Ologies with Alie Ward - Thyroidology (THYROID GLAND) with Kepal Patel

Episode Date: January 29, 2025

Sad? Cold? Hot? Wired? Blame the thyroid. In your throat there is a butterfly-shaped gland under a shield-shaped Adam’s Apple and it controls how you feel. We asked Thyroidologist and surgeon Dr. Kepal Petal of NYU Langone Hospital about everything from how to decipher TSH to T4 to T3, libido factors, radioactive cats, stress and thyroids, how diet can affect them, flim-flam and how being on TV might save your life. Learn more about Dr. Patel Follow NYU Langone Health on Instagram and YouTubeA donation went to The American Association of Endocrine Surgeons (AAES)More episode sources and linksSmologies (short, classroom-safe) episodesOther episodes you may enjoy: Diabetology (BLOOD SUGAR), Laryngology (VOICE BOXES), Trichology (HAIR), Evolutionary Anthropology (METABOLISMS), Environmental Toxicology (POISONS + TRAIN DERAILMENT)Sponsors of OlogiesTranscripts and bleeped episodesBecome a patron of Ologies for as little as a buck a monthOlogiesMerch.com has hats, shirts, hoodies, totes!Follow Ologies on Instagram and BlueskyFollow Alie Ward on Instagram and TikTokEditing by Mercedes Maitland of Maitland Audio Productions and Jacob ChaffeeManaging Director: Susan HaleScheduling Producer: Noel DilworthTranscripts by Aveline Malek Website by Kelly R. DwyerTheme song by Nick Thorburn

Oh hey, it's the guy at the library with that stack of survival books. Allie Ward, let's talk about your thyroid. Do you still have one? If not, let's talk about how it did you dirty. Metabolism, libido, sweating, freezing. You're in the right place for all of it. So I went to New York because I'm sophisticated. And also your favorite diabetic, diabetologist, Dr. Mike Natter was getting married to his bride Alice.

And whilst there, NYU Langone Hospital hooked it up with a thyroid expert and a surgeon who was more than game to answer all my questions about this little hormonal organ that rules our lives. So this guest is a division chief of the NYU Langone Endocrine Surgery Department and a professor in the Department of Biochemistry and Molecular Pharmacology of Otolaryngology, Head and Neck Surgery.

And we met up on a brisk afternoon in this tidy, elegant hospital conference room and I asked so many questions and he didn't even bill us for them. He knows his stuff and he knows your stuff. So we'll talk about your stuff momentarily. But first, let's thank all the patrons at patreon.com slash ologies who make the show possible and send in their questions. You can be one of them if you like for just a dollar a month. Also thanks to everyone in ologies merch from ologiesmerch.com and if you need a kid-friendly version of the show, just a reminder that we launched Smology's recently. It's a spin-off podcast in its own feed, link in the show notes. So thank you

also to everyone who leaves reviews for the show. It matters so much to us and it helps boost the show in the charts and I read all of them. And this week, Positive Steps PDX wrote that they look forward to listening every week and that it's been rad to gain knowledge from fellow queer and trans folks. Positive Steps PDX, it's a joy to introduce the audience to all manner of ologists across all kinds of fields, including your thyroid. Now, thyroidology comes from the Greek thyrodidi. It means shield-shaped, and that refers to the Adam's apple of the throat, which is thyroid

cartilage and then the endocrania gland underneath it that provides hormones that keep your engine running. So let's get to it. Let's figure out just what the hell is happening with that lump in your throat. And if maybe it's making you depressed or cold or tired or sweaty or shaky or hot, when to ask your doctor to check it, how to decipher labs,

as well as info on radioactive cats, stress and thyroids, surviving a nuclear bomb, how diet can affect your thyroid, flim flam, and how being on TV might save your life. Please also remember, however, that we can neither diagnose nor treat you because this is a free audio show. We don't have access to your neck or your blood. Don't be weird about this.

Do be excited. So let's hear from surgeon, professor, endocrinology specialist, and thyroidologist, Dr. Kapil Patel. Kapil Patel and he him. And I'll have you just kind of hold it like an ice cream cone. Like if you were a stand up or doing karaoke. We can do some songs afterwards. Yeah, 100%.

Apologies in advance. Okay. First off, do I have an awful thyroid? I feel like that must be the question everyone asks you. Does my thyroid messed up must be something that you get constantly. Absolutely. I think the poor thyroid gland gets blamed for a lot of things in life, and it's not necessarily this poor little glands fault. The thyroid gland is an amazing organ. It's a small gland that sits right in the middle of your neck, right on top of your windpipe. It's

shaped like a butterfly. You have a right side and a left side of the gland. And its sole purpose is to make thyroid hormone. And you can think of thyroid hormone as like the gas for your engine. It really, it really regulates your metabolism, you know, and that's your primary organ that gives you the fuel that you need to basically do almost all the activities that you perform. You know, from temperature regulation to how you metabolize your food, to how you use your energy,

is all regulated by the thyroid gland. So anytime somebody feels off for whatever reason it may be, it's always, is it my thyroid gland? Yeah. But the beautiful thing about the thyroid gland is it's an easy organ to check, both physically and from a laboratory standpoint. It's easily palpable, you can see it.

It's very much in the front of your neck. So if somebody does have a large thyroid or thyroid mass, you can almost always feel it. And then it's, you know, the blood tests for thyroid function are pretty easy to obtain. So you get the blood tests and it gives you a good idea if your thyroid gland is actually functioning normally or not.

So that kind of gives you an answer most of the time. What about your metabolism? How much of an effect does it have in terms of like how many calories your body burns at a basic metabolic rate? How much of your body composition is determined by it? By the thyroid hormone you're asking. Yeah. Absolutely.

It's a significant portion of it. So your thyroid hormone really does regulate a lot of that So we see that in very sick patients in patients that are admitted to the ICU for for weeks or months You'll see that their thyroid hormone levels start to change and so we know that the thyroid gland is intimately involved in your metabolism And so, you know depending on the situation whether it's a stressful situation Whether it's a situation where your body requires more energy, the thyroid gland definitely plays a significant role in that.

How often are people depressed but they think it's their thyroid or vice versa? Oh, it's very common. Part of the reason is people get online and they'll Google it and thyroid will come up as one of the causes for fatigue or depression or not feeling energetic. And so that automatically is the first thing people think about. Often it's not just the thyroid gland. When you do have loss of function of the thyroid, hypothyroidism. Hypo means under, whereas hyper means above.

And when you do have loss of function of the thyroid, hypothyroidism, often it's autoimmune and it's associated with other symptoms as well. It's not just fatigue or lack of energy or depression. Patients often will feel cold, they'll start to gain weight, they may have some hair loss, the skin gets dry, the nails get brittle. I mean that's classic what we call Hashimoto's thyroiditis or hypothyroidism. And the difference between having let's say low thyroid hormone and having Hashimoto's, Hashimoto's from what I understand is your immune system being like, let's get this thyroid out of here.

Get out of here. We don't like you. You're an invader. And you're like, this is my own thyroid. So Hashimoto's is a type of autoimmune disorder where your body's immune system turns on itself and you're like, can you not? But Hashimoto's is not the cause of all underactive thyroids, AKA hypothyroidism. You can have low thyroid hormone without it being caused

by autoimmune Hashimoto's. Just like all cacti are succulents, but not all succulents are cacti. So all Hashimoto's, hypothyroidism, not all hypothyroidism is Hashimoto's. Do those present differently? The most common cause for hypothyroidism in this country is Hashimoto's. But you can have low thyroid function, a high TSH, and not have Hashimoto's thyroiditis. That does exist.

But the most common cause is Hashimoto's. But the overall effect is probably the same because it's ultimately the effect of your thyroid gland not working the way it should be. Okay, so this is confusing, but how doctors measure your thyroid function is by checking your TSH, that's thyroid stimulating hormone. So this hormone is like a measure of how much your body is pressing the gas pedal to try to get enough thyroid action. So a low TSH means hyperthyroidism or an overactive gland because your body barely has to tap the gas pedal of TSH, but your thyroid is already off to the races. Now, a high TSH means your body is flooring it on the gas pedal so hard and not getting a lot of action to convert to energy.

So a high TSH means low activity, hypothyroidism, and a low TSH means high activity or hyperthyroidism. Just think everything's the opposite, kind of. So walk me through a backstage of the thyroid and the thyroid hormone, it squirts out what T4, the thyroxine, tell me what is it making and what is that effect? Yeah, so the TSH level, which is probably the most important blood test to assess thyroid function, is actually not released by the thyroid gland. TSH is actually released by your pituitary gland, which just sits at the base of your

brain. So when it senses that there's not enough thyroid hormone in the body, the pituitary gland, which is considered the master gland, releases TSH, which is thyroid stimulating hormone. And that's to stimulate the thyroid gland to make more hormone. So if your TSH is high, that means your thyroid's not working well. That's how, you know, TSH is low, that means your thyroid is working too well. So when your TSH is, you know, depending on what your TSH levels are, it'll affect your thyroid gland and your thyroid gland will make thyroid hormone. Now thyroid hormone comes in two

forms. It's something called T4, as you were alluding to, and then T3. T3 is your active form. That's the form that your body cells use to use it for the metabolism and the energy and to use it for all the functions that the cells need thyroid hormone for. But what your thyroid gland actually produces is T4. And then the T4 is actually converted into T3 as needed by your liver, your kidneys, and other parts of your body. So the pituitary is at the wheel and at the gas pedal, and it makes that thyroid stimulating hormone or TSH.

