Thyroidology (THYROID GLAND) with Kepal Patel

Sad? Cold? Hot? Wired? Blame the thyroid. Maybe. In your throat there is a butterfly-shaped gland under a shield-shaped Adam’s Apple and it controls your whole life, kind of. We asked Thyroidologist and surgeon Dr. Kepal Petal of NYU's Langone Hospital about libido factors, radioactive cats, stress and thyroids, how diet can affect them, deciphering labs, flim-flam and how being on TV might save your life. He’s a delight and your thyroid honestly DESERVES the attention. Pass it on to everyone who has ever talked to you about a thyroid.

Speaker names marked ? are inferred from speaking time and the show’s known hosts — they are not voice-verified.

• 0:00Alie Ward?

  How's your ponytail looking? Maybe like a little thinner than it used to? We've talked about this in our menopause episode. At some point, it's bound to happen to all of us. So if you're ready for thicker, fuller hair, start your free online visit today at forhers.com/ologies for personalized care. So that's F O R H E R S dot com slash ologies. Individual results may vary. Featured products include compounded drug products, which the FDA does not approve or verify for safety, effectiveness, or quality. Prescription required. Price varies based on product and subscription plan. See website for full details, restrictions, and important safety information. Being safer on the road starts with the person behind the wheel. That's Mazda's philosophy when designing every vehicle.

• 0:42Alie Ward?

  Their proactive safety features help keep you more aware, connected, and engaged during every drive, which means your car does more than help protect you. It makes you a safer driver, which helps protect everyone. That's why Mazda has been named Consumer Reports' safest new car brand. To learn more, visit mazdausa.com. Consumer Reports does not endorse products or services. This podcast is brought to you by Aura. Your body has a lot going on. Sleep, stress, recovery. You would be surprised how connected it all is. Aura Ring tracks more than 50 metrics from your finger, and the Aura app brings that information together to help you see patterns across your sleep, and stress, activity, and more.

• 1:26Alie Ward?

  So you can start connecting the dots and figure out what works for you. Learn more at auraring.com. Wear your best life with Aura. Oh, hey, it's the guy at the library with that stack of survival books, Ali 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

• 2:10Alie Ward?

  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/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.

• 2:52Alie Ward?

  And if you need a kid-friendly version of the show, just a reminder that we launched Smologies recently. It's a spinoff 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 thyrodi, it means shield-shaped. And that refers to the Adam's apple of the throat, which is thyroid cartilage and then

• 3:37Alie Ward?

  the endocrine 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,

• 4:22Alie Ward?

  Dr. Campbell Patel.

• 4:41Speaker 01

  Kepal Patel and he/him.

• 4:42Alie Ward?

  And I'll have you just kind of hold like an ice cream cone, like if you were stand up or doing karaoke.

• 4:46Speaker 01

  We can do some songs afterwards.

• 4:47Alie Ward?

  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. Do you, is, does my thyroid messed up? Must be something that you get constantly.

• 5:04Speaker 01

  Absolutely. I think, I think the poor thyroid gland gets blamed for a lot of things in life. And it's not necessarily this poor little gland's fault. And the thyroid gland is, it's 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 know, 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.

• 5:47Speaker 01

  So anytime somebody feels off, for whatever reason it may be, it's always, is it my thyroid gland?

• 5:54Alie Ward?

  Yeah.

• 5:54Speaker 01

  But the beautiful thing about the thyroid gland is it's, 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 test 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.

• 6:21Alie Ward?

  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?

• 6:36Speaker 01

  By the thyroid hormone, you're asking?

• 6:37Alie Ward?

  Yeah.

• 6:37Speaker 01

  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 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.

• 7:06Alie Ward?

  How often are people depressed, but they think it's their thyroid, or vice versa?

• 7:11Speaker 01

  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, you know, one of the causes for fatigue, or depression, or not feeling energetic. And so that automatically is the first thing people will think about. Often, it's not just the thyroid gland. When you do have loss of function of the thyroid, hypothyroidism.

• 7:30Alie Ward?

  Hypo means under, whereas hyper means above.

• 7:34Speaker 01

  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.

• 7:57Alie Ward?

  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?

• 8:41Speaker 01

  The most common cause for hypothyroidism in this country is Hashimoto's. But you can have low thyroid function or 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.

• 9:03Alie Ward?

  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.

• 9:48Alie Ward?

  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, thyroxine? Tell me, what is it making and what is that effect?

• 10:10Speaker 01

  Yeah, so your 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 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's working too well. So when your TSH is, you know, depending on what the TSH levels are, it'll affect your thyroid gland and your thyroid gland will make thyroid hormone. Now thyroid hormone comes in two forms.

• 10:54Speaker 01

  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.

• 11:19Alie Ward?

  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.

• 11:56Speaker 01

  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 going to skyrocket. You're going to be bouncing off the walls. So your body actually is smart in that sense. It says, you know, we're going to 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.

• 12:15Alie Ward?

  Where's the T4 hanging out when it's on call to be T3?

• 12:19Speaker 01

  In your thyroid gland.

• 12:20Alie Ward?

  Oh, it's hanging out.

• 12:21Speaker 01

  Your thyroid's making it, and it makes it as it needs it, kind of, and it secretes it.

• 12:25Alie Ward?

  Okay.

• 12:25Speaker 01

  And then your body converts it to T3 as needed.

• 12:27Alie Ward?

  Do you know why they're called T3 and T4?

