Episode 2 | Two Roads Diverged, Part 1: The Endocrinologists

The conventional endocrinology perspective on diagnosing and treating hypothyroidism is explored with several leading endocrinologists.




TRANSCRIPT


Two roads diverged in a yellow wood,

And sorry I could not travel both

And be one traveler, long I stood

And looked down one as far as I could

To where it bent in the undergrowth;

Then took the other, as just as fair,

~ from “The Road Not Taken," by Robert Frost

(Podcast excerpt features an audio recording of Robert Frost reading his poem)

MARY SHOMON: How do you get properly diagnosed and optimized treatment for your hypothyroidism? Should you see an endocrinologist, or an integrative or holistic physician? And, how are their approaches to treating you different? In this two-part special episode, we dive into how hypothyroidism is diagnosed and treated from two very different perspectives.


In this part, we get an overview of the endocrinology side of hypothyroidism diagnosis and treatment from Dr. Gladys Palomeno, an endocrinologist in practice in Southern California.


" Some people treat guidelines as kind of like the word of God, and you follow the guidelines. And then some people use guidelines as kind of like a manual, a guideline... " ~ Gladys Palomeno, MD

We also hear from Dr. Ernest Asamoah, an endocrinologist in practice in Indianapolis.


"For a start, I don't think endocrinologist can see all patients with thyroid disease in the country. We don't have enough endocrinologist to do that...." ~ Ernest Asamoah, MD

As you’ll hear, they agree on some aspects of hypothyroidism, but as is common in the endocrinology world, even they have some differences.


This is Part 1 of “Two Roads Diverged,” episode 2 of the Thyroid Deep Dive podcast.


Thyroid Testing


MARY SHOMON: Getting properly diagnosed with hypothyroidism is essential. You can’t be treated for what you or your doctor don’t even know you have. And diagnosis almost always requires testing. But in the thyroid world, there is a lot of disagreement over which tests you need to diagnose and manage hypothyroidism, and how to use those test results. Some doctors rely almost exclusively on the TSH test, that’s the thyroid stimulating hormone test. Others feel that testing free thyroxine/Free T4, Free T3, and thyroid peroxidase antibodies – known as TPO – is also important when diagnosing and managing hypothyroidism. Let’s hear from Dr. Asamoah, whose approach to testing is representative of the majority of endocrinologists.

DR. ASAMOAH: So I stand with the ATA guideline, or the American Thyroid Association guidelines, because I'm a member of the ATA and I believe that science should drive the discussion rather than subjective measurement. And generally speaking, my take is that if you present to me with thyroid disease, I would like to do the full panel, which includes the autoantibodies or thyroid antibodies. One, it helps me to identify why you have hypothyroidism. And so if it's positive, it tells me you have autoimmune disease. So I will believe the antibodies initially is very critical.


I also believe that TSH probably is the single most important test. Having said that, in certain conditions like pregnancy, we want to see the T4, especially when somebody we think needs to have good levels of people for the sake of the baby.


T3 is not that critical. In terms of management. Of course, when you're talking about hyperthyroidism, T3 is important. But for hypothyroidism, we really don't know how much T3 testing impacts the management.


In some situations, I would do the free T4. And very rarely, they will consider free T3. But for overall management, we believe that TSH is the major test that would help us. But it's a clinical call. And I am one of those doctors that I like to treat the patient holistically.


And I'm open to doing some tests that sometimes psychologically make the patients feel better. But if you ask me as a scientist, what is the best treatment or measurement tool for thyroid monitoring? I think TSH, and to a certain degree free T4. Free T3 really has no real role in monitoring and treating hypothyroidism. It's different from hyper, but for hypothyroidism, which it really has no major role in that.


MARY SHOMON: Dr. Gladys Palomeno has a similar approach to testing.