That tells the thyroid to release more gas, T4, and your organs say, thanks man, I'm going to break this down a little into T3, so we can use it for energy. So imagine your pituitary saying, we're not going anywhere. Where's the gas? Pumping out more TSH to be like, come on, come on, come on. Or if you have too much T4 converted to T3, your pituitary is like, whoa, easy, lead foot

and it releases less TSH. So, T3 is the active form of the hormone. And it kind of makes sense even evolutionarily if you think about it because if you just start putting out T3 your metabolism is gonna skyrocket you're gonna be bouncing off the walls. So your body actually is smart in that sense it says you know we're gonna make T4 and if you need T3 you'll convert it and you'll make as much T3 as you need but this way we're not just pumping out T3. Where's the T4 hanging out when it's on

call to be T3? In your thyroid gland. Oh yeah. Thyroid is making it and your thyroid's making it and it makes it as it needs it, kind of, and it secretes it. Okay. And then your body converts it to T3 as needed. Do you know why they're called T3 and T3? Yep. It's the iodine. It's the amount of iodine particles. So T4 has four iodine, particle T3 has three. So when T4 gets deiodinized, it becomes T3. So when T4 gets deiodized, it becomes T3. So what happens when you've got T3 in the body? Does it affect your adrenal systems? Does it affect cortisol?

Yeah. So that's a great question. So, you know, there's some overlap with the other hormonal systems in the body. For the most part, it's really affecting, you know, the cells that you need for energy. So there's not too much hormonal interplay as there is much like the T3 really affecting your cells for cellular metabolism at the cellular level. So it's like I said, it's temperature regulation, digestion, your energy levels, your ability to think clearly, not be tired, your heart rate, that's all affected by a thyroid hormone. If you have a low heart rate, speaking from experience, at some point my doctors were

like, wow, you're athletically healthy. And then I was like, or does my thyroid suck? I'm not running as much as I used to. It turned out my thyroid sucked a little bit. But when someone comes to your office and they say, I think my thyroid is, let's say sluggish, what are the first things you do if they have symptoms of hypothyroidism, but their labs are within range?

Where do you go from there? Yeah, that's a tough one. I mean, so, you know, it's the first thing, like getting back to your question, the first thing you do, you're gonna take a full history, right, you wanna make sure if somebody's complaining that the thyroid may be sluggish, you wanna ask all those pertinent questions.

Are you tired? You know, do you feel cold? Are you gaining weight? Is your hairuggish, you want to ask all those pertinent questions. Are you tired? Do you feel cold? Are you gaining weight? Is your hair falling out? So you want to ask all the questions that would help you kind of identify what thyroid problem that they may be having. And then you're obviously going to do your physical examination, examine the thyroid. I mean, God forbid, did having thyroid mass or anything that we need to worry about. And then the next step would probably be getting your laboratory studies and looking at your

thyroid function. So for TSH, that thyroid stimulating hormone in range is typically set like 0.5 to 5.0. You could be anywhere in between there, but it varies by lab. And if a patient is feeling symptoms like for hypothyroid, dry skin, feeling cold a lot, low energy, your guts are slow, you have brittle hair, maybe you feel like the embodiment of a cold, limp stalk of celery, that's sad. And you're in the upper end of the TSH range,

even though you're in range technically, some doctors might flag it and medicate with extra thyroid hormone or T4. Doctors can also see, no matter what your TSH is, how much T4 you're actually making and test to see how well your organs are converting that to T3, which you can use. Now there are medications like Synthroid, which the generic name is levothyroxine, and that is just T4, and it's kind of up to your body to make the T3 you need from it. Now with Hashimoto's, the autoimmune issue

where your immune system turns on your own thyroid, that is rude, and it's measured by high TSH as well as labs that measure antibodies to your own organ. And we do see that. We do see situations where the patients don't feel well. They have all the symptoms of thyroid, kind of hypothyroid disease, but their blood tests come back relatively normal. They don't have any antibodies and what do you kind of do with that? And you want to rule out other causes, right?

So you want to do a full autoimmune workup, make sure there's not other causes as to, you know, why this is happening. And at the end of that, even if everything else still comes back normal, there are some individuals out there, including some of our experts at NYU, will try to maybe start them on a little bit of thyroid hormone, see if that makes a difference, see if they feel better with that. But that's very kind of a case kind of a situation. It's not like a universal thing. Do people ever try to score a thyroid hormone as like a no-semphic?

A weight loss. I was gonna wait for that. I said it before you said it, absolutely. Really? Oh yeah, the first question I always usually get when I talk about, I mean, I do a lot of thyroid surgery, right, and so most of my patients will end up on thyroid medication, and it's a question

I get almost every day is, oh, that's great. If I take two pills, will I lose weight? I'm like, no, it doesn't work that way, unfortunately. It's not a weight gain or weight loss pill. What would happen if you overdosed yourself? Oh no, you would feel kind of miserable actually. Really? Yeah, you wouldn't feel good.

I mean, you'd feel hyperthyroid. Your heart will be racing, you'd be sweating, you'd feel anxious, you would not feel well. Yeah, so word of the wise, don't do it. Don't overdose on, leave with the Roxine. Yeah, so word of the wise, don't do it. Don't overdose on leave with the Roxine. Yeah, just like get extra coffee. Does everyone's thyroid kind of poop out as we age? Not necessarily. Most patients actually do really well. I mean most people their thyroid function you know remains relatively normal but as you get

older, like in most organs in your body as you get older, your thyroid gland you know often does become a little bit more sluggish. Bummer. And so it's not uncommon after the age of 60 and actually more common in women actually. And some of it may have to do with the autoimmune aspect of it and the hormonal aspect of it with menopause. But as you get older, the thyroid gland in women sometimes tends to get a little sluggish. It is important when you see your primary doctor to have those blood tests done because patients may come in, they don't feel well, they feel like they don't have energy and often they will chalk it up

to I must be going through menopause and I must be having other hormonal changes and sometimes it's just that your thyroid gland is getting a little weak and a little bit of thyroid hormone makes them feel better. When it comes to women and assigned female birth, what is the connection between autoimmune Hashimoto's and ovaries? What's going on? So autoimmune disease in general is more common in women, right? And when we talk about autoimmune thyroiditis, like I said, usually we're referring to this entity called Hashimoto's thyroiditis. And it's named after Dr. Hakura Hashimoto, I think in 1912,

actually described it for the first time. He was a physician and a scientist in Japan. The concept of Hashimoto's is your body is now creating antibodies against thyroid peroxidase and thyroglobulin. These are the enzymes that your thyroid gland uses to make thyroid hormone. So when you create antibodies against those enzymes, now your thyroid can't make the hormone anymore.

So your thyroid starts to not function. And ultimately it's actually causing destruction of the thyroid. The thyroid actually starts to die. So many of these patients with Hashimoto's have shriveled thyroid glands. Almost at a point where the thyroid gland almost disappears sometimes.

It becomes scar tissue. If you discovered a thyroid disease and they called it Patel's and then everyone complained about having Patel's, how would, would you be like, Yeah. I'll never. Like, Oh my God.

I'll never be forgotten in my field. Or would you be like, bummer that my name is associated with something nobody wants? Yeah. Yeah. I don't know. Probably the latter. Yeah. Call a little, call him a, call him a.

Exactly. Well, okay. Yeah, I don't know, probably the latter. Call a little, call a mate, call a mate. Exactly. Well, okay. I have heard stories of people being diagnosed with thyroid disease just by someone seeing them like across the room or on TV. I don't know if you remember there was a story where someone... Oh, yeah. Do you remember that story?

Absolutely. It was on TV and someone said, you probably want to get your thyroid checked. And they had a thyroid issue. So that was actually a surgeon at NYU. Stop it. Yeah, yeah, yeah. Yeah, so it was a surgeon at NYU, it was Dr. Eric Voigt, one of the ENT surgeons here,

actually noticed somebody on TV. It was a HGTV thing, I think. A small but noticeable lump on her throat. Dr. Eric Voigt was watching the show at his home in New York. He's an ear, nose, and throat surgeon. I was like, gosh, I feel obliged to let this person know. They may not know they have something.

