what is wrong,
Doctors, especially primary care doc- after
be tested (but not too much), and to feel
tors who work in large clinics, are often
better. Your doctor should keep up on all What should your doctor expect
forced to see large numbers of patients
the latest developments in the field. Your from you?
per day. The amount of time you need
doctor should provide for you the treat- Please be on time for the visit, or call
might not fit into the doctor's schedule.
ment options, where they exist, but should if you know you are going to be late to
Thyroid diseases can often be very com-
not turn to you to make a decision with- see if rescheduling is appropriate. If you
plicated, involving undergoing many
out your being properly informed. It is must have an authorization number or
types of evaluations, including physical
my personal feeling, that patients come form before you can see the specialist,
examinations, blood tests, nuclear tests,
to medical doctors for advice on what to make sure that the specialist has this pa-
ultrasounds, and biopsies, and often re-
do. Doctors should be expected to pro- per, or you should stop by your primary
quire detailed explanations.
vide guidance to the proper decision, not care physician's office to pick it up.
Many doctors who do formal train-
leave it to the patient to decide alone. If you are supposed to be on medica-
ing (i.e. residencies) in either family prac-
tice, general practice, or internal medi- How Often You Should Be Seen tions, please take them at the proper time
cine do not spend much time in the every day. They are for your own good.
It is hard to predict how often thyroid
Endocrinology Department. In addition, patients need to be seen by an If you are not so good at taking medi-
most patients with thyroid problems do endocrinologist. Certainly, it depends on cine, please inform your doctor. Some-
not have to enter hospital for anything the activity of the disease, whether the times the strength of a drug is readjusted
except thyroid surgery, so young doctors problem was newly discovered, partially based on the assumption that you are
who have learned mostly from hospital treated, or recurrent. The frequency may compliant. If you do have a problem re-
experience often have not had much ex- depend upon the age of the patient, as well membering to take the pills, perhaps a
perience in diagnosing or treating thyroid as how compliant the patient is. A rough simpler schedule can be arranged.
problems. If you have a lot of questions, please
guide might be:
If you sense that you are not getting Hypothyroidism: write them down on a list and have it
your questions answered, your doctor ready for the doctor when she or he en-
• Initially to establish the diagnosis ters the examination room. Sometimes
seems defensive in answering your ques- • First follow-up visit in one to three
tions, defers the answers to his staff, does seeing the list makes it easier for the doc-
weeks to review the test results tor to answer the questions.
not supply you with written material • Follow-up visits every 6 to 8 weeks
when you ask for it, does not know what If you become sick, require an opera-
until the TSH is normalized tion, or other family members of your
web sites contain the most reliable pa- • Follow-up visit in 6 months
tient information, gives advice that seems family are concerned about you and want
• Follow-up visit yearly thereafter to speak to the doctor, please designate
far fetched or confusing, perhaps it is time
to seek consultation with a specialist. This Hyperthyroidism (Graves' disease): one family member to be the spokesper-
is always a very delicate and sensitive is- • Initially to establish the diagnosis son for the family. Try not to make the
sue, but sometimes patients just have to • First follow-up visit in one to three doctor have to go over the same explana-
yell and scream loud enough to be heard. weeks to review the test results tions and facts on several occasions. If
I personally advocate early referral to • If radioactive iodine is used, treat- possible, try to have someone at the pa-
a specialist for all forms of hyperthy- ment at the next visit in either the tient's bedside when the doctor makes
Continued Page 7
6 Thyroid Flyer Volume 1 Number 1 January 2000 Thyroid Australia
THINK THYROID: Your GP and Your Thyroid from Page 2
roxine itself. That is, there is an the other structures in the neck - such as * There should be an agreed line of
autoimmune reaction or allergy either to the windpipe or gullet - and cause seri- treatment for the condition.
the thyroid tissue (the microsomal anti- ous complications. Thyroid disorders and thyroid screen-
bodies) or to the thyroid hormone. The Thyroid cancer should be treated by ing fulfil all of the criteria outlined above.
result is underproduction of thyroxine or surgical removal of the gland, with or Perhaps it is time for Thyroid Aus-
damage to the thyroid tissue, or both. without radiotherapy. tralia to begin to lobby for thyroid screen-
Ninety percent of patients with ing in the way that Diabetes Australia has
Screening -Think Thyroid
Hashimoto’s thyroiditis will show one or for blood glucose measurement. Perhaps
A few years ago I used one of those
both antibodies in their blood. it is time for the development of easy TSH
throwaway lines that sometimes take on
Hyperthyroidism, or thyrotoxicosis, assays.
a life of their own. I said that “you have
is characterised by an increased metabo-
to THINK THYROID”. The message is
lism. Symptoms include weight loss de-
that it is important for us GPs to remem-
spite an increased appetite, diarrhoea, in- What Should You Expect
ber the thyroid as its activity can mimic
tolerance of heat, trembling of the ex- From Your Doctor?
many other conditions. Thyroid disorders
tremities, increase in heart rate, and, in from Page 5
are the great masquerade. The thyroid
women, reduced menstrual flow. The
hormones affect every part of the body -
most common cause of hyperthyroidism
as most of you will be very aware - and rounds, if the questions are about a hos-
is the autoimmune condition known as
so, like diabetes, thyroid problems can pitalized patient.