DR. PALOMENO: I always test TSH and Free T4 always, T3 sometimes. I usually do a Free T3. And with pregnancy I do a Total T4. So let me explain why that is. So free means it's not bound to any proteins, the T4 is not bound to any proteins in your blood. It's more of an indicator of the active hormone that's in your blood. Because, when you are looking at total T4 as opposed to Free T4, Total T4 also measures the hormone that is bound to proteins, and if the proteins are increased -- there is a protein called thyroxin binding globulin for which the thyroid hormone binds on to -- and that that protein will go up and down depending on certain things. For example, if you're on birth control pills, if you're taking estrogen, your TBG or thyroxin binding globulin will go up and it's going to show a spuriously elevated Total T4. There are certain things that can affect that. So that's why I always get a TSH and Free T4.


Sometimes I get a Free T3, if patients are not feeling well, and I want to see if there’s a possibility they don't have enough free T3. The other thing too is in pregnancy, I always order a Total T4 in addition to the Free T4 because in pregnancy, their estrogen levels are high and their thyroxine binding globulin is high. So their total T4 should also be high. In fact, it should be 1 to 1.6 times the upper limit of normal to make sure you're getting adequately replaced during pregnancy. So, there is reason to get T3 and T4 levels. I also draw T3 levels when a patient is taking T3.


Antibodies Testing


MARY SHOMON: Both doctors mentioned testing for antibodies. For the vast majority of people with hypothyroidism in the U.S., the condition is due to Hashimoto’s thyroiditis, an inflammatory autoimmune disease that targets the thyroid gland. Surprisingly, however, for most endocrinologists, whether or not you have elevated thyroid antibodies doesn’t actually affect how they treat your hypothyroidism. Here’s Dr. Palomeno sharing her thoughts.


DR. PALOMENO: When someone has hypothyroidism, I always check an anti TPO. And it doesn't really matter to me how high it is. Because if it's positive, it's positive. And the reason why I want to know if it's positive, because that tells me they have an autoimmune disease, which actually puts them at risk for other autoimmune diseases. So, if that patient had hypothyroidism and they have a positive anti TPO, then I know if they have other problems later on, that I have to look at autoimmune diseases. So it's not for me necessarily to be a function, it's for me to know where it's coming from -- where their hypothyroidism is coming from -- what is the cause of it, because that's going to help me be able to treat the patient better as a whole in the future in case anything else should come up.


MARY SHOMON: Dr. Asamoah explains why conventional endocrinologists don’t typically use thyroid antibody test results in their treatment decisions.


DR. ASAMOAH: We have no evidence that doing thyroid antibodies really changes our management. I trained in England and one of the professors told me that, “If you're doing a blood test that is not going to change your management, you're wasting money.” And I agree with that. Scientifically doesn't make sense to keep testing the activity forever. So I think you need a baseline to just define the diagnosis. But going forward, I don't insist on testing them if a patient wants to, I do, but it doesn't really change what we do.

Optimal/Target Thyroid Levels


MARY SHOMON: When it comes to the TSH test, there’s what’s known as a reference range for results. It typically runs from around a TSH level of .5 to 4.5 or 5, depending on your lab. Levels above the cutoff are considered hypothyroid. Now, keep in mind that while it’s often referred to as the “normal range,” patients know all too well that even if a TSH result is in the normal range, it can feel anything but normal to you. That’s why some physicians work with a more narrow and targeted range, where patients are optimized, and actually FEEL better. Dr. Palomeno explains:

DR. PALOMENO: Each patient is a little bit different. Interestingly, older patients might feel more jittery, or they might feel not well or feel more anxious or have inability to sleep. And of course, if they have osteoporosis, if they have any heart disease, you don't want their TSH too low, because you could actually cause problems. You want those patients to run a little bit higher on their TSH. However, for younger people that have a full schedule, have a full time job and take care of their kids, when their TSH starts getting close to 3.0, they notice that they can't function very well and have all this fatigue, they can't do what they normally do. So those patients you want to get to TSH of 1 or a little bit less than 1. Obviously, the guidelines for pregnancy are .3 to 2.5. I mean, that's just the guidelines, and you just stick with that to make sure that you don't have any problems with your pregnancy. And then thyroid cancer again, you really have to stick with those recommended ranges to prevent the recurrence of thyroid cancer.