• 12:31Speaker 01

  It's the iodine. It's the amount of iodine particles. So T4 has four iodine particles, and T3 has three. So when T4 gets deiodenized, it becomes T3.

• 12:40Alie Ward?

  So what happens when you've got T3 in the body? Does it affect your adrenal systems? Does it affect cortisol? What else does it pinpoint?

• 12:50Speaker 01

  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, you know, like I said, it's temperature regulation, digestion, your energy levels, you know, your ability to think clearly, not be tired, your heart rate. You know, that's all affected by your thyroid hormone.

• 13:20Alie Ward?

  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 you, 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?

• 13:50Speaker 01

  Yeah, that's a tough one. I mean, so, you know, so first thing, like getting back to your question, the first thing you do, you're going to take a full history, right? You want to make sure if somebody's complaining that their thyroid may be sluggish, you want to ask all those pertinent questions. Are you tired? You know, 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, you're 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.

• 14:23Alie Ward?

  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.

• 15:05Alie Ward?

  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.

• 15:40Speaker 01

  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, other causes as to you know, why this happening. And at the end of that, if even if everything else still comes back normal, you know, there are some individuals out there, including some of our experts in NYU, will, 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.

• 16:19Alie Ward?

  Do people ever try to score thyroid hormone as like a, like an Ozempic?

• 16:24Speaker 01

  Weight loss. I said it before, you said it, absolutely.

• 16:28Alie Ward?

  Really?

• 16:29Speaker 01

  Oh yeah. The first question I always, I usually get when I talk about, I mean, I do, I do a lot of thyroid surgery, right? And so most of my patients will end up on thyroid medication. And it's, it's a question I get almost every day is, oh, that's great. If I take two pills, but I lose weight? I'm like, no, it doesn't work that way. Unfortunately. It's not a weight gain or weight loss pill.

• 16:45Alie Ward?

  What would happen if you overdosed yourself?

• 16:47Speaker 01

  Oh no, you would feel kind of miserable, actually.

• 16:49Alie Ward?

  Really?

• 16:50Speaker 01

  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 wouldn't, you would not feel well.

• 16:57Alie Ward?

  Yeah. So word of the wise, don't do it.

• 17:00Speaker 01

  Don't overdose on, leave with the roxine.

• 17:02Alie Ward?

  Yeah. Just like get extra coffee. Does everyone's thyroid kind of poop out as we age?

• 17:08Speaker 01

  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, you know, 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

• 17:52Speaker 01

  weak and a little bit of thyroid hormone makes them feel better.

• 17:54Alie Ward?

  When it comes to women and assigned female birth, what is the connection between autoimmune?

• 18:02Alie Ward?

  Hashimoto's and ovaries. What's going on?

• 18:07Speaker 01

  So auto, so yes, 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. Your thyroid actually starts to die.

• 18:51Speaker 01

  So many of these patients with Hashimoto's have shriveled thyroid glands, almost at a point with thyroid gland almost disappears sometimes. It becomes scar tissue.

• 18:57Alie Ward?

  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?

• 19:06Speaker 01

  Yeah.

• 19:08Speaker 01

  I'm like, oh, my God.

• 19:08Alie Ward?

  I'll never be forgotten in my field? Or would you be like, bummer that my name becomes synonymous?

• 19:14Speaker 01

  With something nobody wants.

• 19:17Speaker 01

  Yeah, I don't know. Probably the latter.

• 19:20Alie Ward?

  Call a little column A, column B.

• 19:21Speaker 01

  Exactly.

• 19:23Alie Ward?

  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.

• 19:33Speaker 01

  Oh, yeah.

• 19:34Alie Ward?

  Do you remember that story?

• 19:35Speaker 01

  Absolutely.

• 19:35Alie Ward?

  Someone was on TV and someone's like, you probably want to get your thyroid. And they had a thyroid issue.

• 19:40Speaker 01

  So that was actually a surgeon at NYU.

• 19:42Alie Ward?

  Stop it.

• 19:42Speaker 01

  Yeah, yeah, yeah, yeah. So it was a surgeon at NYU, Dr. Eric Voight, one of the ENT surgeons here, actually noticed somebody on TV. It was a HGTV thing, I think.

• 19:51Speaker 02

  A small but noticeable lump on her throat. Dr. Eric Voight was watching the show at his home in New York. He's an ear, nose and throat surgeon.

• 19:59Speaker 03

  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.

• 20:08Speaker 01

  I think it was this HGTV personality person. And then he called into like the TV show or says, you know, by the way, I think one of your. One of your presenters has a goiter, you know, or thyroid mass.

• 20:21Alie Ward?

  And then she got treated, right?

• 20:23Speaker 01

  Yeah, yeah.

• 20:24Alie Ward?

  So for Nicole McGinnis, 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.

• 21:00Speaker 04

  When I was watching Flipper 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.

• 21:14Speaker 05

  Within a month, Tarek had his thyroid and lymph nodes removed and began iodine radiation treatment.

• 21:19Alie Ward?

  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 thyroid, both on HGTV. So in addition to that lady looking for the cheap seaside cottage, Tarek El Moussa, 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.

• 22:01Alie Ward?

  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 scrote. 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?

• 22:41Speaker 01

  Yeah, it's one of the occupational hazards. I want to look at people's neck before I look at their faces, probably. It's unfortunate.

• 22:50Speaker 01

  But yeah, no, I mean, it's it's natural, right? Because that's what I do.

• 22:53Alie Ward?

  Yeah.

