P.O. Box 982 Evanston, Illinois 60204

IN THIS ISSUE:

VOL. 4, NO. 11

/ ;;;-g; llp.t . 909 NG13 2 £.17

Thyroid Problems

Sylvia Locks hin 120 Shcloornc -Toronto , Ont . Canada

Q

Q

When Muhammad Ali came in a very weak Number Two in his recent heavyweight championship match, he blamed his slowed-down pace on his doctor-prescribed thyroid pills. Ali, taking thyroid for weight loss, reasoned that if one small pill would be good, two would be twice as good. It's too bad that The Greatest never opened the pages of the Physician's Desk Reference. If he had,

Dr. Robert Mendelsohn

a black-bordered box labeled "Warnings" would have told him, "Drugs with thyroid hormone activity ... have been used for the treatment of obesity .... Doses within the range of daily hormonal requirements are ineffective for weight reduction. Larger doses may produce serious or even life-threatening manifestations of toxicity .... " Perhaps it's just as well that Ali never read this warning, for while he may well have missed the mark with Larry

Holmes, he no doubt would have been capable of punching out his doctor. Thyroid hormones, no matter how small their size, are not innocuous. Thyroid

glands are not organs whose surgical removal is to be taken lightly. Thyroid tumors are not always malignant, and malignant thyroid tumors usually are self­contained. That's the message of this month's Newsletter which examines thyroid tr ea tment, surgical removal of thyroid glands, radioactive iodine, and thyroid scans.

During my yearly physical, I told my doctor I had had x-ray treatment for acne when I was a teenager. I was concerned about the possibility of thyroid cancer because of what I had read. The doctor said I did have a small lump on my thyroid, and I either would have to undergo a yearly thyroid scan, or I would have to take pills for the rest of my life to inactivate the thyroid.

I decided to have the thyroid scan, but now I'm concerned about whether this yearly x-ray won't just add to the problem. What informa­tion can you give me?--M.~.

My son, who is now 32 years old, had x-ray treatments as a child for an enlarged thymus. Although the scan he recently took showed negative, he was advised to take thyroid hormones to keep the thyroid from over-1-Jorking. What do you think about this treatment?--Mrs. L.L.

1

A Thyroid

scans and

thyroid hormones

Q

A Stde effects of thyroid medication

Letters like yours continue to come in from people who have been damaged by x-ray treatment for either diseases which never existed (enlarged thymus glands) or diseases (acne, enlarged neck glands, ringworm of the scalp, large tonsils) which could have been managed much more safely and effectively through other treatments.

Ironically, thyroid tumors resulting from this treatment which was prescribed decades ago occur for the most part in those patients who had access to "the highest quality" physicians and "the best" medical centers. Since, in the 1950's, I was practicing high quality medicine, I also prescribed x-ray treatment for tonsils and adenoids in the shortsighted view that the radiologist's beam was safer than the surgeon's knife.

In the intervening decades, a number of my former patients have returned to me for advice about their thyroid glands, some of which have developed nodules. My original response was to throw up my hands and exclaim, "Why would you return to the same guy who was stupid enough to x-ray you in the first place?"

I hope I have learned enough in the intervening years to avoid compounding the error by adding a new form of overtreatment. Like you two ladies, I question the rush to treatment with lifelong thyroid hormones, prophylactic thyroidectomies, and even further radiation.

Many people are unaware that the thyroid scan involves irradiation. According to the booklet ''Information for Physicians on Irradiation­Related Thyroid Cancer" (U.S. Department of HE',;T Publication Number NIH 77-1120), the new agents deliver much lower radiation doses than those previously used, but that's hardly a reassuring statement to those already damaged by supposedly safe doses of radiation. This booklet adds that, "the risk-benefit ratio of repeated scans is not known at this time."

If hormonal therapy is elected, the patient must be re-examined annually to check the adequacy of the therapy and to make sure that the dosage is not producing chronic hyperthyroidism.

When surgery is prescribed, one should remember that the incidence of nerve paralysis to the vocal cords is about 10 per cent, and there is also a significant incidence of permanent tetany and hypothyroidism.

All the above new treatments for x-ray damaged thyroids are long on theory and short on clinical experience. Therefore, before submitting to scans or swallowing the pills, you should ask your doctor what the documented experience is of those patients who have agreed to these treatments vs. those who have rejected them.

And I wonder how many patients who receive diagnostic radioactive procedures are properly instructed to eat separately from the rest of the family, refrain from feeding or bathing small children, and abstain from sexual intercourse for at least two weeks to avoid spreading the radiation.