Everybody's a little bit different. And I have some patients that don't have heart disease, but they might feel that they get a little bit of anxious or get palpitations when their TSH is too low, like 1, or less than 1.5. So they like to be between 2.0 and 3.0. And then again, I have some patients that feel excessively tired, have extreme constipation, when you've got a patient, you got a TSH of between 2.5 and 3.0. So everybody's a little bit different. As a physician, you kind of have to get a good history, you kind of have to see where they feel the best, and then put them in that range as long as it’s safe, obviously within the correct range, you don't want them to be too hyper. You don't want it to be too high. Both you want to have them within the normal range, but each person lies differently within that range. I think that's the art of it all.


MARY SHOMON: Exactly. One size does not fit all.

DR. PALOMENO: One size does not fit all. Correct!

MARY SHOMON: Dr. Asamoah has a similar approach for his target TSH levels.

DR. ASAMOAH: Again, this is a very subjective number, because nobody really knows what your perfect TSH is. Remember that physiologically, for you and I, if you test your TSH four times a day, morning, afternoon, evening and night, you will probably get four different numbers, because there's a diurnal variation. So there is no magic TSH number. The question is how much variation can we tolerate. And so I would say for younger patients, we tend to keep the TSH on the low half of normal. And that.45 to about 2 for younger patients. For older patients, you got to be careful, because there's evidence that even in the patient population that has no thyroid disease, when we are older -- 70s, 80s, 90s -- low TSH actually has increased morbidity and mortality, even for people without thyroid disease. So if somebody's 90 years old and comes in with a TSH of say, 6, for them, if they’re functioning, you probably shouldn't treat them, even though that by definition is outside of the range.


So this is age-dependent, patient- dependent. But, as a general rule, yes, if you're younger, I am open to keeping TSH on the low side of normal. Bear in mind that even within that range, they may be variation. And then if you're older, because of risk of cardiac arrhythmias, and osteoporosis or osteopenia with extra thyroid hormone, you may have to be careful and potentially keep the TSH on the high side of normal. So that's kind of a general rule that I tend to follow.

Treatment Path


MARY SHOMON: Getting diagnosed is just the first step. Next comes treatment. Most endocrinologists start with levothyroxine, a synthetic form of the T4 hormone that is the standard treatment for hypothyroidism. You may recognize the brand names—Synthroid, Levoxyl, Unithroid, and Tirosint. Here, Dr. Asamoah outlines his specific approach to getting patients on treatment.


DR. ASAMOAH: When I see a patient who presents with hypothyroidism, first, I would like to find out what symptoms they have. I usually write them down, I would say most of the time, they have multiple symptoms, some of which may be thyroid-related, some of which may not be. And then ask the patients to identify the top three symptoms they have. When you just identify two or three top symptoms, it makes it easier to focus on that. And also, it's easier than to see whether these are thyroid-related or not.


Two, I would then go through the facility of thyroid disease or hypothyroidism with them, because prior to coming to see me, this patient would have seen lots of information online, sometimes misinformation about it. So I try to define what thyroid symptoms really are, especially when you’re hypothyroid which is what most of the time they are, and also tries to tell them how the symptoms relate to the severity of the blood test or the disease, in that somebody can come in with TSH of 6, or 10, or 12 and have all the symptoms in the world, and then somebody has a TSH of 25 and not have my symptoms. And I also try to emphasize that sometimes the symptoms are related to how high the TSH is. So, somebody with a TSH of 50 may have more symptoms than somebody with a TSH of 10.


If they have not been on any thyroid hormone therapy at all, then my first option is to tell them that generally the recommendation is to use LT4, or levothyroxine. And bring out the fact that we have generic versions and branded products. I also emphasize the fact that because of the narrow therapeutic index of levothyroxine as a whole, it's important that we get consistency in terms of supply or source of supply or manufacturing. Because there is a probability that just switching from one manufacturer to another, you may not get exactly what the label says. And it's so critical that we are consistent with the source of the products. In in that regard, generic medications of levothyroxine may not be as consistent, because the pharmacies may change suppliers with time. Whereas if it's a branded product, it's likely that the manufacturer is going to be coming from the same company, which then leads to consistency.