• 22:53Speaker 01

  Every day I examine people's necks. Yeah, I mean, you know, large goiters are easily visible. I mean, for people that know, like, that's an abnormal neck.

• 23:02Alie Ward?

  Does it cover the the Adam's apple?

• 23:04Speaker 01

  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, you know, huge goiters, huge, you know, thyroid masses. And it's almost always either familial or iodine deficiency.

• 23:29Alie Ward?

  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

• 24:12Alie Ward?

  children in some areas having clinically apparent goiter. 70%. That's like a higher percentage of kids mewing in class.

• 24:21Speaker 01

  And so I don't know if you're familiar with the whole goiter belt story.

• 24:25Alie Ward?

  Yes.

• 24:25Speaker 01

  I mean, fascinating.

• 24:26Alie Ward?

  Yeah. Well, first off, is it goiter or goiters?

• 24:29Speaker 01

  Goiter.

• 24:29Alie Ward?

  Okay. There's there's no goiters.

• 24:32Speaker 01

  There's no goiters. So this is multiple people.

• 24:33Alie Ward?

  Got it. I guess you can't have more than one.

• 24:37Speaker 01

  You have one goiter.

• 24:37Alie Ward?

  Yes. Have those changed in rates historically? Have we seen epidemics of goiter? What causes those?

• 24:47Speaker 01

  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. Their thyroid glands 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.

• 25:32Speaker 01

  And how do you get people to take iodine? So, I mean, it was a brilliant, you know, 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.

• 26:01Alie Ward?

  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.

• 26:22Speaker 01

  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.

• 26:29Speaker 01

  But back then, that wasn't available.

• 26:32Alie Ward?

  Is the thyroid trying to compensate by enlarging in tissue size? What's going on?

• 26:38Speaker 01

  That's exactly, it's hypertrophying.

• 26:39Alie Ward?

  Hypertrophy, hyper means it's growing bigger.

• 26:43Speaker 01

  That's exactly what's happening. The thyroid gland is hypertrophying because it needs iodine to make thyroid hormone.

• 26:48Alie Ward?

  Mm hmm.

• 26:48Speaker 01

  And it's not getting the iodine. So it's actually increasing in size, trying to get iodine, trying to accumulate iodine.

• 26:53Alie Ward?

  And if you add iodine to someone's diet, does it just shrink down? Or does it, does it need a surgical intervention?

• 26:59Speaker 01

  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.

• 27:07Alie Ward?

  Uh huh.

• 27:08Speaker 01

  But it's not going to shrink.

• 27:09Alie Ward?

  Okay.

• 27:09Speaker 01

  And so at that point, they're stuck with the goiter that they have.

• 27:12Alie Ward?

  And then.

• 27:13Speaker 01

  Yeah, either you take it out or if they're, if they're, they can tolerate it and it's not really bothering them, you can even leave it alone.

• 27:18Alie Ward?

  Ah, I've 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?

• 27:40Speaker 01

  Well, not necessarily hyperthyroidism per se, but you do, you can get iodine toxicity for sure. And so you do have to be careful, right? I mean, and you also, I mean, depending 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.

• 27:54Alie Ward?

  Yeah.

• 27:55Speaker 01

  But, 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, and you should be fine.

• 28:03Alie Ward?

  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 pink stuff, you never know what you're getting. What's the deal?

• 28:27Speaker 01

  So you're right about both.

• 28:31Speaker 01

  Most of us really prefer using levothyroxine, which is the brand name of Centoride. But 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, that we know exactly what the patients are getting. From a physician's standpoint, you know, 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, it's, we're talking about a very small subset of patients that don't tolerate thyroid hormone. I would say 95% plus, they take their Centoride 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,

• 29:16Speaker 01

  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, you know, feeling kind of like I feel normal again. I feel like I have my energy levels back because you're getting T4 and T3.

• 29:32Alie Ward?

  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

• 30:17Alie Ward?

  of 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 US 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

• 30:58Alie Ward?

  of bovine thyroid for individuals who, for religious or cultural reasons, don't eat pork. Still not vegan.

• 31:06Speaker 01

  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 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'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 you're actually getting.

• 31:33Alie Ward?

  Yeah.

• 31:33Speaker 01

  But if the patients feel well and they like it and they're doing well, then I think most physicians are OK with it.

• 31:38Alie Ward?

  OK. 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?

• 31:51Speaker 01

  So, but 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 thyroid response.

• 32:10Alie Ward?

  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.

• 32:27Speaker 01

  What's fascinating and what we're looking at right now here in our institution and we were 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.

• 32:43Alie Ward?

  Really?

• 32:44Speaker 01

  Yeah. So one of our own, you know, medical students here actually ended up with hyperthyroidism after COVID.

• 32:50Alie Ward?

  Hyper?

• 32:51Speaker 01

  Hyper.

• 32:51Alie Ward?

  Really?

• 32:52Speaker 01

  Yeah, because it triggered some form of autoimmune response. It actually triggered the thyroid gland to make more hormone.

• 32:57Alie Ward?

  So can an autoimmune response happen kind of with any exposure to a virus that just says, hey, immune system, like, let's kick into gear?

• 33:06Speaker 01

  Exactly. One of the, you know, kind of theories out there, at least is why women tend to be more prone to autoimmune diseases. And it's, it's a theory and nobody really knows for a fact, but there are some data to support environmental toxins, right? So some certain environmental toxins, synthetic estrogens, cosmetics, you know, some chemicals that are involved in, in some of those products can trigger an autoimmune response. And so I don't want to tell people not to, you know, 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 somebody's environmental toxins, which may lead them to develop these autoimmune problems.