And as an expert in the field, I was concerned for her. I think it was this HGTV personality person. And then he called into the TV show or said, you know, by the way, I think one of your presenters has a goiter or thyroid mass. And then she got treated, right? She got treated, yeah, yeah. So for Nicole McGuinness, being on Beachfront Bargain Hunt saved her life while having a

doctor watch Beachfront Bargain Hunt saved her life. What an anomaly, right? How often would someone be watching an HGTV show and notice thyroid cancer? It's like one in a million, one in a billion. Wait, no, hold on. Okay, I was fact checking Nicole's story and I found out maybe this was apocryphal, maybe this was wrong because it was actually HGTV personality Tarek El Moussa

who had thyroid cancer. And it was a nurse who spotted his enlarged gland. When I was watching Flip or Flop on TV at home, I noticed that at certain angles, at certain times, it just caught my eye that Tarek had a lump on his throat. And I thought it was something that needed to be brought to his attention. Within a month, Tarek had his thyroid and lymph nodes removed and began iodine radiation treatment. Wait, what?

What? Okay. I went on a deep dive about the health of a guy on HGTV. Turns out both of those stories are right. Nicole and Tarek, different shows, different thyroids, both on HGTV. So in addition to that lady looking for the cheap seaside cottage, Tarek Elmoussa, co-host of HGTV's Flipper Flop,

found out that he had thyroid cancer from that viewer's heads up. And this is after he'd been seeing a doctor for a while trying to figure out why his throat hurt and was tight. And his doctor just kept brushing aside as like allergies. Turns out it wasn't hay fever. It was stage two cancer having spread to his nearby lymph nodes. He had to get the thyroid removed and undergo radioactive iodine therapy, which we'll discuss in a bit. And then unrelated, side note, Tarek's old doctor

also was like, don't worry about that lump in your scrot. It's probably nothing. But it turned out it was testicular cancer unrelated to the thyroid cancer at the same time, at which point I'd want to sue my doctor or my endocrine system or both of them. Now for the testicular stuff, it's not something that a doctor on the subway

or something would notice in passing, hopefully, depending on what kind of vibe you're running. But as for a goiter or an enlarged thyroid, do you ever notice that on people? Yeah, it's one of the occupational hazards. I run looking at people's neck before I look at their faces, probably. It's unfortunate. But yeah, no, I mean, it's natural, right?

That's what I do every day. I examine people's necks. Yeah, I mean, large goiters are easy visible. I mean, for people that know it, like that's an abnormal neck. Does it cover the Adam's apple? It does. So, you know, the term goiter is just basically an enlargement of your thyroid gland. It's almost always benign.

It's an overgrowth of your thyroid. And you know, I think everybody at some point has probably seen pictures in like National Geographic or whatever, where you have these huge goiters, huge thyroid masses. And it's almost always either familial or iodine deficiency. So according to the 2020 paper, Iodine Deficiency and Goiter in the Williams textbook of endocrinology, 75% of people with goiter live in less developed countries where iodine deficiency is prevalent. And this prevalence of goiter is most common in mountainous areas, including the Himalayas and the Andes, where there is significant iodine deficiency.

And it's also common in large parts of Africa, areas of Central Europe, and in Papua New Guinea. But this textbook notes that highly developed countries can also fall prey to goiter conditions and iodine deficiency, like the United Kingdom and Australia. And the US had a real goiter-ish back in the early 1900s with up to 70% of American children in some areas having clinically apparent goiter. 70%, that's like a higher percentage

of kids mewing in class. And so I don't know if you're familiar with the whole Goiter belt story. Yes. I mean, fascinating. Yeah. Well, first off, is it Goiter or Goiters? Goiter. Okay. There's, there's no Goiters. There's no Goiters. No, this is multiple people. I guess you can't have more than one. You have one Goiter. Yeah. Um, have those changed in rates historically? Have we seen epidemics of goiter?

What causes those? As I was saying, the most common cause for goiter is still iodine deficiency worldwide. The rate of people having goiter in this country has dropped tremendously. And I think it's probably one of the most, if not probably the greatest success story for the US Public Health Service was in the 1920s. They discovered that there was a good portion of the middle aspect of America, which was called the goiter belt across the Midwest, where you didn't have access to fresh seafood, good sources of iodine, and patients had large thyroid.

That thyroid gland's really enlarged and they had goiters. And I think that became a real public problem. And the solution was easy to get these patients to take in iodine, but it was hard to administer iodine because iodine doesn't taste good, number one. And how do you get people to take iodine? So, I mean, it was a brilliant, you know, there's a whole, there's a big backstory to this, but it was basically a stroke of genius to say, Hey, why don't we just put iodine into the salt?

Salt is a known quantity. Everybody consumes salt. Salt doesn't spoil. And iodine, you don't taste the iodine. The salt, you taste the salt. And so you just iodize the salt. And all of a sudden, our rate of goiters in the Midwest has dropped to basically average to what it was on each coast.

So the goiter belt, on trend for the Midwest in the 1920s, but has since, thankfully, gone out of fashion. Now, when you see iodized salt, you can say, hey, thanks, goiter buster. That's why you're iodized. But don't overdo the salt, and don't panic if you use uniodized kosher or sea salt. Chances are you have enough in the small amounts you're getting. It's no longer much of a problem anymore. Obviously now you can get great sushi in the middle of the desert like in Vegas. But back then that wasn't available.

Is the thyroid trying to compensate by enlarging in tissue size? What's going on? That's exactly it's hypertrophy. Hypertrophy hyper means it's growing bigger. That's exactly what's happening. The thyroid gland is hypertrophying because it needs iodine to make thyroid hormone and it's not getting the iodine. So it's actually increasing in size trying to get iodine, trying to accumulate iodine. And if you add iodine to someone's diet, does it just shrink down or does it need a surgical intervention?

Yeah, I think once you've developed it, it's probably not going to go away. If you give that patient iodine at that point, it'll probably prevent it from getting any bigger, but it's not going to shrink. Okay. And so at that point, they're stuck with the goiter that they have. And then? Yeah. Either you take it out or if they're taken tolerated and it's not really bothering them, you can even leave it alone.

I always thought that it would just shrink. This is why you're a surgeon and I'm not. But are certain populations, let's say you're a seafaring person or you're a fishmonger on a coast, do you ever see increases in iodine and therefore hyperthyroidism? Well, not necessarily hyperthyroidism per se,

but you can get iodine toxicity for sure. And so you do have to be careful, right? I mean, and you also, depending on how much fish you eat, not just iodine, but you can get mercury toxicity as well, which is even more dangerous. So you gotta be a little careful. But no, I think, look, the bottom line is a healthy diet, right, you know, good amount of fruits and vegetables

and meats and fish, and I think,, you know, you should be fine. But again, if you're low on that thyroid hormone in your body, that T4 and thus T3, what about hormone replacement? I've heard synthroid. I've also heard that sometimes they take desiccated pink thyroid and there are two camps and some people are very much like, don't give me the fake stuff. And other people are like, that pig stuff, you never know what you're getting. What's the deal?

So you're right about both. Okay. But most of us really prefer using levothyroxine, which is the brand name is Synthrebo. Levothyroxine is the synthetic T4 hormone. And I think the reason behind that, it's easy to test, it's easy to regulate. It's a known

quantity that you're giving them, the patients, so that we know exactly what the patients are getting. From a physician standpoint, it's an easier drug to manage, levothyroxine. The flip side to that is that it is synthetic. Most patients tolerate it beautifully. I mean, we're talking about a very small subset of patients that don't tolerate thyroid hormone. I would say 95% plus, they take their synthroid once a day and they're totally fine. But you know, there are a percentage of patients in whom that they don't do well. And the other formulation, as you were mentioning, is this, you know, this natural desiccated pig thyroid, which is a combination of T3 and T4. So it's not just T4, which levothyroxine is.

So I think some patients do feel a little bit better with that extra T3, as far as feeling kind of like I feel normal again, I feel like I have my energy levels back because you're getting T4 and T3. So remember T4 is what the thyroid pumps out naturally. And then it's up to your body to convert it to T3. As for what your body is making and what medications

might work best on you if you're hypothyroid, there's that levothyroxine or the natural desiccated thyroid made from pigs. It's just what it sounds like, it's from ground-up pig parts. Now I have had some thyroid problems in the past that have now resolved, but I did take desiccated pig thyroid for a while. And it has kind of a subtle flavor, kind of like a boiled pork chop water. Why put it in your mouth, you're asking the universe? Well, a 2024 Frontiers in Endocrinology paper titled Inquisitively, Natural Desiccated Thyroid for the Treatment of Hypothyroidism noted that people with hypothyroidism. Noted that people with hypothyroidism who don't respond to levothyroxine, T4,

are prescribed a natural desiccated thyroid preparation, which contains that mixture of T4 and T3. But it could vary between batches. You're not quite sure what you're getting. And so that natural desiccated thyroid may be better for some patients with hypothyroidism, but it's not the first go-to for doctors in the U.S., especially because it's technically not greenlit by the FDA.