Are there any side effects from taking thyroid? I have been tested by several doctors during the 22 years I've been married, and all say I need one to two grains of thyroid daily. When I don't take the medica­tion for a while, I have to go back to taking an afternoon nap.

I also have low blood pressure (I think it's around 100 to 110 / 70). The doctors say, "No one ever died of low blood pressure, so you'r e fine."

The thyroid seems to make a difference in my energy level, but if the side effects are worse, I'd rather be tired.--G.P.

The adverse reactions to thyroid hormone result from too large a dose, thus mimicking the picture of hyperthyroidism.

Since you are a woman of childbearing age, you should be informed of existing studies, admittedly based on small numbers, which show that intrauterine exposure to thyroid hormone has been associated with cardiac malformations in the fetus ("Birth Defects and Drugs in Pregnancy," 2

Q

A Overdose

of thyroid

hormone

Q Q

Pub l ishing Sciences Group, Inc., Littleton, Mass.). I' m happy your doctors a re not concerned about your low blood

pr essure and, a s one who likes to t a ke a brief afternoon snooze, I wish they were equally unconcerned about your afternoon nap.

I t ake one grain of Euthroid daily because a goiter was removed 18 years a go. I a lso take two gr a ins of Estrace because I had a complete hyster­ectomy three years a go. (I am 46 years old.)

Ever since my last surgery, I have been unable to return to my secreta rial job which I had had for eight years. I shake so badly that I can neither write nor use the typewriter. When I have these shaking spells, I am unable to think, my head seems swollen, and I feel as though I'm in a daze. During these periods, I find it difficult to talk to people. I break out in perspiration and shake if I have to go inside a bank or if I have to sign any papers; sometimes I can't even write a check. This problem has immobilized me.

I have asked my doctor about this, and he always says, "You are a healthy woman. Go home and keep busy."

Well, doctor, I do keep busy . I enroll in every sewing, crafts and exercise class I can find, yet my symptoms persist. I have tried taking a ll the Vitamin B's, I've gone on a low blood sugar diet, I've stopped drinking coffee, and I've read many, many self-help books.

The shakes are not with me today. If they had been, I would have been unable to write this letter. I need your advice and help.--M.J.

The very symptoms you have--shakiness, nervousness, and sweating--are classic symptoms of overdosage with Warner-Chilcott's Euthroid, a synthetic thyroid hormone. Since you have been taking this drug for so many years, why would you suddenly develop symptoms after your complete hysterectomy ? A lo gical explanation (based on the established inter­relationship of all endocrine glands) is that the removal of your reproductive organs may have altered the functioning of your thyroid gland. Therefore, you should ask your physician to investigate the possibility that your dosage of thyroid hormone is now too high.

But, on second thought, since your present physician seems exclusively interested in lecturing you about your lifestyle, maybe you had better find a doctor who will approach your problem in a more scientific manner.

About two years ago I developed thyroid trouble and had a lump in my neck. After many tests, I was given radioactive iodine. A few months later I was told it had gone too far. How safe is radioactive iodine? I am now on Synthroid and was told I can expect to take it for the rest of my life. Please give me any information you can.--D.G.

Because of an overactive thyroid, I had to take radioactive iodine. I am now taking thyroid medication and am having no trouble except for one thing--my sense of taste and my sense of smell have been affected. The main problem is with my sense of taste--I can taste sugar, salt and citrus flavors, but I can taste other foods only faintly and some not at a ll. Some foods now taste so vile to me that they make me nauseous.

My doctor says nothing can be done about this. Can you help me?--F.H.

3

A Radioactive

iodine for thyroid

condition

Q A Surgical removal

of thyroid gland?

Endocrinolo gist Sheldon Waldst e in, professor of medicine at Northwestern University, has told me that while radioactive iodine itsel f would not interfere with your sense of t aste or smell, some of the antithyroid drugs used until the radioiodine bec omes effective may bring on these symptoms.

Radioiodine, now in use for almost four decades, is often used instead of surgical removal of the thyroid gland. Like surgery, problems dre associated with its use, some of which are pointed out in your letters. There also are other problems. For example, a case recently was brought to my attention in which a mother who was breastfeeding her infant wa s trea ted with radioiodine, and this resulted in the destruction of the infant's thyroid gland.

While s ynthetic thyroid hormone is used for replacement therapy, there is little doubt that it falls short of the natural substance. The concept of obtaining second opinions before undergoing elective surgery seems to be ga ining ground, and some insurance companies already have reported a decrease in a number of certain surgical procedures. Since radioactive iodine is r epla cing thyroid surgery , in order to prevent second thoughts AFTER treatment, it may be good policy to secure a second opinion before treatment.