• 33:42Alie Ward?

  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.

• 33:55Speaker 01

  And then you microwave it, so it's great.

• 33:56Alie Ward?

  Oh, yeah, it's fine. Absolutely fine.

• 33:58Speaker 01

  Absolutely fine.

• 33:59Alie Ward?

  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, what, what are they exactly?

• 34:10Speaker 01

  Now you're, this is, this is what I do on a day to day basis. Thyroid nodules. They're basically growths in the thyroid gland. If you want to think of it that way. It's a small tumor. So I like to think of thyroid nodules as, 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.

• 34:31Alie Ward?

  Okay.

• 34:32Speaker 01

  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.

• 34:40Alie Ward?

  And what, what do you do? Do you stick a needle in there and check it out?

• 34:43Speaker 01

  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? Have 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.

• 35:06Alie Ward?

  Oh.

• 35:06Speaker 01

  Yeah, so it's one thing that we really, you know, we really are worried about. Once you've done the appropriate evaluation, usually it's an ultrasound, the first thing.

• 35:13Alie Ward?

  Okay.

• 35:13Speaker 01

  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. Ah, 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.

• 35:33Alie Ward?

  Okay.

• 35:33Speaker 01

  And so that's what we use to kind of decide.

• 35:35Alie Ward?

  What's under the microscope when you squirt out whatever was in the needle?

• 35:38Speaker 01

  Cells. So 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's 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 or 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.

• 36:05Alie Ward?

  So if it's benign, they'll keep checking maybe a couple of times a year, but what if it's not great news?

• 36:11Speaker 01

  If they call us back and say there's malignant cells, then we talk about surgery.

• 36:16Alie Ward?

  Do you numb it up before you put the needle in there?

• 36:18Speaker 01

  That's a great question. So we used to 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.

• 36:29Alie Ward?

  Really?

• 36:29Speaker 01

  Cause it's gluteic, it burns.

• 36:31Alie Ward?

  Uh huh.

• 36:31Speaker 01

  And the needle's 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.

• 36:38Alie Ward?

  Oh.

• 36:39Speaker 01

  Yeah.

• 36:40Alie Ward?

  Is it somewhere in between a blood needle and like an acupuncture situation?

• 36:42Speaker 01

  Yeah, exactly.

• 36:43Alie Ward?

  Yeah.

• 36:43Speaker 01

  Most patients, honestly, like if I tell them, you know, here's a needle, they'll feel like, eh, it felt like a small little pinch, but it's not even painful.

• 36:49Alie Ward?

  Oh, so don't freak out if you got a nodule.

• 36:51Speaker 01

  Do not freak out.

• 36:52Alie Ward?

  Yeah, just, and you said, what percentage would you say are benign versus?

• 36:57Speaker 01

  95% benign.

• 36:58Alie Ward?

  That's what I thought you said, and then I thought, there's no way I could have heard that, right? Okay.

• 37:03Speaker 01

  So, most thyroid nodules are not cancers.

• 37:05Alie Ward?

  But you want to get them checked out in case they are, because that is not a good situation if they are.

• 37:09Speaker 01

  Absolutely.

• 37:09Alie Ward?

  Okay. When it comes to getting them out, do you just remove the nodule? Or do you have to take a chunk of thyroid?

• 37:17Speaker 01

  I love these questions. These are like, these are the questions I get every day.

• 37:20Alie Ward?

  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.

• 37:28Speaker 01

  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 the nodule, that you may leave tumor behind. And then you have to go back and potentially do another operation, which could be even more difficult, because then you have scar tissue, and the patient's already had one operation there before.

• 38:01Alie Ward?

  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.

• 38:08Speaker 01

  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. Man, 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, and try to preserve the rest of the thyroid. So, hopefully, you'll continue to make enough hormone that you won't even need medication.

• 38:39Alie Ward?

  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?

• 38:46Speaker 01

  Yeah, they always want to take it home.

• 38:48Alie Ward?

  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.

• 38:54Speaker 01

  Zero.

• 38:54Alie Ward?

  I was like, it was mine 10 minutes ago.

• 38:57Speaker 01

  It all gets, unfortunately, gets sent on 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.

• 39:06Alie Ward?

  That's nice. What percentage of people are like, take a snap, doc?

• 39:11Speaker 01

  Oh, I would say probably like 30 to 40%.

• 39:12Alie Ward?

  Really?

• 39:13Speaker 01

  Oh, yeah, they want to see what their thyroid looks like.

• 39:15Alie Ward?

  Yeah, I would want to see.

• 39:16Speaker 01

  Yeah.

• 39:16Alie Ward?

  It's mine after all.

• 39:17Speaker 01

  We'll take a picture.

• 39:18Alie Ward?

  I think that's helpful. It's like when a mechanic is like, look at how bad your brake pads.

• 39:22Speaker 01

  Exactly.

• 39:23Alie Ward?

  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?

• 39:34Speaker 01

  Yes, so thyroid cancers are thyroid nodules that are malignant.

• 39:37Alie Ward?

  Okay, got it. So it's not, there's not a different kind of like spider webby cancer that starts.

• 39:41Speaker 01

  No, no. So thyroid cancers are basically thyroid nodules that are malignant. Malignant nodules are thyroid cancers. It's actually one of, I think, one of the most interesting, and I'm not biased.

• 39:52Speaker 01

  I think it's one of the most interesting cancers in the human body. And the reason for that, it really, it really spans the entire spectrum from like 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.