And it may not be right for some people who have heart disease or thyroid cancers or diabetes. And if crunched up pork thyroid is not for you, the paper does offer the suggestion of bovine thyroid for individuals who, for religious or cultural reasons reasons don't eat pork. Still not vegan. And so there's no right or wrong answer to this honestly. It's a lot of it that just deals with what the patient feels best taking. But there are two camps.

With the natural desiccated pig thyroid, it's hard to know exactly how much hormone you're taking in because it comes in granules and you don to know exactly how much hormone you're taking in because it comes in granules and you don't know exactly how much hormone is in each granule per se. So it's not as well kind of calibrated. And that's why many of us don't feel comfortable giving it because I don't know if you're how much actually getting. But if the patients feel well and they like it and they're doing well, then I think most physicians are okay with it. Okay. What about infections? Like does Epstein-Barr have an effect on thyroid? Does COVID have an effect on thyroid? Or is that just part of the like an autoimmune response? So yes, I mean, so it is part of the autoimmune response, but was the

autoimmune response triggered by the virus? And the answer is probably yes. Viral pathogens in general have been known to trigger autoimmune responses. And Epstein-Barr has been one that's been written about and people have studied it and there is some data to support that it can trigger an autoimmune virate response. EBV or the Epstein-Barr virus is mono, AKA the kissing disease, which in my case,

you can get in your 20s without even kissing anyone, but by sipping a friend of a friend's plum wine at a party and then regretting it for the rest of your life, which is how long EBV stays in your body. What's fascinating and what we're looking at right now here in our institution, NYU, we're actually looking at COVID. And we've actually seen probably close

to a dozen patients now, some after they actually got COVID. So they're exposed to some form of COVID antigen that had hyperthyroidism, transient. Really? Yeah. So one of our own medical students here actually ended up with hyperthyroidism after COVID. Hyper? Hyper. Really? Yeah, because it triggered some form of autoimmune response that actually triggered the thyroid gland to make more hormone. So can an autoimmune response happen kind of any exposure to a virus that just says,

hey, immune system, like, let's kick into gear? Exactly. One of the kind of theories out there, at least as to why women tend to be more prone to autoimmune disease, and it's a theory and nobody really knows for a fact, but there are some data to support environmental toxins, right? So certain environmental toxins, synthetic estrogens, cosmetics, some of the chemicals that are involved in some of those products can trigger an autoimmune response. And so I don't want to tell people not to use synthetic estrogens or cosmetics,

but I'm just saying there are some thoughts out there that say that maybe that's why women are more exposed to some of these environmental toxins, which may lead them to develop these autoimmune problems. I used to drink my tea out of a plastic cup from the 99 cent store, hot tea. to somebody's environmental toxins, which may lead them to develop these autoimmune problems. I used to drink my tea out of a plastic cup from the 99 cent store, hot tea. Sometimes I think, wow, that was a terrible decision I didn't realize I was making every day.

Sure, that cup didn't break, but my body did. And then you microwave it, so it's great. Oh yeah, it's fine, absolutely fine. Absolutely fine. What about nodules? When I think of thyroid nodules, I think of like little like lumps and beads and I'm like, do you pop them?

What's going on? What are they exactly? Now you're, this is what I do on a day to day basis. So thyroid nodules, they're basically growths in the thyroid gland. If you want to think of it that way. So small tumor. So I like to think of thyroid nodules as a true abnormal growth. Now, it doesn't mean it's cancer. Most of

these, as a matter of fact, over 95% of them are going to be benign. Most thyroid nodules are benign. But a small percentage of them can be malignant or cancer. And so when you have a patient who has a thyroid nodule, it needs to be appropriately evaluated. And what do you do? Do you stick a needle in there and check it out? Well, the first thing you're going to do is obviously examine the patient, get the appropriate history, ask the appropriate questions. Are they having difficulty swallowing, breathing? Are there any changes in their voice?

Because a nodule, depending on where it is and what type of nodule it is, it could be compressing other vital structures in the neck. The nerve that controls your vocal cords and your voice runs right behind the thyroid gland, so it's very sensitive to any kind of thyroid disease. Yeah, so it's one thing that we really are worried about. Once you've done the appropriate evaluation, usually it's an ultrasound, first thing, to look at a thyroid nodule.

So you get an ultrasound exam, which is very easy to do. The thyroid is very superficial. You get a good look at the thyroid nodule. And then based on certain findings or characteristics of the nodule, you'll get an idea that nodule looks like it's benign. We don't need to stick a needle in it or that nodule looks kind of concerning. Let's stick a needle in it. Okay.

And so that's what we use to kind of decide. What's under the microscope when you squirt out whatever was in the needle? Cells. So we, when we do a needle biopsy, which I do in the office on a regular basis, we put the needle into the nodule so we can see exactly where the needle is going. And we basically suck out a couple of cells, put them on a slide, send them to our pathologists,

who will take a look at it and tell us what they see. And if they say these cells are benign, are not concerning, then we'll probably just tell the patient, let's get another ultrasound in six months. Let's make sure it's not increasing in size or causing any problems. So if it's benign, they'll keep checking maybe a couple of times a year. But what if it's not great news? If they call us back and say there's malignant cells, then we talk about surgery.

Do you numb it up before you put the needle in there? That's a great question. So we do that all the time. Always numb it up, right? And I've had a couple of patients now that complain that the numbing medication actually hurts more than the actual needle does. Because it's a good laticate, it burns. And the needle is such a small, fine needle. It's what we call a 27 gauge needle. It's actually smaller than the needle that we use to draw blood. Oh, is it somewhere in between a blood needle and like an acupuncture situation? Yeah, exactly.

Most patients, honestly, like if I tell them, here's the needle, they'll feel like, eh, it felt like a small little pinch, but it's not even painful. Oh, so don't freak out if you get a nodule. Do not freak out. Yeah, just, and you said, what percentage would you say are benign versus?

95% benign. That's what I thought you said, and then I thought there's no way I could have heard that right. Okay. So most thyroid nodules are not cancerous. But you want to get them checked out in case they are because that is not a good situation if they are.

Absolutely. Okay. When it comes to getting them out, do you just remove the nodule or do you have to take a chunk of thyroid and then... I love these questions. These are the questions I get every day. I figured these are things either you think about when you're in the room or you're taking the subway home and you go, oh, fuck it. I should ask that question. I know, right?

No, that's a fantastic question. Unfortunately, you can't just pluck the nodule out of the thyroid because one is it's embedded in the thyroid tissue and two, if it is a cancer, then you want to do a good operation. You don't want to leave any cancer cells behind. If you're just plucking the nodule out, there's a good chance that you may disrupt a nodule, that you may leave tumor behind, and then you have to go back potentially to another operation, which could be even more difficult because then you have scar tissue and the patient's already had one operation there before. So you can't pluck a thyroid nodule out like a pearl in an oyster. Doesn't work that way.

That's news to me. So the right thing to do is actually remove that portion of the thyroid. It doesn't mean you need your entire thyroid removed. As a matter of fact, I would argue that most thyroid surgeons now, unlike maybe even 10 years ago, try to be more minimalistic as opposed to maximalistic in the sense that we don't try to take out the entire thyroid. If I can preserve as much thyroid tissue as possible, I'll preserve it. So I'll take out half your thyroid if I can, then try to preserve the rest of the thyroid.

So hopefully you'll continue to make enough hormone that you won't even need medication. Oh, I know people probably want to keep the nodule. Are you ever like, sorry, buddy, I've got to send this down to the lab? Yeah, they always want to take it home. I mean, I recently had a hysterectomy and I was like, how much of this can I keep in a jar? And they're like, absolutely none of it. Zero.

I was like, who's mine? 10 minutes ago. Exactly. It all gets, unfortunately, gets sent down to pathology because we need to know whether it's cancer or not or what stage it is. And so it all gets sent to pathology. So no, you cannot take it home. But we can take a picture for you.

That's nice. What percentage of people are like, take a snap, doc. Oh, I would say probably like 30 to 40%. Really? Oh yeah, they want to see what their thyroid looks like. Yeah, I would want to see. It's mine after all. We'll take a picture.

I think that's helpful. It's like when a mechanic is like, look at how bad your brake pads pads are. Exactly. Well that's a good thing you should have done it. What about, let me see, thyroid cancer. What causes the nodules? What causes a malignancy? Does thyroid cancer typically start as a nodule? Yes, so thyroid cancers are thyroid nodules that are malignant. Okay, got it. So it's not, there's not a different kind of like spider webby cancer that starts. No, no. Thyroid cancers are basically thyroid nodules that are malignant nodules of thyroid cancers. It's actually one of the most interesting, and I'm not biased.