MARY SHOMON: I asked Dr. Palomeno how she approaches a common hypothyroidism treatment situation that occurs in thousands of doctors’ offices every single day.

One scenario that I'm sure you see on a pretty regular basis is usually a woman -- because women are much more likely to have thyroid problems and men -- comes in to see you. She's on regular levothyroxine. Maybe her GP or her primary care doctor has identified she's hypothyroid and given her some generic medication or levothyroxine. And her TSH is in the reference range. And she does not feel well. She's still got a laundry list of symptoms. She's brain fogged, she can't lose weight, she's tired, her skin is dry, she's constipated, her hair is thinning and shedding. What sort of process or steps do you take in order to help her get to a place where she's feeling better?


DR. PALOMENO: First of all, what I do is I want to make sure that there isn't a reason behind that. Do you have a GI issue that you're not absorbing? Are you having some other issues that are not helping you to absorb what you're taking? The other thing too is then I probably would switch them to something, and we'd maybe get their TSH a little bit lower, so they get a little bit more thyroid hormone. We'd switch them to either a brand name if they're on the levothyroxine, one of the brand names, or something like Tirosint. And if they're still not feeling well, then we go down the line, I might try a little bit of T3 and then we might try a little bit of the desiccated. I am willing to open the door to any possible treatment just to get the patient feeling well, as long as we stay within an appropriate range.


T3-T4 Treatment


MARY SHOMON: One thing many patients don’t realize is that levothyroxine is not the only treatment available for hypothyroidism. There is also Cytomel, a synthetic form of the second thyroid hormone T3 that can be added to your levothyroxine treatment. Most patients who take T3 swear by it. Many endocrinologists, however, are not on board with the T3-T4 combination treatment. I was, however, encouraged to hear that they are increasingly more open-minded.


Do you ever see a role for combination therapy, T4 and T3, so adding, for example, Cytomel or generic T3 synthetic to a levothyroxine treatment?


DR. ASAMOAH: Yes, for some patients, that may be an option. This is actually a very controversial issue that almost all the thyroid organizations across the world deal with. And recently, there has been a call for large clinical trials to look into this more. There have been a number of studies over the years with moderate or small amount of patient population, looking at T4/T3 combination. As the results have been kind of mixed bags. Some of them have said there’s a benefit, others have come up with no real conclusive evidence that there's a benefit. In my clinical practice, I will say there are some patients that will say yes, they do feel better with T3/T4 combination and others they'll see they don't. In my experience, the amount of T3 that I give, and I tend to give the synthetic T3, liothyronine, or Cytomel, from about five micrograms to 10 micrograms. I hardly go above 10. Five is probably the dose that most people would need to get a benefit. And the population that I think do benefit are patients that come in with chronic fatigue syndrome. There may be some benefit there. Patients who are depressed or on antidepressants, they may also benefit. So I found those patients tend to respond better than the general hypothyroid patients. So, I am always open to trying that. And I tell them, “if you feel better in a month or two or three, I'm open to keeping you on that.” On the other hand, if you come back two months later, or three months, and I don't see any difference at all, then I'll probably say “Well, it’s not worth staying on that medication if you're not seeing a difference.”


MARY SHOMON: Do you ever prescribe combination T4 T3 treatment? Levothyroxine plus Cytomel or generic Cytomel, or even compounded T3?