• 40:08Alie Ward?

  Like the woman shopping for the beach house on HGTV.

• 40:11Speaker 01

  The overall survival is 95% 20 year 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 anaplastic or undifferentiated thyroid cancers, which probably is the most aggressive thyroid cancer in the human body with a, 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.

• 40:49Alie Ward?

  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?

• 41:01Speaker 01

  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, where we won't even operate on the patients, we'll just follow them if they're, 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 transoral thyroid surgery, so there's no scars in the neck. You could take out the thyroid through the mouth.

• 41:34Alie Ward?

  Woo.

• 41:34Speaker 01

  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 thyroid surgeon and go to a place where they have a thyroid program in 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, you know, 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.

• 42:17Speaker 01

  And so many of these patients, you know, they were, yeah, I was, you know, I was somewhere in Ukraine or on 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.

• 42:36Alie Ward?

  Wow. You know, with the earthquake in Japan in, I want to say 2010. 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 over the Pacific. Are thyroid doctors, are oncologists in general, keeping an eye on that?

• 43:11Speaker 01

  Yeah, I mean, 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 this, when does that happen? Every single pharmacy on the West Coast ran out of iodine.

• 43:29Alie Ward?

  Really?

• 43:32Speaker 01

  Because people started hoarding the iodine pills because you wanted to pop iodine as soon as you know there's a nuclear fallout. If you take iodine, you protect your thyroid gland from getting thyroid cancer.

• 43:39Alie Ward?

  Really?

• 43:40Speaker 01

  Yeah, yeah.

• 43:40Alie Ward?

  Is that why iodine pills are used in bunkers and stuff?

• 43:45Speaker 01

  Yeah.

• 43:46Alie Ward?

  That's fascinating. I also, can iodine pills also be used to disinfect water?

• 43:50Speaker 01

  Yeah, you can.

• 43:51Alie Ward?

  Okay, okay. That's so interesting. Why does iodine protect against?

• 43:56Speaker 01

  It blocks the thyroid cells from absorbing the radiation. You're basically saturating your thyroid cells with iodine.

• 44:01Alie Ward?

  Does that actually affect it?

• 44:02Speaker 01

  Yeah, I mean, it seems to help. Absolutely. I mean, even when you had the nuclear fallout in Chernobyl, I mean, you know, the people that knew what was going on, they started taking iodine pills.

• 44:12Alie Ward?

  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 iodine. 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.

• 44:57Speaker 01

  You'd probably need a lot of salt.

• 44:58Alie Ward?

  Can I ask you listener questions?

• 45:00Speaker 01

  Please, Scott. Let's do it.

• 45:01Alie Ward?

  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. This podcast is brought to you by Squarespace. If you haven't heard me gushing about Squarespace for years, it's an all-in-one website platform. Whether you're trying to grow a business you have- Or if you're just a baby business getting started, it has everything you need. That's where I secured my domain name. It helped me build a professional site.

• 45:45Alie Ward?

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• 46:27Alie Ward?

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• 47:10Alie Ward?

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• 47:53Alie Ward?

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• 48:38Alie Ward?

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• 49:22Alie Ward?

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• 50:04Alie Ward?

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• 50:47Alie Ward?

  Download the Quince app for app-exclusive offers, or you can go to quince.com. Get free shipping on your order and 365-day returns, now available in Canada and the UK, too. And when Quince asks you where you heard about them, just let them know it was Ologies. It's the best way to support the show. Okay, your questions. If you're a patron at patreon.com/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,

• 51:30Alie Ward?

  Daniel Suter, Devin, Jessica Chance, I mean, a lot of people, Earl of Grammalkin, Vanessa Adams, Rykonz, 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?

• 52:03Speaker 01

  So the first part of your question is, you know, you're probably, they're probably right, we don't chat, we probably should.

• 52:07Alie Ward?

  Yes, right?

• 52:08Speaker 01

  We probably should chat, this is fascinating. I need to talk to my vet. We have a nice little dog and yeah, so, yeah, I, you know, 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, you know, to other environmental toxins, as humans, we are not, you know?

• 52:30Alie Ward?

  Mm-hmm. Earl of Grammiken said I had a cat with hyperthyroidism who got the I-131 treatment and we had to keep her poop sequestered for a month.

• 52:39Speaker 01

  Yeah, that's even for humans too, actually.

• 52:41Alie Ward?

  Well, okay, this was my next question.

• 52:43Speaker 01

  But not just so you poop for one month.

• 52:46Speaker 01

  But you have to sequester yourself.

• 52:47Alie Ward?

  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 kitty'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?

• 53:31Alie Ward?

  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

• 54:12Alie Ward?

  The 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 Lysensky, Sarah Mans, 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.

• 54:34Speaker 01

  We can talk Graves.

• 54:35Alie Ward?

  What's going on with it? What do you do? Where does radioactivity come into it?

• 54:40Speaker 01

  Absolutely. So Graves' disease is kind of the opposite of Hashimoto's. It's also named after Dr. Graves, who first prescribed Graves' disease. And it turns out that in Graves' disease, what's happening is you're 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 is making antibodies that destroy the thyroid. In Graves' disease, your body is making immunoglobulins that actually stimulate your thyroid. So Graves' disease is one of the most common causes of hyperthyroidism. And these are patients who present in the exact opposite fashion.

• 55:22Speaker 01

  They say that they're losing weight, they always feel hot, they have tremors, anxiety, they feel like their heart's 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 going to be super low.

• 55:37Alie Ward?