Graves’ Disease. There can also be eye
present as all sorts of conditions. I have Cooperate with your physician when
involvement, which is characterised by
seen thyroid disorders mimic everything she or he recommends a test which can-
dry and/or protruding eyes. However,
from anorexia nervosa and atrial fibrilla- not be done at the doctor's office and have
Graves’ or thyroid eye disease (also
tion to Alzheimer’s Disease. it done promptly. Make sure you tell the
known as exophthalmos) would be the
So we GPs need to add thyroid screen- hospital or diagnostic center to send a
subject of another talk altogether.
ing tests to those other routine blood tests copy of the results to your primary doc-
Treatment we do as part of the general health check. tor, and also to the specialist.
The treatment of thyroid conditions The TSH is the test that we normally use. If you are seeing a specialist for the
depends on a number of factors. I will It is a simple blood test that can be added first time, try to gather up copies of all
only mention these briefly as these too to the other blood tests wherever appro- your recent lab results and bring them
are subjects which really need to be ad- priate. We do not need to do the T3 and with you to your appointment. In addi-
dressed separately at another time. T4 estimations as first line tests. They are tion, if you have had any recent thyroid
For overactive thyroid, we have a more useful as tests to assess the results scans, sonograms, or CAT scans, please
choice of tablets, surgery or radioactive of treatment than they are to screen for bring the original x-ray films with you.
iodine, monitored by TSH and T3 and T4 thyroid function. Call ahead to the hospital or diagnostic
levels. There are certain rules for routine center. They should release them to you.
For underactive thyroid, we have thy- screening tests. They are: Please learn as much as possible about
roid hormone replacement, monitored by * The test should be looking for a your thyroid disorder because the more
TSH and T3 and T4 levels. common condition. informed you are, the easier you can be
For nodular goitres, especially those * The test should be simple. treated.
that have had a bleed into a nodule, sur- * The test should be cheap. Patients, nowadays, deserve to be bet-
gery is the only choice. This type of bleed- * The test should be accurate and spe- ter informed than they used to be. There
ing is a potentially life-threatening con- cific for the condition. are many resources available (including
dition because the thyroid may enlarge * The test should be as non-invasive the TFA). But use the resource most eas-
to such a degree that it can press upon as possible. ily available and the one that you need to
trust the most - your doctor. In turn, co-
operate with the doctor so that you can
return to good health as quickly as possi-
Dr. Levy is Clinical Professor of Medi-
cine, University of Miami School of Medi-
cine, in Miami, Florida.
Originally published by Thyroid Founda-
tion of America, The Bridge, Volume 14,
Number 4, Winter 1999.
Republished with permission.
The audience listening to Dr Dammery
Thyroid Australia Thyroid Flyer Volume 1 Number 1 January 2000 7
Editorial from Page 1
Thyroid material in LOTE ing an over-active thyroid gland, resulting
from Graves’ disease. His older brother
In our previous newsletter we asked for
assistance in providing material in lan- had been similarly diagnosed only a few Books
guages other than English (LOTE). We years before and his uncle, on his father’s
have since received permission from the side, had also had the same diagnosis in The Thyroid Solution: A Mind-Body
Associazione Italiana Basedowiani e the 1960’s. Aunties and great-aunts on both Program for Physical Health, Ridha
Tiroidei (AIBAT) to use their Italian mate- sides of his family had suffered from Arem, (Ballantine Books, New York) 1999.
rial, for which we are most grateful. underactive thyroids. With this family his- (ISBN 0 345 42919 2.)