DR. PALOMENO: Yes, I do. And it depends on the patient. Again, I have some patients that still don't feel optimized on just the T4. And let's say the level is like 1.5 and they feel okay, but they don't feel 100% optimized and let’s say they get a little bit tired in the afternoon. The T3 is a little bit shorter-acting and you could give them an extra boost of energy in the afternoon without pushing their TSH so low, out of range. Some of those patients do well on a little bit of T3. Some patients actually like having a combination of T3-T4, I always go about how patients feel. There's was a study done in the New England Journal of Medicine years ago, they did Synthroid or levothyroxine versus Armour or a combination T3-T4. And when they looked at EKGs, and all these different parameters, it was actually all equal except for one thing: the one thing that wasn't equal was surveys. And some people felt better on the combination of T3 T4. I don't really know what that means. But my whole goal is to get people to feel better. So if they don't feel 100% better on just the T4, I might add a T3 or give them a combination to get them feeling better.

Natural Desiccated Thyroid Drugs


MARY SHOMON: There’s yet another treatment option, and it’s the most controversial one of all, especially for endocrinologists. Natural desiccated thyroid drugs – drugs like Nature-throid, Armour Thyroid, WP Thyroid, and NP Thyroid – are derived from the dried thyroid glands of pigs. These drugs have been prescribed for more than a 100 years. And even though some patients will tell you that they can’t live without it, natural thyroid doesn’t have many fans among endocrinologists, as you’ll hear from Dr. Asamoah.


DR. ASAMOAH: And when it comes to the so called natural thyroid medication, Nature-throid, Armour Thyroid, and all that. I again go with the American Thyroid Association guidelines that say, “Well, we don't think there's any major rule for this in thyroid hormone management. Why? Because the evidence says it doesn't really make much difference. But I would admit that some patients say they feel better on it. And they call it natural thyroid medication, I beg to differ on using the term “natural,” because I always tell patients, “Cocaine is natural. Arsenic is natural. Cyanide is natural. Natural doesn't equal good or safe.” And so when you use the term natural it becomes a sales pitch. Because even when you talk about Armour Thyroid and Nature-Throid, somebody has to make it in the lab, it’s synthetic in a way. So it's not really truly natural, the way they call it. But we know it comes from animal abstract, and it has a higher level of T3 than what we normally give when we do T3/T4. Or if you give T4 alone you’re not getting the T3. So in a way, patients are getting what I call a stimulant with the so called natural thyroid medicine.


And of course, if they’re tired and they get more T3, they may feel better. And patients equate feeling better to mean the product is better for me than the T4 alone. So again, I am open to using it because my take is that if I don't prescribe it, somebody else would. And that doctor or provider may not know about much about it like I do. So I’d rather own it. I’d rather have patients on it so I can regulate it fairly well to prevent problems. Because unfortunately, when our heart patients come in on Armour Thyroid or Nature-Throid, they are always given more than they need, and there are heart patients with atrial fibrillation or osteoporosis because of that. So I am willing to work with patients all the time, and I'll keep them on it as long as it's safe. Because remember that the first tenet in medicine is do no harm. So yes, if you want to stay on it, I'm open to it. I will explain the whole thing to you, knowing that it’s not the ideal. But as long as there's no risk or harm. I am open to using it. But that is not the first option that I give to patients.


MARY SHOMON: My philosophy has always been that the best thyroid treatment for you is the one that safely works best for you. I was glad to hear Dr. Palomeno echo this approach when discussing natural desiccated thyroid, and I want to point out that her approach is a departure from the conventional endocrinology perspective.

DR. PALOMENO: This is where medicine becomes an art. You really have to go with the how the patient feels. Because some patients do feel better on the desiccated T3-T4. The one thing you have to worry about desiccated T3-T4 is each batch is a little bit different so you’re going to have some variability. As long as my patients understand that they have variability, if they prefer it, because they say that they feel better on it, I'll give it to them. And as long as their TSH range is appropriate their TSH doesn't go too high or doesn't get too low, and we stay within where they're supposed to be, and if they're feeling well, I'm okay with it. Because that's my goal, I want my patients to be functioning and making them feel well and making sure that they're getting on with their lives.

How to Take Thyroid Medications


MARY SHOMON: If you are hypothyroid and your doctor has prescribed some form of thyroid hormone replacement medication, what next? Well, you need to take your medication—correctly -- as the doctors explain.