  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?

• 55:46Speaker 01

  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. 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.

• 56:28Speaker 01

  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, 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 thymazole or the other drugs that we treat for graves.

• 56:56Alie Ward?

  Dr. Patel gives some advice if your doctor opts for surgery.

• 57:00Speaker 01

  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.

• 57:12Alie Ward?

  Right.

• 57:13Speaker 01

  Because you took the radioactive iodine, you can't get pregnant for six months to a year.

• 57:16Alie Ward?

  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?

• 57:32Speaker 01

  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. You know, 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, you know, there are risks associated with surgery, but there are also risks with the radioactive iodine.

• 57:52Alie Ward?

  Right.

• 57:53Speaker 01

  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, what, 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, pretty common.

• 58:17Alie Ward?

  Okay. What if you take the radioactive iodine? Do you have to stay in any kind of lead bunker?

• 58:25Speaker 01

  No.

• 58:26Alie Ward?

  Okay.

• 58:27Speaker 01

  The amount of iodine you're getting is minimal.

• 58:29Alie Ward?

  So to treat Graves' disease, it's not much radioactive iodine. But with thyroid cancer, you're bringing out the big guns.

• 58:36Speaker 01

  Those patients do have to be in quarantine for about a week. So for about a week, you know, they don't, 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 disposables better. You want to sequester it in a certain space. You don't want to throw it down the regular garbage. So there's a whole protocol that we utilize for patients. We tell them how to kind of, you know, manage all the disposables. And you want to stay in a place that's kind of away from other people.

• 59:03Alie Ward?

  What about bedding and stuff like that?

• 59:05Speaker 01

  Yeah, I tell people, don't throw your beds away. Don't throw your couches away. People do, used to do that. They're like, I threw everything away. But you don't have to throw it away. There's a half-life to radiation, right? Just like there's a half-life to radiation. So yeah, you know, 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.

• 59:19Alie Ward?

  Okay. Oh, good to know. I was, that's, the idea that you're potentially turning into Spider-Man is exciting now. You knows what kind of superpowers you might 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 Calabranly, Matea Orr, Little C SiD, Sarah Jo, Cassie Lebon, Kaitlin Fitzgerald, Annie Dullos, Elliot, Brooklyn Barron, and Vanessa Adams, all asked, what's up with 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 heifer here, wondering what exactly are those normal ranges?

• 1:00:02Alie Ward?

  And what's the difference between T4, T3, or rather, in the free versions of them?

• 1:00:07Speaker 01

  Yeah, so the free version is just, because of the way the laboratory studies are designed, often these, these molecules bind with other proteins. So the free version is just, in theory, is supposed to be more accurate. The blood test is 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, 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 in the United States, depending what lab you use.

• 1:00:50Speaker 01

  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 the normal range, but you may still not feel well.

• 1:01:06Alie Ward?

  Yeah, yeah.

• 1:01:07Speaker 01

  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?

• 1:01:28Alie Ward?

  Yeah.

• 1:01:28Speaker 01

  You know?

• 1:01:29Alie Ward?

  Why is Patrick Duffy, I wanted to know, why is the normal range so large?

• 1:01:33Speaker 01

  Is this Patrick Duffy the actor?

• 1:01:34Alie Ward?

  I don't know, I have to ask. That would be amazing.

• 1:01:40Alie Ward?

  I'll Instagram him and be like, 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?

• 1:01:53Speaker 01

  Oh, because it's a population-based, 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.

• 1:02:08Alie Ward?

  Do people then say, okay, my TSH is normal, let's check the T3 and T4?

• 1:02:13Speaker 01

  Yeah, you can do that. In all likelihood, if your TSH is normal, your T3 and T4 are probably going to 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.

• 1:02:27Alie Ward?

  And don't blame the thyroid.

• 1:02:29Speaker 01

  Don't blame the thyroid for everything. I should make t-shirts, don't blame the thyroid.

• 1:02:31Alie Ward?

  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? Or is your body converting more energy to heat? Is that what's really contributing to the fluctuations?

• 1:02:46Speaker 01

  It's your ability to convert your food into energy, right? So, you know, 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.

• 1:03:23Alie Ward?

  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 his shit together? And I'm looking at you, first time question askers, Michaela Ballard and Mary Ann 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?

• 1:04:00Speaker 01

  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 an expert in that area, but my recommendation to my patients is yes, you know, 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.

• 1:04:40Speaker 01

  So whatever trigger there was that was causing it, you know, you maybe can try to undo some of that with your lifestyle. Is it curative? Hard to say.

• 1:04:51Alie Ward?

  Would like alcohol and sugar also be included in that?

• 1:04:55Speaker 01

  Yeah, I mean.

• 1:04:56Alie Ward?

  Cleaning that up?

• 1:04:57Speaker 01

  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? Because it's a chicken or the egg kind of thing.

• 1:05:06Alie Ward?

  Right.

• 1:05:06Speaker 01

  And so if you decrease your stress levels, maybe that may, you know, help your immune system.

• 1:05:10Alie Ward?

  That was my next question. Also on the minds of Maya Lecker, who's a Graves' disease have, Danielle Poweris, Angie Dulles, and Annie Sayers, who asked, can stress make an underactive thyroid worse? Jen O. 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 podcasts? 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?

• 1:05:55Speaker 01

  I think it does. I mean, you know, we're just learning more about this, you know, over the last 10, 20 years. Where 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 is, 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.

• 1:06:37Alie Ward?

  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?