I think it's one of the most interesting cancers in human body. And the reason for that, it really spans the entire spectrum from being one of the most Indolent cancers where the prognosis is excellent So if you have what's called papillary thyroid cancer Classic papillary cancer like the woman shopping for the beach house on HGTV You know the overall survival is 95 percent 20 or survival You almost don't get that in any cancer other than the small skin cancers So you have on one end of the spectrum, one of the most treatable cancers in the human body. And then you have something called anoplastic

or undifferentiated thyroid cancers, which probably is the most aggressive thyroid cancer in the human body with basically a mortality of close to 100% within six months to a year. So you really have this disease that spans this entire spectrum. Thankfully, the percentage of patients who have anaplastic cancer is very, very low and most patients have papillary cancer, which is very, very treatable.

Okay. So most people with thyroid cancer have a very treatable papillary type. Now, anaplastic, less dicier, it's pretty dangerous. What happens if a person gets that diagnosis? So when you have a patient who has a malignant thyroid nodule, thyroid cancer, most of these patients will undergo surgery. We have a program here now where we have an active surveillance program for really small thyroid cancers but we won't even operate on the patients. We'll just follow them if they're okay with that. We have a lot of minimally invasive ways of treating it. There are a lot of new

technologies coming down the pipeline, interventional procedures where you can just stick a needle in it and ablate the cancer and do not even take out the thyroid anymore. One of my colleagues here does trans-oral thyroid surgery, so there's no scars in the neck. You could take out the thyroid through the mouth. So we have a lot of like cool, really innovative, you know, new ways of doing things.

But, you know, that requires you to see a thyroid surgeon and go to a place where they have a thyroid program in place. Getting back to your question as to what causes this, so there are only really two known causes for thyroid cancer. One is genetic and familial. So we know that there are certain patients in whom it does run in their family and it's usually three first generation family members. So if you say, my sister has thyroid cancer,

my mother and my aunt all had thyroid cancer and then you have it, it could be familial. And the second one is radiation exposure. So, you know, in the early part of my career, we used to see a lot of patients who were exposed to Chernobyl. We have a huge Ukrainian population in Brooklyn. And so many of these patients, you know, they were,

so yeah, I was, you know, I was somewhere in the Ukraine or in a southern border of Poland or Belarus and they all remember, you know When Chernobyl happened and they weren't told what was going on and they were all exposed to nuclear fallout nuclear radiation And we saw a lot of these patients had thyroid cancer Wow, you know with the earthquake in Japan in I want to say to them yeah, March 2011, my bad. There was a 9.0 undersea earthquake that led to a seaside nuclear reactor disaster. It was rated seven out of seven on the international nuclear event scale, the worst since the Chernobyl disaster in 1986, which also ranked a seven. Living on the West Coast, of course,

there was more concern about radiation coming up in the Pacific. Are thyroid doctors, are oncologists in general keeping an eye on that? Yeah, so thankfully we haven't seen any incidents at all from the Fukushima nuclear reactor meltdown, not even in Japan. There was very little radiation fallout from that.

So thankfully, I don't think we're going to have any issues with that disaster. But if you notice, as soon as that happened, every single pharmacy on the West Coast ran out of iodine. Really? Because people started hoarding the iodine pills because you wanted to pop iodine as soon as you know there's nuclear fallout. If you take iodine, you protect your thyroid gland from getting thyroid cancer. Really?

Is that why iodine pills are used in bunkers and stuff? Yeah. That's fascinating. Can iodine pills also be used to disinfect water? Yeah, you can. Okay, okay. That's so interesting. Why does iodine protect against... It blocks the thyroid cells from absorbing the radiation. You're basically saturating your thyroid cells with iodine. That actually affect it? Yeah, I mean, it seems to help, absolutely. I mean, even when you had a nuclear fallout in Chernobyl, I mean, the people that knew what was going on,

they started taking iodine pills. For no reason at all, I decided to bone up on what to do if World War III breaks out. And I found myself on the CDC site, radiation emergencies, which let me know that a person must take potassium iodide before or shortly after being exposed to radioactive iodine. But before you risk feeling safe, the article mentions that this potassium iodide protects only against radioactive iodide.

It doesn't protect against any other type of radioactive material. And then it breaks it to us gently that, quote, potassium iodide will not help in a nuclear bomb emergency. But I mean, hey, it's worth having these emergency tablets in your bug out bag, which we should all have. I mean, salt would be tastier, but you'd probably need a lot of salt. Can I ask you listener questions? Please, Scott, let's do it.

But before we get to them, we'll donate to a cause chosen by Dr. Patel, who selected the American Association of Endocrine Surgeons and the AAES promotes research and education in the field of endocrine surgery to advance the science and the art of endocrine surgery. So a donation was made to them in Dr. Patel's honor to further research in this area, in your neck area. So thank you to sponsors of the show for enabling us to toss some money to charities. Okay, your questions. If you're a patron at patreon.com slash ologies for just $1 a month, you can submit these

before we record. And we even have a tier to submit audio questions so you could hear your voice on the show, which is pretty sick in a good way. This is not your species. However, several people, Timmy H., Deborah Gray, Scalebar, Daniel Sucher, Devin, Jessica Chance, I mean, a lot of people, Earl of Gramelkin, Vanessa Adams, Bry Kahnz, wanted to know in Devin's words, my vet once told me that cats in the seacoast, this person is from Maine, are more likely to develop hyperthyroidism, overactive thyroid, that

is. Were you aware of this? Do interspecies thyroidologists ever chat? And if cats on the seacoast are more likely to get it, Is that an iodine thing you think? So the first part of your question is, you know, you're probably, they're probably right. We don't chat. We probably should. Yes, right? This is fascinating. I need to talk to my vet. We have a nice little dog. Yeah. So yeah, I, you know, I, I, we don't chat with our veterinary colleagues. Unfortunately. Do I think it's related to iodine? Probably, if I had to guess. Because as long as the cats are prone

to other environmental toxins as humans, we are not. Mm-hmm, Earl of Gramelkin said I had a cat with hyperthyroidism who got the I-131 treatment and we had to keep her poop sequestered for a month. Yeah, that's even for humans too, actually. Well, okay, this was my next question. But not necessarily your poop for one month. Yeah, that's even for humans too actually. Well, okay, this was my next question. But not necessarily your poop for one month. I mean.

For a month. But you have to sequester yourself. Just get that box, go right to Petco. So I checked out the Cornell School of Veterinary Medicine's article, Feline Hyperthyroidism, and 98% of the time it's benign, it's just from an enlargement in a kiddie's thyroid as it ages, and treatment can involve

restricting iodine in the diet, which also includes any outdoor hunting, which is good because that's bad for birds and lizards and such anyway. And other treatments might include surgical removal of the thyroid and yes, radioactive treatment which cures 95% of feline hyperthyroidism with one shot. But yeah, avoid that poop for as long as the vet tells you. Now what about geography and your pet's thyroid? So the Banfield Science and Quality News published an article titled, Feline Hyperthyroidism, Common in Northwest and East Coast.

And it detailed that yeah, the Pacific Northwest and the Eastern seaboard of the US have more kitty hyperthyroidism, but they don't know why. Could be that the cats there live longer than in southern states, maybe because of the weather, they might be kept indoors more. It could be dietary sources of too much iodine. Could be endocrine disruptors in canned foods

or scented kitty litter or flame retardants, and only 177 out of 10,000 cats will have the problem though. And it's a relatively easy fix, so don't start sobbing. But you can hug your cat right now if it lets you. So hyperthyroidism. Let's leave your kitty alone. Let's talk about the rest of your bod. Ari Losensky, Sarah Manns, Dave Cannon, Hannah Bale, Stephanie Lingard, Rachel May, Sam Aker,

all asked in Rebecca Fitchett's words, please talk about Graves' disease with an exclamation point. Let's talk Graves' disease. We can talk Graves'. What's going on with it? What do you do? Where does radioactivity come into it? Absolutely. So Graves' disease is kind of the opposite of Hashimoto's. It's also named after Dr. Graves, who did the first one describe Graves' disease. And it turns out that in Graves' disease, what's happening

is actually your body is creating these what they call thyroid stimulating immunoglobulins, which is similar to the antibodies that your body makes. But these particular immunoglobulins end up stimulating your thyroid as opposed to destroying your thyroid. So in Hashimoto's, your body's making antibodies that destroy the thyroid.

In Grave's disease, your body's making immunoglobulins that actually stimulate your thyroid. So Grave's disease is one of the most common causes of hyperthyroidism. And these are patients who present in the exact opposite fashion. They say that they're losing weight. They always feel hot They have tremors anxiety. They feel like their hearts racing

Their eyes sometimes get a little bulgy and that's all consistent with Graves disease And in those patients your TSH level is going to be undetectable It's gonna be super low remember that TSH is the inverse of how much thyroid Remember that TSH is the inverse of how much thyroid function you actually have. If you're one step ahead, a low low TSH means what? And your T3 and T4 levels are going to be high. And so that's the way you make the diagnosis of Graves' disease. The treatment for that, since your thyroid is hyperactive, is you take anti-thyroid medication. So you're actually taking drugs such as Methimazole and PTU that actually block

the thyroid from making thyroid hormone. And that medication works great. And so for a lot of patients, that's all they'll need. Sometimes if their heart is really racing fast, they may put the patient on a beta blocker to help reduce the heart rate. But for most patients, that works really well. The problem with some of these drugs, especially in younger women,

is that they're not necessarily safe during pregnancy. So if you have a young female patient who is deciding to start a family, wants to get pregnant or is planning on getting pregnant, they really can't be on those medications. So people, if you got a uterus and you are planning to use it to cook a baby, you've got to figure out something that's not those medications that will block the thyroid from making too much T4. So what do you do? You're asking me, a podcast host?