DR. PALOMENO: The main problem with thyroid pills is absorption. That is always the main issue. Are you absorbing it? Is it not sticking to your food, your vitamins? So if you want to be absolutely sure that you're absorbing it properly, it should be taken away from food. I always tell people at least an hour, I say “give it an hour to be absolutely sure.” And I tell people, “if you're wanting to be sure on vitamins, take it four hours away from vitamins.” And I don't really care if it's an hour before or an hour after the food or the vitamins, just as long as it's away from it, so it's being absorbed by itself. The other thing too is you have to be careful if you are taking medications for stomach acidity. If you have gastroesophageal reflux disease, and you're taking medications to decrease acidity, because if you're decreasing your acidity of your stomach, you are not going to absorb this.


MARY SHOMON: So this is everything from antacids like calcium or Tums to proton pump inhibitors.


DR. PALOMENO: Yes, you are right. Prilosec, Prevacid. All of them.


You know the other thing too, that's very interesting that I just started seeing in the last couple years is alkaline water. People are drinking more alkaline water. It's kind of a fad, so that you increase the pH of your blood. And what they do in doing the alkaline water is they also decrease the acidity of the stomach and then they're not absorbing the thyroid either. So that's another trend that I'm seeing.


MARY SHOMON: Interesting. I have not heard that. And that's a really interesting observation. So don't take your thyroid pills with alkaline water people, right?

DR. PALOMENO: Yes, yes.


MARY SHOMON: Here’s what Dr. Asamoah tells his patients about how to take their thyroid medication.


DR. ASAMOAH: I also lay out the fact that taking the medicine should be also important in terms of consistency, because we know that iron, calcium and some other elements in food do bind to thyroid hormones when they’re in the stomach. With that said, we prefer taking the thyroid medication on an empty stomach, waiting at least half hour to an hour before patients eat. Or if they take it after the food, it has to be after three to four hours, especially when there's calcium in the food they took. And so with that most people tend to take it in the morning, you don't have to, but generally, it's easier to take in the morning with 30 to 60 minutes before they eat. So that is the general recommendation for compliance for taking the medication.


Then I throw in the third caveat, which is that certain conditions do affect absorption of these medications. Like the pH of the stomach, some GI disorders, celiac disease being one of them, or malabsorption being another. So patients who have autoimmune diseases like celiac or Crohn's disease, potentially could have absorption issues without hormone therapy. And so, that is important to choose medications that have the least effect or are least impacted by these conditions. So initially, the discussion would again talk about medications, compliance, and other comorbid conditions that could all impact the medication absorption. Then, with that said, I would then say, "Okay, based on other presentations, you have a choice," because I don't believe in telling people that you know, you have no choices, they have choices, they can choose to go generic or brand.

Excipients/Absorption/Reactions


MARY SHOMON: Both doctors raised an important issue—absorption. Levothyroxine in particular DOES NOT work if you’re not absorbing it, and there are many factors that can get in the way of absorption of levothyroxine, and tablets especially. In particular, there are ingredients added to thyroid drugs – called excipients – including things like lactose, acacia, gluten, and iodine – as well as colored dyes. There are also digestive conditions that can make it difficult to absorb levothyroxine tablets, as the doctors explain.


DR. ASAMOAH: I remember about 20 years ago, just when I started practice in Indianapolis, a patient of mine, a very nice guy, was on Synthroid and swore that anytime he took it, he had headaches. Within a few weeks, another lady on Synthroid said the same thing. And I really at the time didn't believe that. I said, “well, I mean, unfortunately, I can’t measure your symptoms, so I can’t have any tests for that, so I have to believe you. And at the time, I actually remember switching to Levoxyl. And guess what, the symptoms went away, they never had them again at the time. And I've also had patients even on Synthroid or Levoxyl, complaining of symptoms, allergy, hives, headaches, just not feeling right. And I thought, “Maybe that’s the excipient.” And I know that the 50 micrograms all these other medications is colorless or dyeless. And so I've tried some of them on that.


