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Deciding on Practitioners for Your Thyroid Care

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Updated May 14, 2012

Deciding on Practitioners for Your Thyroid Care

Thyroid patients face some confusing choices in choosing a practitioner for thyroid care

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The process of deciding what types of practitioners to see for your thyroid diagnosis and care can be complicated and even daunting. In some cases, the initial suspicions of, diagnosis of or treatment of a thyroid condition may be made by your primary care doctor, internist or family practice physician, who may suggest that you don't need any specialist followup. Or, your physician may immediately refer you to an endocrinologist or even a surgeon. In some cases, you may have already seen a long list of practitioners -- regular doctors, endocrinologists, otolaryngologists, surgeons, integrative physicians, naturopaths, chiropractors, even herbalists -- and are not sure who would be the best person in which to entrust your care in the long term.

Here are some guidelines to consider.

For Thyroid Cancer or Suspicious Nodules, Always See a Thyroid Cancer Specialist

Even though, according to the American Cancer Society, thyroid cancer is still one of the least common cancers in the U.S., it is one of the only types of cancer that is actually on the rise. With only around 55,000 people a year diagnosed with thyroid cancer, however, some physicians -- even endocrinologists -- have never diagnosed or treated a thyroid cancer patient. Diagnosis, treatment, and follow-up for thyroid cancer is constantly changing, and so it is crucial to see an endocrinologist who specializes in thyroid cancer. This may require traveling to the nearest major medical center that handles a volume of thyroid cancer patients, but it is well worth the time to consult with someone who is knowledgeable and up-to-date regarding the latest techniques for fine needle aspiration (FNA) biopsy, and thyroid cancer treatment.

For example, only recently, physicians now have access to a new type of FNA analysis, the Afirma Thyroid Analysis from Veracyte, that can virtually eliminate inconclusive FNA results and prevent unnecessary thyroid surgery. But many physicians who do not specialize in thyroid cancer are unaware of this test, and instead send their patients for traditional FNA biopsies. Then, when inconclusive nodules are discovered, these patients are sent for surgery to remove the thyroid, and some discover too late that the nodules were not cancerous.

A good starting point for anyone with suspicious thyroid nodules or a thyroid cancer diagnosis is the Thyroid Cancer Survivor's Association. This group has online listservs and support groups, moderated by physicians who specialize in thyroid cancer, as well as lists of endocrinologists and other specialists who focus their practices on thyroid cancer.

When You Need Thyroid Surgery, Choose an Experienced Thyroid Surgeon

While general surgeons, ear/nose/throat surgeons, and some other types of surgeons can and do perform thyroidectomies, statistics suggest that the best outcomes, and the lowest risk of any complications in thyroid surgery, are found when surgeons have performed a substantial number of thyroid surgeries, and who in fact make thyroid surgery a significant part of their practice.

New York's Columbia-Presbyterian, one of the nation's top thyroid surgery centers, rates surgeons as follows, in terms of total number of thyroid/parathyroid surgeries performed:

  • Less than 200 surgeries: inexperienced
  • 200 to 500 surgeries: intermediate
  • More than 500 surgeries: experienced
  • More than 1,000 surgeries: expert
Also keep in mind that there are cutting-edge surgical techniques offered by only a few surgeons in the country, including endoscopic axillary underarm surgery, that allow a patient to undergo a thyroidectomy without an incision in the neck, or resulting scar, and with shorter recovery times.

See Finding a Top Thyroid Surgeon for resources and referral sources for top thyroid surgeons.

When You Have a Graves' Disease, See an Endocrinologist

Graves' disease, the autoimmune condition that causes the thyroid to become overactive, can be complicated to diagnose and treat. And treatment guidelines are regularly changing. For example, physicians now prefer to use the antithyroid drug methimazole (Tapazole), versus propylthiouracil (PTU), due to concerns that PTU can cause liver damage. More physicians are now measuring TSI - thyroid stimulating immunoglobulins -- to assess Graves' disease severity as well. Endocrinologists -- and in particular, those who focus their practice more heavily on thyroid patients -- typically are more knowledgeable about the current thinking in Graves' disease diagnosis and treatment.