I don't know. So the other two options for definitive treatment for Graves' disease are radioactive iodine where you give the iodine, it's radioactive, the thyroid gland absorbs the iodine and since it's radioactive, it kills the thyroid. So ultimately your thyroid's dead and you've treated the Graves and you're probably going to end up on thyroid medication for the rest of your life like levothyroxine because your thyroid doesn't work anymore. And the other option is surgery, take out the thyroid. So same exact result, you're taking out the

thyroid, your thyroid's no longer there, you no longer have graves and now you're on thyroid medication for the rest of your life. But levothyroxine is such a safe drug that most patients would rather be on levothyroxine than be on the thimazole or the other drugs that we treat for Graves. Dr. Patel gives some advice if your doctor opts for surgery. If you want to go somewhere for surgery, you want to go to a high volume center that does a lot of thyroid surgery with good results because also the same population of patients who want to get pregnant also don't want radiation.

Right. Because you took the redactive iodine, you can't get pregnant for six months to a year. Yeah, I myself, if I had the chance to go night night and wake up with no thyroid versus sequestering myself with radioactivity, I would probably go night night and get a popsicle later. Why would someone choose the radioactivity? It's really a fear for surgery sometimes.

They don't want surgery. It could be a cosmetic thing. They may not want a scar. Surgery does have its risks, right? There is risks of injury to the nerves that control your voice. There's injury, potential injury to little glands called parathyroid glands that live next to the thyroid that can affect your calcium level. So there are risks associated with surgery, but there are also risks with the radioactive

iodine, right? It's radioactive. It can have fertility issues, it can cause other secondary malignancies or cancers 10, 15 years down the line. So it's really, it's a little bit of a, where the patient's comfort level falls. I would say the trend that we've seen here at least is more and more patients are opting towards surgery

and less towards the radioactive iodine. But I think nationally still, radioactive iodine is still pretty common. OK. What if you take the radioactive iodine? Do you have to stay in any kind of lead bunker? No. The amount of iodine you're getting is minimal.

So to treat Graves' disease, it's not much radioactive iodine. But with thyroid cancer, you're bringing out the big guns. Those patients do have to be in quarantine for about a week. So for about a week, they can't go out in public, they can't be around pregnant women, they can't be around children. Everything you kind of use, your utensils, probably disposable is better. You want to sequester it in a certain space.

You don't want to throw it on the regular garbage. So there's a whole protocol that we utilize for patients. We tell them how to kind of manage all the disposables and you want to stay in a place that's kind of away from other people. What about bedding and stuff like that? Yeah, I tell people don't throw your beds away, don't throw your couches away. People used to do that, they throw everything away, but you don't throw it away. There's a half-life to radiation, right? Just like there's a half-life to radiation. So yeah, once it's out of you, it's going to go out of your bed also. So yeah, maybe you may not want to use that bed for a few weeks, but then after that, it's fine.

Okay. Oh, good to know. I was, that's the idea that you're potentially turning into Spider-Man is exciting now. You know, it's what kind of superpowers you get. If you are inspired to be the radioactive center of the Marvel universe, what do your labs have to look like? So many of you, Daniel Johnston, Karen Kala-Brantley, Matea Orr, Little C. Syde, Sarah Jo, Cassie LeBond, Caitlin Fitzgerald, Annie Dulas, Elliot, Brooklyn Barron, and Vanessa Adams all asked, what's up with the labs that are in the normal range, but you still feel awful,

whether it's hypo or hyper? So did Elliot Feeling, first time question asker, hyperthyroidism and Graves disease have her here. Wondering what exactly are those normal ranges and what's the difference between T4, T3, or rather in the free versions of them? Yeah, so the free versions, because the way the laboratory studies are designed,

often these molecules bind with other proteins. So the free version is just in theory is supposed to be more accurate. The blood test that's actually the most important for us is still the TSH level because that's what the body is sensing, right, as your thyroid levels. That's what the brain, your pituitary gland is making TSH based on what it's sensing, you know, the need is. Because your T3 and T4 levels can vary even during times of stress or during times of the day. So, you know, it's not as consistent as your TSH level is going to be.

So TSH is probably the best test for thyroid function. The range is a variable range, right? You can go anywhere from one to four and it states what lab you use could be a normal range. But the way I like to talk to my patients about this is that these are kind of population-based ranges, but for each individual person, you know, just because you're in the normal range and your TSH may be three, it's in a normal range, but you may still not feel well at a normal three.

Because for you, maybe one is the normal, right? And so I think, you know, we have to treat each patient individually. So ranges are wonderful to have just to get an idea of whether somebody's falling and where they should be falling. But I don't go crazy overlooking at the exact number per se. If I have a patient who has a TSH of four, but they feel fantastic, I probably won't give them thyroid medication. They feel great. What am I treating? Yeah. You know, why is Patrick Duffy wanted to know? Why is the normal range so large? Is Patrick Duffy the actor or is it?

I don't know, I have to ask. That would be amazing. I'll Instagram him. Sure. You submit that? He's an actor from the 1980s soap opera, Dallas, which was its Yellowstone of the era. But anyway, why is that normal range so large?

Oh, because it's a population, right? So for, you know, looking at millions of people, you have a larger range. So if you have a TSH that's around three or four, which is a little bit on the higher side, you may still be slightly hypothyroid, but your blood work would be in the normal range. Do people then say, okay, my TSH is normal, let's check the T3 and T4? Yeah, you can do that. In all likelihood, if your TSH is normal, let's check the T3 and T4. Yeah, you can do that. And all likely, if your TSH is normal, your T3 and T4 are probably gonna be normal.

And if you're still not feeling well, I think it's time to do other workup just to make sure there are not other issues and make sure you're not anemic, make sure there are not other things that are going on. And don't blame the thyroid. Don't blame the thyroid for everything. I should make T-shirts, don't blame the thyroid.

You should. It's like, get off my back, get off my thyroid. I would love to know what about the metabolism? Is it the temperature gauge that is speeding it up? Is your body converting more energy to heat? Is that what's really contributing to the fluctuations? It's your ability to convert your food into energy, right? So your cells at the cellular level, there's a whole oxidative process that occurs down at the mitochondria and at the cellular level.

And it's that process of how much energy you are producing is regulated by the thyroid hormone. It's not even like your temperature level. Yeah, it's all regulated, but that's like the end product of what's going on at the cellular level. You're seeing an increase in energy expenditure across the board. So like I said, your heart rate would go up, your digestive system, your nervous system, everything is affected by that. All of that encompasses what we call metabolism. Okay, so we have a whole episode on metabolism, the evolutionary anthropology episode with

Dr. Herman Ponser. But some of y'all wanted to know if what you're eating, like cutting out inflammatory foods, can help your thyroid get its shit together. And I'm looking at you. First time question askers, Michaela Ballard and Marianne Mazinski. Kelly Paul, Felicia Chandler, a bunch of people wanted to know, can diet help manage thyroid issues? Amy wants to know, Amy Johnson, any support for the autoimmune protocol diet helping reduce

inflammation levels with hypothyroidism? Any suggestions on foods you should avoid or you should eat? Since a lot of thyroid disease is autoimmune based, anything that you can do to decrease that kind of stress and your immune response can be potentially beneficial. So there are a lot of diets out there that are designed to decrease inflammation. I would definitely talk to a nutritionist or somebody who's more of diets out there that are designed to decrease inflammation. I would definitely talk to a nutritionist or somebody who's more of an expert in that area, but my recommendation to my patients is yes,

try to find a diet that does work for you. I know there are a lot of things that if I decrease gluten and I get rid of this and I eat more of that, try it. I mean, if it works, that's fantastic. And I have had patients who had Hashimoto's thyroiditis and they changed their lifestyle to be sleeping better, eating better, exercising, and you do see their antibodies go down. So whatever trigger there was that was causing it, you can try to undo some of that with your lifestyle. Is it curative? Hard to say.