We also have French material from the tory, and growing up in Tasmania, devel- How Your Thyroid Works, H Jack
Thyroid Foundation of Canada, which is oping a thyroid condition seemed almost Baskin, 4th ed., (Adams Press, Chicago)
also gratefully acknowledged. inevitable. 1995. (Also available on the internet at
The Multicultural Health Communica- Megan Stevens came to Australia from http://www.thyrolink.com/baskin/
tion Service of the Department of Health South Africa in 1981, with a BA, a librar- index.htm)
in New South Wales have also recently pub- ianship diploma, and her husband, Alun, Thyroid Disease: The Facts, RIS
lished an excellent leaflet, entitled How thy- in hand. She was diagnosed with Bayliss & WMG Tunbridge, 2nd ed. (OUP,
roid problems can affect your health. This Hashimoto’s Thyroiditis in November Oxford) 1991. (ISBN 0 19 262103 3.)
leaflet is available in Arabic, Chinese, 1994, 9 years after the birth of their sec-
ond child. Since then she has tried hard to The Thyroid Gland: A Book for Thy-
Croatian, English, Greek, Italian, Khmer, roid Patients, Joel I Hamburger & Michael
Korean, Laotian, Macedonian, Portuguese, understand her thyroid condition, and all
other aspects of thyroid disease. When she M Kaplan, 7th rev. ed., 1997 (Available
Russian, Spanish, Thai, Turkish, and Viet- through the Thyroid Foundation of
namese. We have permission to provide is not reading up on matters thyroid, she is
working (well, trying to) on her MA His- America or Amazon.com)
copies of this leaflet to those who require
tory thesis on the Commissariat in the Thyroid Disorders, Rowan Hillson,
Crimean War. (Macdonald Optima, London) 1993.
Other initiatives are also in the offing,
Alun Stevens came to Australia with (ISBN 0 356 18686 5).
particularly relating to Russian material -
but more of that in another newsletter! Megan. He only suffers the side effects of Understanding Your Thyroid Prob-
thyroid disease. He is an actuary and man- lem, Mark Ragg, (Gore & Osment, Syd-
The Thyroid Australia Committee agement consultant and is helping estab- ney) 1993.
It gives me great pleasure to introduce lish Thyroid Australia. The Thyroid Sourcebook: Every-
some of the members of the Thyroid Aus-
Features thing You Need to Know, Sara M
In this newsletter we are concentrating Rosenthal, 3rd ed. (Lowell House, Los An-
Colleen Dean has been a nurse for
on the relationship you have with your geles) 1998. (ISBN 0 7373 0014 0)
thirty years and has a keen interest in
endocrinology and the immune system. doctor, and how best to foster that relation- The Thyroid Book: A Book for Pa-
Although not a thyroid sufferer, she has a ship. Our thanks to Dr. David Dammery tients, Martin I. Surks., (Consumer Reports
strong family history of thyroid disease, for his input, and for his wonderful talk on Book, New York) 1993. (Available from
diabetes, MS, ADD and arthritis. Her Your GP and Your Thyroid at our first pub- Dr MI Surks, Montefiore Medical Center,
mother developed heart disease as a result lic meeting on 20 November 1999. (Thanks Div of Endocrinology, 111 East 210th
of a chronic untreated hypothyroid condi- too to those who attended - it was great Street, Bronx, New York 10467;
tion and her father’s thyroid condition was meeting you all!) We also include a great or by internet at
drug induced. She feels that support groups article by Dr. Elliot Levy, who talks about http://www.thethyroidbook.com)
such as Thyroid Australia give access to doctor/patient expectations of each other. Thyroid Problems: A Guide to
information, and individuals can then de- And, following our feature on Iodine Symptoms and Treatments, Patsy
velop a better understanding of their con- Deficiency Disorder (IDD) in our last Westcott, (Thorsons, London) 1995.
dition enabling them to take charge and newsletter, we are providing an editorial (ISBN 0 7225 3164 8).
move on with their lives. by Prof. Cres Eastman which was recently
Your Thyroid: A Home Reference,
Kay Horley is married to Ed and they published in the Medical Journal of Aus-
Lawrence C. Wood et al, 3rd ed. (Ballantine
have a 14 year old son, Ben. She has tralia. We had wanted to include in our last
Books, New York) 1995. (ISBN 0 345
Hashimoto’s Thyroiditis. In hindsight she newsletter an article written by Prof.
thinks her mother had thyroid disease, but Eastman in 1993, in which he suggested
was never diagnosed - she did however that there was “no evidence for IDD in Aus-
have diabetes. tralia”. However, Prof. Eastman asked us
Christopher McDermott has lived in not to do so, and informed us that that in- All materials provided by Thyroid
Melbourne for almost two years and works formation was out of date, and that IDD is Australia are for information purposes
in arts administration. In late 1997, just in danger of having a resurgence here in only and do not constitute medical
before moving, he was diagnosed as hav- Australia, which is a matter of grave con- advice.
Postal Address: PO Box 2575, Fitzroy Delivery Centre VIC 3065
Office: 43 Donald Rd, Wheelers Hill VIC 3150
Phone: (03) 9561 2483 Fax: (03) 9561 4798
E-Mail: firstname.lastname@example.org Web: www.thyroid.org.au
8 Thyroid Flyer Volume 1 Number 1 January 2000 Thyroid Australia