I had one patient who was on Levoxyl and was having hives, and symptoms just didn't make sense. So at the time, Tirosint wasn’t on the market. So I actually went for the 50 microgram dose, which is white, and has no dye. And suddenly the symptoms went away. And so now, fortunately for us, since 10 years ago when Tirosint capsule came in, and now the solution as well, I have really found that to be my go to. Anytime somebody comes in and says, “Well, I've had a reaction to the tablet,” I tell them “I can tell you so far, I had not had a single patient react to the Tirosint liquid or gel,” and when I switch they take it and have none of those symptoms they had.”


DR. PALOMENO: Usually when I have patients that come in to see me and they've been on levothyroxine or Synthroid and they've tried different doses, and it's still not getting to where they're supposed to be in terms of their goal levels, then I start looking at other stuff. And one of the one of the things that I noticed with a lot of these people is they might, for example, have a GI problem that no one bothered to look at. And so those kind of patients do great on Tirosint and Tirosint-SOL. As a matter of fact, I just saw a patient two weeks ago, who I was seeing for thyroid cancer, and she had been on a stable dose of Synthroid and she came in to see me and her all of a sudden her thyroid dose is out of control. And I said, “What's going on with you that’s new?” And she said, “Well, I got recently diagnosed with gastroesophageal reflux disease, I got put on some medications for that.” And right then, that was the reason. She's not absorbing very well. She wasn't doing that well on her Synthroid. So I put her on Tirosint, because I knew with her gastroesophageal reflux disease and with her getting on medications to decrease the pH of her stomach, she's not going to absorb her Synthroid very well, so she was a good candidate. I've also had patients that have come in, for example, I had this one lady, poor thing, she came in pregnant, she couldn't get her thyroid controlled. She’d been on the same dose of levothyroxine generic for years. And the endocrinologist she was seeing, never took her off, or tried anything different. And her TSH was markedly out of control. Which was dangerous because she's pregnant. And so she came in for a second opinion. And I knew she was another one that probably was not absorbing very well, I switched her to Tirosint, and sure enough, within two months, we got her to goal. Another patient has celiac disease, or gluten insensitivity, they're another one, they don't absorb very well, their levels aren't stable. And they may have intermittent fluctuating levels. Patients that might be taking iron, because of iron deficiency anemia, and they're on multiple vitamins, their vitamins prevent adequate absorption of their thyroid. So those are good patients that that you can try Tirosint and Tirosint-SOL, and most of the time, you're going to get excellent results when you do that when you switch.


Do You Need an Endocrinologist?


MARY SHOMON: Many hypothyroid patients are diagnosed by their primary care doctors, GPs, family doctors, even gynecologists, who then continue to manage their treatment. So I asked both doctors a question that I am always asked by thyroid patients: “Do I really need to see an endocrinologist?” And if so, when?


DR. ASAMOAH: For a start, I don't think endocrinologist can see all patients with thyroid disease in the country. We don't have enough endocrinologist to do that. We are already overwhelmed, we are stretched with what we're doing. So I would not subscribe to further all of them should see us because we can just see them. There's just not enough time. So that would mean that we need to probably educate our primary care doctors.


Coming from England to the US, I think if you have good general practice doctors, they really become the gatekeepers of health care. And if they know what they're doing, they actually will do a great job for the most part.


I think if a patient has been treated by primary care doctor, and they're not feeling right, maybe six months, one year, it may be appropriate to then refer them to endocrinologist. And then we will try and sort out. So at that point, I do agree that some of them need to refer sooner than later, but not routinely. So if they respond, well, they're doing fine. Why can't the primary care doctor not continue and they are allowed to. But if the patient is still complained of symptoms, six months later, a year later, two years later, it probably is time then to refer to an endocrinologist, because our patients that don't onl have heart disease, but they have other autoimmune conditions. And I can tease that apart. So that's where I would say, we need to come in and help sort it out.