Would alcohol and sugar also be included in that? Yeah. I mean, I think sometimes not just the alcohol and sugar. I mean, sometimes, you know, you may be drinking and eating a lot of sugar because you're stressed. And so is it what comes first, right? And is it the chicken or the egg kind of thing? Right. And so if you decrease your stress levels, maybe that may, you know, help your immune

system. That was my next question. Also on the minds of Maya Lecker, who's a Graves disease have her, Danielle Baueris, Angie Dulas, and Annie Sayers, who asked, can stress make an underactive thyroid worse? Jen Oh wanted to know, so many symptoms associated with hypo or hyperthyroidism seem like they could also be caused by stress or other common mental or physical issues. When should a person start to suspect thyroid issues specifically and prompt a discussion with their physician,

especially without being looked at as a hypochondriac who spends too much time online listening to that. They ask. Amazing question. But yeah, how much is stress and common like mental or physical issues? How much does that have like an effect down the line? I think it does.

I mean, we're just learning more about this over the last 10, 20 years. I think we're realizing how much our mental status plays a role in our immune system, right? People that are depressed and don't feel well tend to get sick. Your immune system gets weaker. And so there's definitely a lot of interplay

between the two systems. You know, to answer her question, I think the easiest thing to do is just get your thyroid function tests, right? Get a blood test, see what your thyroid levels are. If your thyroid, if all your thyroid levels are normal, then it's probably not your thyroid gland, at which point I would investigate further into,

you know, what your mental health is and what else is going on, stressors, et cetera, to see if that can help. Kelly Shaver had a funny question. They said, I'm fat and every doctor I have keeps insisting on doing thyroid blood tests, even though they're always fine. Why are they so obsessed with my thyroid?

Yeah, I'm not sure why, but you know, majority of our obesity issue in this country is not thyroid related, right? There are so many other factors, once again, that go into that as well. And so I think once you've ruled out the thyroid gland, you can kind of put that aside and it's probably not the thyroid and then focus on what other issues may be going on metabolically. Because yes, thyroid hormone is an integral component of your metabolism and when it's not functioning properly, it can affect your metabolism.

But once again, metabolism is also based on other things as well. Right. So it's keep looking if you suspect that there's something else going on. There are other tests to move on to, right? Absolutely. Okay. I thought this was a great question, Tiger Udi and Greg Wallach. Greg asked, can you have queen Anne eyebrows

and your thyroid be fine? And Tiger Udy wants to know, do thin eyebrows really lean toward poor thyroid function? The last half of the eyebrow sort of pieces out early from what I understand. And I have a friend whose mom was like, never pluck your eyebrows, never. Mine never grew back in the last portion. And then it turned out she has had thyroid disease.

I'm looking at my eyebrows now. I know. I'm checking my tails. I'm checking my tails. Yes. I mean, hair loss in general is associated with thyroid disease, right? Dry skin, hair loss. And so the combination of the two may affect your eyebrows. I understand that there is a lot of blame for 90s eyebrows when really get your thyroid checked. Yeah, exactly. So I'll have to do a little bit of an aside on that.

Okay, this symptom is called eyebrow hypotrichosis. And a 2023 paper titled, Eyebrow Loss and the Queen and Sign in Hypothyroidism said that loss of the outer third of the eyebrows is called the queen and sign in hypothyroidism said that loss of the outer third of the eyebrows is called the queen and sign and it's an uncommon manifestation of hypothyroidism. However, the exact mechanism of eyebrow loss only at the outer third portion, it's unknown. They don't know why it happens and clinicians should consider hypothyroidism as a diagnosis for patients presenting with that loss of the outer third of the eyebrows, despite the fact that it doesn't happen very frequently.

And I was like, who's Queen Anne? So this is named after Anne of Denmark, who was a 16th century hottie, who was a patron of the arts and noted to be a woman of boundless intrigue, although others called her frivolous and self-indulgent. And those people are haters. But according to her official portraits, her eyebrow tails were like, see ya. And the reason for that is lost in the sands of time.

Maybe she was hypothyroid, maybe not. So it's possible if you didn't overpluck the outer tails of your eyebrows, but they are MIA. And you're also feeling cold constipated and dry all over you might want to get that thyroid checked now if you over plucked and you know it let me direct You to the 2023 live science article Why don't over plucked eyebrows fully grow back which essentially says that you abused the follicles so much They don't want to come back to your eyebrow party

the follicles so much they don't want to come back to your eyebrow party. Like you know how sometimes old guys who wear tube socks for decades have bald shins? It's like that. But now you have like permanent Kate Moss eyebrows. Now there are worse things, but yeah we have a whole episode on the drama of hair called trichology. Now brows be damned, let's talk about other hormones in the tomato soup of your body. Carol Young asked, is there a difference in thyroid functions between males assigned at birth and females assigned at birth? Midnight Cat and Breconz also asked about female hormone systems and thyroids.

And what about J. Ramsbald wanted to know, are there any thyroid implications for people assigned female at birth who are taking testosterone for gender affirming care? Does hormone replacement therapy have any role in thyroid issues? Yeah, I think in general, whenever you're doing any kind of hormone therapy or any hormonal changes in your body, your thyroid needs to be followed. And the prime example of that is obviously during pregnancy, right? So many women during pregnancy end up on thyroid medication. Really?

Yeah, you get pregnancy induced Hashimoto's, not really Hashimoto's, but pregnancy induced hypothyroidism. And even before pregnancy, hypothyroidism or low levels of T3 can disrupt ovulation and egg release and hinder the ability to conceive. Or if underlying causes like a pituitary issue or autoimmune disease is causing the hypothyroidism, it might also be thrown a wrench and getting a baby in there.

Respectfully speaking to those who asked, Renee Wenger, Maddie Denison, Sarah, Cassie Kenton, Danielle Sucher, and Amber McIntyre, why during pregnancy your thyroid can also cause a bit of a hullabaloo? So one of the few things that every obstetrician is going to check during pregnancy is going to be gestational diabetes and your thyroid levels. Cause those hormonal changes can affect your thyroid function.

And so if you're, if you're undergoing any kind of hormonal therapy, I think it's smart just to get a baseline thyroid function test and then while you're undergoing that therapy, just check the thyroid and make sure it's not being affected. As someone who is on all kinds of hormones, who hasn't checked their thyroid in a while, can it go with the wind? Are you typically on a trajectory where if you have a thyroid issue it's never going

to resolve on its own? No, I would say so many of you have, for example, patients that show with Graves' disease often they'll come see me and they've had it for like two or three months and I'll tell them wait six months to a year because it may resolve on its own. It may go away. Your body may whatever triggered it that you know may Untrigger at some point. So if your body calms down somehow and stops overprovoking your poor Exhausted overworked thyroid things can chill and return to normal pretty suddenly, which is a big yay. And for those on the other end of the seesaw whose TSH is too high and the thyroid function is hypo or low.

In general though, if you have somebody who's headed towards Hashimoto's where you know they already have the antibodies and your TSH is slowly going up, in all likelihood they'll probably end up on thyroid medication at some point. But you know, once again, you know, your thyroid function varies depending on what else is, what other stressors are on you going on in your life. What about ways to prevent thyroid nodules? And I'm asking literally for a friend who has them, Erin, I've got your back. She's like, I got another one they got to go check out. Anything that she can do in her power?

Thyroid nodules are really under, unfortunately there's nothing you can do. There's nothing you do to cause thyroid nodules. Like under, unfortunately there's nothing you can do. There's nothing you do to cause thyroid nodules. Like I said, they can be genetic at times, they do run in families, and sometimes your thyroid gland is just prone to developing nodules. Some people get ovarian cysts, some people get, there are many parts of your body that just tends to develop nodules and cysts. But yeah, I mean, my only advice would be just to do, you know, annual testing, annual screening, just to make sure that none of these nodules are getting larger or none of them are starting to look suspicious. Can you, when you palpate a thyroid, can you really feel if there's a nodule in there?

If it's large enough, absolutely. Anything, anything over, you know, one to two centimeters, you should be able to feel. And it depends on a patient's neck, their body size, if they have a larger neck and maybe a little bit harder to feel. But for the most part, if they have a large enough nodule, you should be able to feel it. The thyroid gland is so anterior, it sits so out in the front of your neck, it bit harder to feel. But for the most part, if they have a large enough nodule, you should be able to feel it. The thyroid gland is so anterior, it sits so out in the front of your neck, it's easy to feel.

So BFF and recent birthday girl Erin and patrons Emma Wren, Lydia Tromm and Addie Capello who says, mine is just chilling, but I know they can become a problem for others. Keep an eye on them. Do people ever come in with just lymph nodes that are? 100%. And they're like, I have cancer. And you're like, that's a lymph node. You're good.

Totally. But you have to make sure it's a benign node, not a cancerous node. So we do see patients who will present the lymph node lower in the neck and it's big. And those patients do worry me and scare me because that's probably a cancer that spread. And so we'll probably stick a needle in it and see what's going on. You mentioned earlier thyroid cancer that could have spread. Are those like endometriosis? Is it like bits of thyroid tissue that are around that respond to radioactive iodine

or? So, the reason why the prognosis for papillary thyroid cancer is so great and the patients do so well is because once we take out their cancer, we can actually treat them with the iodine. So, even if the cancer is spread to the lungs, to the bones, you give them the radioactive iodine, the iodine will get into those cells and kill them. And so that's why the prognosis for thyroid cancer remains.