I was diagnosed as having a multinodular goiter three years ago due to having x-ray treatments on my tonsils when I was a child in the Midwest. I take three grains of thyroid replacement daily. There seems to be a divided opinion as to whether my thyroid gland should be surgically removed . ~~at do you think?--J.M.

In the 1940's and 1950's, it wa s standard procedure in many hospitals to shrink tonsils with x-rays rather than to remove them surgically. In the 1960's, a new iatrogenic (doctor-produced) epidemic surfac ed: Many of the pa tients who had been treated with x-rays developed growths in their thyroid gl and.

In response to your question and similar ones which I have received from many readers, I would like to share with you excerpts from a letter on this subject written to me by an outstanding thyroidolo gist, Dorothea E. Hellman, M.D., of Tucson, Arizona. Dr. Hellman writes:

''Certainly one of the major issues t ha t physicians are now con­fronting is the problem of potent i al thyroid cancer induced by childhood radia tion for such benign dis orders as enlargement of the thymus gland, recurrent tonsillit i s, cervical adenopa thy , acne, etc.

"Thyroid cancer, especially in young people and in women, is a relatively indolent and benign disea se which can be present for many years without affecting the health or longevity of the patient. It tends to be a more serious problem in patients over 40 and in males. It also tends to vary in its prognosis, depending on tissue type.

"S econdly, and of at l east as great significance, the nodule that is often palpable in these thyroid glands is frequently benign, and a carcinoma, when found in a r ad i a ted gl and, may be occult and located in the area considered to be benign both by palpation and radioiodine s can.

"The morbidity of a tota l or subto tal thyroidectomy in inexperienced hands may exceed the morbidity from an unsuspected carcinoma of the thyroid gland. Only an experienced surgeon who specializes in thyroid surgery should a ttempt to deal with a gland that a referring physician feels is suspicious under these circumstances. Here in Tucson, we use one thyroid surgeon for all procedures and have thus far encountered no complications of hypoparathyroidism or recurrent laryng~al nerve damage

4

Q

A Removal

of thyroid tumor and

thyroid gland

in a series totaling over 60 patients. General surgeons have such a high incidence of operative complications in this area that they should not be asked to do this procedure unless the patient is located in an area where a surgeon who specializes in thy roid surgery cannot be located.

"In my experience, most internists are not able to discriminate between a benign a nd a malignant thyroid nodule. This takes many years of experience a nd is often not achieved even by people who are in the field, especially if they are supervising endocrine clinics at teaching hospitals and allowing their house staff and fellows to do most of the physical examinations. In Tucson, we have developed considerable expertise in this area and have a statistical 'success rate' in diagnosing thyroid cancer by palpation accurately as often as physicians elsewhere utilizing needle biopsies for diagnosis . However, I hesitat e to tell patients that this experience is available to them in most areas since it took me nearly 20 years to develop, and I am still working a t it.

"To recommend removal of the thyroid gland in a ll patients who have thyroid nodules following x-ray exposure is to commit a very large number of patients to unnecessary surgery with all its attendan t risks a nd complications. Thyroid cancer in such patients has usually been confined to the thyroid gland and possibly to local nodes. These can cers have often been qui t e small and apparently indolent, a nd highly invasive disease has not been encountered as yet in such patients. None of our patients with very invasive or metastatic disease has a history of child­hood radiation. It might be advisable to discuss going on long-term t hyroid therapy with all patients who have received more than 200 rads of radiation during infancy and early childhood.

"I urge an overall cautious and conservative approach, encourage patients not to be unduly frightened, and am hopeful that, in this par­ticular instance, we have indeed deve l oped a method of therapy and prevention which is logical, non-invasive, and easily tolerated by most patients." (Portions of Dr. Hellman 's remarks h ave appeared in my NetJs­letter Vol. 2, No. 5, The Dangers of X-Rays.)

My 32-year-old son was contacted by the Cancer Society and was asked to participate in a study being conducted at the Roswell Park Institute in our horne town, Buffalo, N.Y. This study would determine whether he had malignant tumors as a result of x-ray treatments for acne which he underwent as a teenager .

My son joined the study, going to the hospital once a month over a six-month period. He took the medication prescribed for him. At the end of that time, three doctors (one of them a surgeon) reported their findings and suggested treatment. An operation was advised to remove the nodes (or nodules), and all or part of his thyroid gland was to be removed. He was told he must t ake medication (desiccated thyroid g l a nd) for the rest of his life even though there is no malignancy.

My son, his father, and I are very much against these procedures! Dr. Mendelsohn, can you suggest an alternate treatment or some other place he can go for further consultation?--A.C.