DR. PALOMENO: I would probably definitely go see an endocrinologist. The thing you have to understand about doctors is they’re from all different walks of life. They're all different people. And the studies that are out there are supposed to be guidelines. There are guidelines to help us treat patients. But doctors treat studies a little bit differently. Some people treat guidelines as kind of like the word of God, and you follow the guidelines. And then some people use guidelines as kind of like a manual, a guideline, but you don't have to follow it exactly, but it's there to help you. All doctors are a little bit different. So the ones that are more strict aren't going to be more flexible, but the ones that aren't so strict, are going to be more flexible, as long as you're within range, and as long as you're not doing anything that's going to harm you. So, in my opinion, you should see an endocrinologist, if you think you have a thyroid problem, go see an endocrinologist, because the GPs are not as aware of a lot of the nuances of hypothyroidism, and the nuances of the different levels. And find one that you feel a connection with, that you feel you can trust.


Closing Messages


MARY SHOMON: Before we finished our discussions, I asked both doctors if they had any other message to share with you.


DR. ASAMOAH: What I would recommend strongly -- this is actually probably the biggest message I want to leave for every listener -- is American Thyroid Association is the premier source for thyroid disease information, particularly in this country. I know there's a lot of internet information. Google, all of that, but you want science to lead it and ATA has the world's best experts in terms of thyroid disease overall, hypothyroidism, thyroid cancer, hyperthyroidism and we've got a site dedicated to patient information. We've got excellent physicians that are constantly providing up to date clinical information, research information on thyroid patients. So what I advise people to do is go to the American Thyroid Association website, and seek out patient educational material. Because all these questions we're talking about, we've got access to. So please reach out to the ATA website to get both information and also experts in your local area where you can actually connect with them to be able to give you the best care that you need.


DR. PALOMENO: If you think you have a problem, and you're not feeling well, you should take your body’s advice and advocate for yourself, and go out there and look for answers. Don't just ignore it, because you could have an underlying thyroid problem, and no one knows it, and that's not being looked into, you should definitely, you know, trust your body, trust what your body's telling you.

MARY SHOMON: I’d like to thank this episode’s guests, Dr. Gladys Palomeno, and Dr. Ernest Asamoah.


So, now you’ve heard from the endocrinologists. Do you know yet which road you’ll be taking in your hypothyroidism treatment? Be sure to listen to Part 2 of “Two Roads Diverged” to hear from several leading integrative physicians about their unique approaches to diagnosis and management of hypothyroidism. It probably won’t come as a surprise, but it’s quite different compared to the endocrinology perspective.


Don’t forget that you’ll find a full transcript of this podcast, as well as additional resources, at the Thyroid Deep Dive website, at www.thyroiddeepdive.com. This is Mary Shomon. Live well, and feel well!



Resources and Links


Ernest Asamoah, MD https://fad.ecommunity.com/provider/Ernest+Opoku+Asamoah/186057

Gladys Palomeno, MD https://www.providence.org/doctors/profile/196212-gladys-encarnacion-palomeno

American Thyroid Association Hypothyroidism Guidelines https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4267409/

New England Journal of Medicine, "Effects of Thyroxine as Compared with Thyroxine plus Triiodothyronine in Patients with Hypothyroidism" https://www.nejm.org/doi/full/10.1056/nejm199902113400603

American Thyroid Association - http://www.thyroid.org


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The Levothyroxine Deep Dive is a free, comprehensive educational program that covers everything you need to know about levothyroxine treatment for hypothyroidism, including information about Synthroid, Levoxyl, and Unithroid tablets, Tirosint capsules, Tirosint-SOL oral solution, and generic levothyroxine tablets. The program includes an online guide, a multi-part video webinar, and a downloadable book, available at no cost. See https://www.mary-shomon.com/dive to access the program at no cost.

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The Natural Thyroid Guide is a free, comprehensive educational program that covers everything you need to know about natural desiccated thyroid (NDT) treatment for hypothyroidism, including information about Armour Thyroid, Nature-throid, WP Thyroid, and NP Thyroid. The program includes an online guide, a video webinar, and a downloadable book, available at no cost. See https://www.naturalthyroidguide.com to access the program at no cost.

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