Excellent, that's what I tell my patients. I'm like, yeah, you know, even if you do have cancer that spread, we can still treat you and you should still do very well. As opposed to like radiation gamma knife or something that can just zap one area, this can actually systemically go and find it. This is systemic. This is better than any chemotherapy out there.

This specifically targets thyroid cancer cells and kills them. Nice. It's like their kryptonite. I know. What about libido and thyroids? That's a good question. I mean, they're not, so your sex hormones are not directly related

to the thyroid gland, but if you are hypothyroid, you will probably have a decreased libido. And like I said, it may not be a direct relationship, but if you're fatigued, you have no energy, you don't feel well, you're tired. Do people with Graves' disease get hornier? That's a great, I knew you were going to ask me that question next.

I didn't mean to. I was curious. Not that I know of. They may also be really tired and exhausted. Right, exactly. Yeah. What kind of heart rate do you have if you've got Graves' disease? It could be pretty high.

Yeah, people who have really bad hyperthyroidism, they can have a pretty high, but that's what these patients often go on beta blockers. Heart rate go up to 120, 130, I've seen 150. Do you find that now that people have fitness trackers and I've got an aura ring that checks my heart rate, Apple watches, do you think people come in with more data being like, what the hell's up with this? Absolutely, 100%. I've had patients who can track their blood, they show me their numbers, like, oh, it was 110, that's 120.

Sometimes, you know, I don't know how accurate the data are. But it's nice. It's actually a good tool, right? Because the more information we have, the more we can act upon. You know, we can see trends. Is it happening more often at a certain time of the day? What else is going on that time of the day? So, you know, it's good.

I think those devices are actually very helpful. Right. Well, okay. One more question. Mercedes Tarasovic, Hannah Katsurano-Hudson, what's the connection between hypothyroidism and chronic eudicaria, which are hives, right? What's up with hives and thyroids? I think it's all related to your immune system, once again.

It's autoimmune, right? So if you have hypothyroidism from autoimmune thyroiditis, which is Hashimoto's, once again, it's autoimmune, right? So if you have hypothyroidism from autoimmune thyroiditis, which is Hashimoto's, once again, these are all kind of other side effects of the autoimmune process that's going on. So the dry skin, the hair falling out, the hives, these are all autoimmune problems, right? This isn't a generalized immune thing.

That's what you get. It's not like hives in one area. It's not like a contact dermatitis where you were allergic to something, you touched it and you broke out in hives. This is like systemic. And so that's almost always autoimmune. Good to know. Hardest part about your job?

Hardest part about my job. What sucks the most? It can be anything. It can be petty. It can be huge. I actually love my job. I know, I'll ask that next. I'm gonna ask that next.

Actually, it's one of the beautiful things about coming to work is actually enjoy it. It's kind of sad and scary, I'll ask that next. I'm gonna ask that next. Actually, it's one of the beautiful things about coming to work is actually enjoy it. It's kind of sad and scary, I guess. But no. You're like, I have nothing outside. No, no, no, no. I'm kidding, I'm kidding. The hardest part of my job, and honestly,

and this is gonna be a little bit more of a, I love my patients, I love what I do from a physician standpoint. The hardest part of this, I think most doctors will agree with this, is dealing with all the administrative stuff. Right, I mean, getting insurance authorizations and I mean, stuff that where you just feel like

this is not valuable time spent. I'd rather see more patients and do what I do than worry about administrative stuff, which is unfortunately necessary and we need to do it, unless we don't get paid. So we need to do it. It's fine. It's part of the job too. It's part of the job too. We need to do it,

unless we don't get paid. But just paperwork. Rather be palpating thyroids than filing paperwork. Absolutely. Yeah. Rather than be in the operating room taking care of patients, yeah. One insurance scholar, Jay Feynman, wrote in a recent op-ed piece that in the murkiness of healthcare insurance, when consumers need coverage, they discover that there are significant protection gaps. And for an expose on how, Feynman writes, the denial of valid insurance claims is not occasional or accidental or the fault of a few bad employees.

It's the result of an increasing and systematic focus on maximizing profits by major companies. You can see his 2010 book, Delay, Deny, Defend, Why Insurance Companies Don't Pay Claims and What You Can Do About It. Best thing about your job, what do you love? I know you love your job, which is why I'm talking to you and not some other. You love what you do. I love NYU. I got to you do. I love NYU. I got to say that before I get fired. No, I'm sorry.

So we have your communication team. NYU is awesome. I love it. What I love about my job, honestly, are my patients. I love my patients. And I think most of us will probably give the same answer. I love talking to my patients. I love getting to know them.

I love taking care of them. There's nothing more fulfilling, you know, like going home and knowing that you did something and, you know, you made somebody's life even 5% nothing more fulfilling, you know, like going home and knowing that you did something and you know, you made somebody's life even 5% better, hopefully, you know, it's a great feeling. Do you ever see someone come back after medication and they look and feel so much better? Absolutely. Yeah. Even from a surgical standpoint, right? I mean, I did whatever nine thyroid cancer operations is last week and being able to tell somebody,

you know, we took your cancer out and you're gonna be fine. It's such a great feeling, right? And to see the patient and their family members and they're all like, you know, just happy. What about any myths that you would wanna bust about thyroids, any soap boxes you wanna get on? Woo! I mean, one thing I could say,

don't blame the thyroid for everything. You know, that's number one. You know, thyroid disease is very treatable. I think, you know, the one thing I think patients need to understand is that if you do have a thyroid problem, you should go see an expert, see somebody who really specializes in this. When should someone get a second opinion? Anytime they're not happy with the first opinion, definitely. Okay.

No, I think, I'm a huge proponent of second opinions. I would recommend you get one from somebody who's, you know, an expert in the field and who specializes in this. And I like to think that we have a fantastic program here. So, you know, I think we, we offer the best care. But having said that, you know, I have no problems with getting a second opinion. If the patient feels like they just want to hear from other people, it's a more peace of mind and comfort. I think majority of the time, it's not that they don't trust you. I think most patients

trust you a hundred percent. They just want to hear from somebody else as well. Yeah. So smart. Thank you so much for making me better friends with my own thyroid. My pleasure. This is great. I appreciate everything it's doing for me at the moment. Great. You can keep it. I'm going to keep it. Thank you, doctor. So ask surgical people on serious questions, because sometimes those are the ones that most need the answers.

And to find out more about Dr. Keppel-Pattel, see the links in the show notes, as well as one to the charity of his choice, the American Association of Endocrine Surgeons, or AAES. Thank you so much, NYU, for loaning him to us for that hour. What a time we had. I loved it. Say hi to us on social media. I'm at Ologies on Blue Sky.

Still at Ologies on Instagram and at Alli Ward on there too. We have shorter, kid-friendly episodes called Smology's in their own feed now. Just search S-M-O-L-O-G-I-E-S. Wherever you get podcasts, look for the new green artwork and hit subscribe. You can join Patreon at patreon.com slash ologies. You can find hats, totes, tees,

and more at ologiesmerch.com too. Thank you so much to recentbirthdaygirl and human gem, Erin Talbert, who admins the Ologies podcast Facebook group. I love you, Erin. I hate your thyroid. I'm sorry about it. Tell it to be nice. Aveline Malik makes our professional transcripts.

Callie R. Dwyer does the website. Noel Dilworth steers our calendar as scheduling producer. Susan Hale is the pituitary gland of a managing director. Jake Chafee is our T4 of an assistant editor. And the T3 that gets the episode out of the garage is Mercedes Maitland of Maitland Audio. Nick Thorburn has the aux and made the theme music. If you stick around till the end of the episode, I tell you a secret. And this week, it's that social media doom scrolling has become a problem because I'm not learning vital info about current

events. I'm just like piecing together fragments of what's happening in the world based on other people's reactions to them and then the reactions to the reactions in the comments. And I spent all day Saturday on my phone, on the couch, mindlessly locked in like a tractor beam of other people's front-facing camera hot takes, not learning much. And so yesterday and today, I told myself, I said, if I looked at social media,

I would have to donate $1,000 to a political action committee that goes against everything I stand for and harms women, trans people, immigrants, people of color, and our environment. If I scrolled social media, I would have to do that. Not wanting to give them $1,000 was a surefire way to keep me off of it. And I had a great day off social media, consuming more comprehensive news from reliable sources. So if you feel out of sorts and constantly scared, make a bet with yourself that you cannot afford to lose.

Make the stakes so high that there's no way you will do the thing that you don't wanna do. Cut bangs, text your crush, we're all gonna die. So chin up, keep going, bye bye. Hacodermatology, homology, cryptozoology, Text your crush. We're all gonna die. So chin up keep going. Bye bye Your thyroid