When You Have Hashimoto's Disease or Hypothyroidism, Be Sure To See An Endocrinologist at Least Periodically

Many thyroid patients believe that if they have Hashimoto's disease -- the autoimmune disease that typically causes the gland to become destroyed -- or hypothyroidism -- an underactive thyroid -- that there's no reason to see an endocrinologist. And in fact, I have often argued that for ongoing care, an endocrinologist may not be the best choice.

It is important, however, to at some point be evaluated by an endocrinologist. (Note, however, that given the shortage of endocrinologists in the U.S., it can take time to get an appointment.) An endocrinologist can typically perform the detailed clinical examination, as well as order or perform the thyroid imaging tests that can evaluate the structure of your thyroid gland to determine if there is a goiter (an enlarged gland), if the location of othe goiter is compromising breathing or swallowing, if there is atrophy of the gland, if there are any nodules, and if so, if those nodules warrant further investigation.

One important reason? Having Hashimoto's disease increases the risk of developing thyroid cancer. Many doctors simply treat the hypothyroidism that results from the Hashimoto's, without any consideration of the increased cancer risk, making a periodic check-in with an endocrinologist particularly important.

When You Need Optimal Hypothyroidism Treatment, Consider an Integrative or Functional Medicine MD, DO or Prescribing Naturopath For Ongoing Hormone Management

Most thyroid patients end up hypothyroid -- with an underactive, non-functioning, or surgically removed thyroid -- and will require lifelong thyroid hormone replacement medication. It is in this area where the integrative, functional medicine, complementary and holistic MDs, osteopathic physicians (DOs) and naturopaths (in states where they have license to prescribe medications), can be an asset to your care.

These physicians are typically more willing to run the complete panel of thyroid tests -- not just TSH, but Free T4, Free T3, thyroid antibodies, and Reverse T3 -- to help diagnose and manage thyroid treatment. They are also typically far more willing to work with the full range of prescription thyroid medications -- i.e., levothyroxine drugs like Synthroid and Levoxyl), T3 drugs like Cytomel, natural desiccated thyroid like Armour and Nature-Throid, and compounded thyroid drugs, like time-released T3. Traditional endocrinologists and internists often rely solely on the TSH test, and will only treat with a levothyroxine drug. Additionally, these physicians often look at the complete hormonal picture -- adrenal function, sex hormone balance, and blood sugar/insulin -- and offer natural approaches, lifestyle changes, and in some cases, prescription medications to help restore health and balance.

For a look at how innovative practitioners view optimal hypothyroidism treatment, see Practitioners Share Their Approaches to Optimal Hypothyroidism Treatment.

Consider Other Practitioners to Complement Your Care

When you have exhausted all the options offered by more traditional practitioners and integrative medical doctors, consider looking to others who may be able to advise regarding natural approaches to symptom relief, supporting the immune or intestinal systems, and other more holistic approaches. Here, you may wish to bring in a naturopath, an herbalist, a nutritional expert, a chiropractor with a focus on nutritional approaches, or a mind-body expert. (Again, keep in mind that in many states, naturopaths can not prescribe any medications, and in the U.S., chiropractors by law are not permitted to prescribe any prescription drugs, and thus can not prescribe thyroid hormone replacement medication.)

* * *

Remember that these guidelines are not hard and fast. You will sometimes find a primary care doctor or endocrinologist who has a keen focus and interest in thyroid disease, and does a wonderful job managing your hypothyroidism, for example. Trusting your judgement, along with good communications with your practitioner, will go a long way toward keeping you on the path to thyroid wellness.

Source:
American Cancer Society, "What are the key statistics about thyroid cancer" : 01/20/2012, Online: http://www.cancer.org/Cancer/ThyroidCancer/DetailedGuide/thyroid-cancer-key-statistics

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