• 1:06:50Speaker 01

  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, you know, if you, 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, yeah, yes, thyroid hormone is a integral component of your metabolism. And when it's not functioning properly, it can affect your metabolism. But once again, the metabolism is also based on other things as well.

• 1:07:20Alie Ward?

  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?

• 1:07:27Speaker 01

  Absolutely.

• 1:07:27Alie Ward?

  Okay, I thought this was a great question. Tiger Yudi and Greg Wallach. Greg asked, can you have Queen Anne eyebrows and your thyroid be fine? And Tiger Yudi 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 just had thyroid disease.

• 1:07:56Speaker 01

  So I'm looking at my eyebrows.

• 1:07:57Alie Ward?

  I know. I'm checking my tails. I'm checking my tails.

• 1:08:01Speaker 01

  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.

• 1:08:10Alie Ward?

  Mm hmm. I understand that there is a lot of blame for 90s eyebrows when really get your thyroid checked.

• 1:08:17Speaker 01

  Yeah, exactly.

• 1:08:18Alie Ward?

  I'll have to, 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 Anne Sign in Hypothyroidism said that loss of the outer third of the eyebrows is called the Queen Anne 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?

• 1:09:01Alie Ward?

  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 sea, 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 over-pluck. 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 overplucked and you know it, let me direct you to the 2023 Live Science article,

• 1:09:45Alie Ward?

  "Why Don't Overplucked 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. 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 Brecon's also asked about female hormone systems and thyroid.

• 1:10:27Alie Ward?

  And what about, Jay 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?

• 1:10:41Speaker 01

  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.

• 1:10:54Alie Ward?

  Really?

• 1:10:54Speaker 01

  Yeah, yeah, you get pregnancy-induced Hashimoto's. Not really Hashimoto's, but pregnancy-induced hypothyroidism.

• 1:11:00Alie Ward?

  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 throwing a wrench in getting a baby in there. Respectfully speaking to those who asked, Renee Wenger, Maddie Dennison, Sarah, Cassie Kenton, Danielle Suter and Amber McIntyre, why during pregnancy, your thyroid can also cause a bit of a hullabaloo?

• 1:11:31Speaker 01

  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 because those hormonal changes can affect your thyroid function.

• 1:11:41Alie Ward?

  Mm hmm.

• 1:11:42Speaker 01

  And so 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.

• 1:11:52Alie Ward?

  As someone who is on all kinds of hormones, who hasn't checked her thyroid in a while, can it go with the wind? Like, are you typically on a trajectory where if you have a thyroid issue, it's never going to resolve on its own?

• 1:12:04Speaker 01

  No, I would say, so when you have, for example, patients that show up 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.

• 1:12:21Alie Ward?

  So if your body calms down somehow and stops over provoking 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.

• 1:12:40Speaker 01

  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 and 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 your, going on in your life.

• 1:12:58Alie Ward?

  What about ways to prevent thyroid nodules? And I'm asking literally for a friend who has them, Erin at Gutterback. She's like, I got another one they gotta go check out. Anything that she can do in her power?

• 1:13:09Speaker 01

  Thyroid nodules are really 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. You know, some people get ovarian cysts, some people get, you know, 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.

• 1:13:38Alie Ward?

  Can you, when you palpate a thyroid, can you really feel if there's a nodule in there?

• 1:13:42Speaker 01

  If it's large enough, absolutely. Anything, anything over, you know, one to two centimeters, you should be able to feel. It depends on the patient's neck, their body size, if they have a larger neck, it may be 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's easy to feel.

• 1:13:58Alie Ward?

  So BFF and recent birthday girl Erin and patrons Emma Wren, Lydia Trom 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?

• 1:14:11Speaker 01

  A hundred percent.

• 1:14:13Alie Ward?

  And they're like, I have cancer. And you're like, that's a lymph node. You're good.

• 1:14:15Speaker 01

  Totally. But you have to make sure it's a benign node, not a, not a cancerous node. Right? So we do see patients who'll present with a 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's spread.

• 1:14:26Alie Ward?

  Ooh.

• 1:14:27Speaker 01

  Right? And so we'll probably stick a needle in it and see what's going on.

• 1:14:30Alie Ward?

  You mentioned earlier thyroid cancer that could have spread. Are those like endometriosis? Is it like, is it like bits of thyroid tissue that are around that respond to radioactive iodine or?

• 1:14:42Speaker 01

  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 has 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's spread, we can still treat you and you should still do very well.

• 1:15:13Alie Ward?

  As opposed to like radiation gamma knife or something that can just zap one area, this can actually systemically go and find it and?

• 1:15:21Speaker 01

  This is systemic. This is better than any chemotherapy out there.

• 1:15:24Alie Ward?

  Yeah.

• 1:15:24Speaker 01

  This specifically targets thyroid cancer cells and kills them.

• 1:15:28Alie Ward?

  Nice. It's like their kryptonite.

• 1:15:30Speaker 01

  I know.

• 1:15:30Alie Ward?

  What about libido and thyroids?

• 1:15:33Speaker 01

  Yeah, that's a good question. I mean, you know, 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.

• 1:15:50Alie Ward?

  Do people with Graves' disease get hornier?

• 1:15:52Speaker 01

  That's a great, I knew you were going to ask me that question next.

• 1:15:55Alie Ward?

  I didn't mean to. It's curious.

• 1:15:58Speaker 01

  Not that I know.

• 1:15:59Alie Ward?

  Okay.

• 1:16:01Speaker 01

  They may also be really tired and exhausted.

• 1:16:03Alie Ward?

  Right, exactly. Yeah. What kind of heart rate do you have if you've got Graves' disease?

• 1:16:07Speaker 01

  It can be pretty high. Yeah, people who have really bad hyperthyroidism, they can have a pretty high. That's what these patients often go on beta blockers. Heart rate go up to 120, 130. I've seen 150.

• 1:16:17Alie Ward?

  Do you find that now that people have fitness trackers and I've got an Oura 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?

• 1:16:26Speaker 01

  Absolutely. 100%. I've had patients who can track their blood. They show me their numbers, you know, 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, 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.

• 1:16:51Alie Ward?

  Right. Well, okay, one more question. Mercedes Tarasovich, Hannah Petzrano Hudson. What's the connection between hypothyroidism and chronic uterarhea, which are hives, right? What's up with hives and thyroids?

• 1:17:07Speaker 01

  I think it's all related to your immune system. Once again, it's autoimmune, right? So if you're, if you're, 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 like in one area. It's not like a contact dermatitis where you were allergic to something and you touched it and you broke out in hives. This is like systemic. And so that's almost always autoimmune.

• 1:17:39Alie Ward?

  Good to know. Hardest part about your job?

• 1:17:41Speaker 01

  Hardest part about my job?

• 1:17:43Alie Ward?

  What sucks the most? It can be anything. It can be petty. It can be huge.

• 1:17:48Speaker 01

  I actually love my job.

• 1:17:49Alie Ward?

  I know. I'll ask that next. I'm gonna ask that next.

• 1:17:53Speaker 01

  Actually, 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.

• 1:18:00Alie Ward?

  You're like, I have nothing outside.

• 1:18:02Speaker 01

  No, no, no, no. I mean, the hardest part of my job, I mean, honestly, I mean, so then this is going to be a little bit more, more of a, you know, I, I love my patients. I love what I do from a physician's standpoint. You know, the hardest part of this, I think most doctors will agree with this is, is dealing with all the administrative stuff, right? I mean, you know, 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. Um, and we need to do it. Otherwise, we don't get paid.

• 1:18:35Alie Ward?

  It's part of the job.

• 1:18:36Speaker 01

  It's part of the job too. We need to get paid at some point. So.

• 1:18:40Alie Ward?

  But just paperwork.

• 1:18:41Speaker 01

  Paperwork, paperwork, paperwork, never ends. Never ends.

• 1:18:44Alie Ward?

  Rather be palpating thyroids than filing paperwork.

• 1:18:48Speaker 01

  Absolutely. Yeah. Rather be in the operating room, taking care of patients. Yeah.

• 1:18:51Alie Ward?

  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 thar- Brony. You love what you do.

• 1:19:33Speaker 01

  I love NYU. I gotta say that before I get fired. No.

• 1:19:38Alie Ward?

  So we have your communication team.

• 1:19:39Speaker 01

  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% better, hopefully, you know, it's a, it's a great feeling.

• 1:19:59Alie Ward?

  Do you ever see someone come back after medication and they look and feel so much better?

• 1:20:06Speaker 01

  Absolutely.

• 1:20:07Alie Ward?

  Yeah.

• 1:20:07Speaker 01

  Yeah. Even from a surgical standpoint, right? I mean, I did whatever nine thyroid cancer operations last week and being able to tell somebody, you know, we took your cancer out and you're going to be fine. It's, it's such a great feeling, right? And, and to see, you know, the patient and their family members and they're all like, you know, just, just happy.

• 1:20:23Alie Ward?

  What about any myths that you would want to bust about thyroids? Any soapboxes you want to get on?

• 1:20:31Speaker 01

  I mean, one thing, like, 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.

• 1:20:45Alie Ward?

  When should someone get a second opinion?

• 1:20:47Speaker 01

  Anytime they're not happy with the first opinion, definitely. You can get a second opinion. 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 specializes in this. And I like to think that we have a fantastic program here. So, you know, I think 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 it from other people, it's 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 100%. They just want to hear from somebody else as well.

• 1:21:20Alie Ward?

  Yeah. So smart. Thank you so much for making me better friends with my own thyroid.

• 1:21:26Speaker 01

  My pleasure. This is great.

• 1:21:27Alie Ward?

  I appreciate everything it's doing for me at the moment.

• 1:21:30Speaker 01

  Great. You can keep it.

• 1:21:33Alie Ward?

  Thank you, doctor.

• 1:21:36Alie Ward?

  So ask surgical people unserious questions because sometimes those are the ones that most need the answers. And to find out more about Dr. Keppel Patel, 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 Ally Ward on there, too. We have shorter, kid-friendly episodes called Smologies 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/ologies.

• 1:22:18Alie Ward?

  You can find hats, totes, tees, and more at ologiesmerch.com, too. Thank you so much to RecentBirthdayGirl and HumanGem, Aaron Talbert, who admins the Ologies Podcast Facebook group. I love you, Aaron. I hate your thyroid. I'm sorry about it. Talent to be nice. Aveline Malick makes our professional transcripts. Callie Ardwire does the website. Noell Dilworth steers our calendar as scheduling producer. Susan Hale is the pituitary gland of a managing director. Jake Chaffee 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

• 1:23:02Alie Ward?

  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.

• 1:23:43Alie Ward?

  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 want to do. Cut bangs, text your crush, we're all gonna die. So chin up, keep going. Bye-bye.

• 1:24:33Speaker 06

  Your thyroid. Revolve.

• 1:24:35Speaker 07

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