The doctors at the center you mention as well as all the other cancer hospitals around the country are the direct descendants of all of us doctors who pointed the x-ray beam in the direction of the skin, tonsils, chest and l ymph glands decades ago . And just as their ancestor-doctors experimented with radiation, these cancer doctors now are experimenting with surgery and hormones.

5

Q

A Complications

from thyroid surgery

Lest anyone draw the improper conclusion that Buffalo is in a catego r y by itself, let me assure you that the advice your son received could have emanated from any other high-quality, prestigious medical center in the country. My own hospital, Michael Reese Medical Center in Chicago, several years ago began offering a highly-publicized recall program providing free examinations for everyone to whom they had given this kind of irradiation in the past. Laudable as this program is, the management (surgery, thyroid scans, thyroid hormone, continued surveillance) resulting from these examinations is not free.

Now, back to your questions. Since your son, his father, and you all are opposed to the recommended procedures, the burden of proof lies with the doctors who believe in those procedures. I would advise you to ask them the following questions:

1) Since the treatment of accidentally irradiated thyroid glands has been going on for at least five years, what are their own statis­tical results?

2) How many thyroid tumors have metastasized with a fatal outcome? 3) Wh~t do the doctors think of the evidence that the overwhelming

majority of such tumors, while appearing malignant under the microscope, do not spread in the patient?

4) What is the mortality rate from the surgery? 5) What are the complications of these methods? 6) What is the experience with the considerable number of these

patients who have rejected both surgery and thyroid hormones? 7) Since you ask for alternative treatment, are your son's doctors

familiar enough with various nutritional approaches to provide a care­fully considered judgment?

In addition to the verbal responses of the researchers, they also should be able to provide you with published scientific reports of their own and of other medical centers which can back up their recommendations. Only by thoroughly examining the evidence can you intelligently decide whether the advice you are getting represents a true advance in medicine or whether it represents a compounding of one bad experiment with another. (Editor's Note: This question has appeared in a previous Newsletter, but I am repeating it because of its relevance to the subject of thyroid surgery.)

Last October, I had a benign growth removed from my thyroid. At that time, the surgeon told me the growth had resulted from an inflammation of the thyroid, and he prescribed Synthroid to control it. Now, seven months later, my throat is numb from the line of the incision to my jaw line. At times it is very uncomfortable, and I am not very happy about my family doctor's prediction that it will remain numb.

Is this a common problem, and is there anything that can be done to improve the situation?--Colorado Reader

The list of complications from thyroid surgery includes damage done by cutting certain nerves, most commonly the recurrent laryngeal nerve which controls the voice box. Therefore, it is time for you to carefully ask your surgeon and your doctor whether you are suffering from any of the large number of complications of this kind of surgery. While the thought of legal action may have occurred to you, I would suggest consultation with another surgeon or a neurologist if your own doctor's answers prove less than satisfactory.

6

What's inside

law journals?

Have those of you who are not lawyers ever looked inside the pages of a law journal? While I read plenty of medical journals, I hardly ever see those of the legal profession. However, since the May 1980 issue of Trial carried a review of my book, Confessions of a Medical Heretic, I closely studied the entire issue, and I would like to share with you some aspects of this magazine which were fascinating to me.

Just preceding the review of my book is one of the best articles I have seen about the dangers of Bendectin, the anti-nauseant used in morning sickness. Written by Thomas H. Bleakly, a Detroit lawyer who has co-authored two medical textbooks, the article traces the history of Bendectin anomalies beginning with the 1969 discovery of Canadian physician Donald Paterson that a seven-week premature baby he had delivered had a missing finger, a deformity of the right leg, and only three toes on the right foot. The mother had taken Bendectin . Never­theless, Merrell- National, which has sold Bendectin to 20 million pregnant women, continues to claim that the drug is safe, and as of May 1980, U.S. government agencies supported that position. Paterson's article is required reading for all mothers and fathers whose children were born with any kind of deformities, including club foot, cleft lip and palate, limb reduction, intestinal obstruction, and Down's syndrome.

The article immediately following the review of my book deals with the latest risks of Sear1e's Copper 7 (Cu-7) intrauterine device, particu­larly the possible role this contraceptive appliance may play in causing birth defects if it is allowed to remain in place during pregnancy. This article by a ttorney Jonathan T. Zackey should be read by any woman with pelvic inflammatory disease (salpingitis), blocked tubes, ectopic (tubal) pregnancies, and offspring with birth defects. Attorney Zackey concludes, "Manufacturers and physicians are not conveying or heeding these warnings, and injuries to patients or their offspring result. As it has in the Dalkon Shield matter, the plaintiffs' bar can play an important role in reducing copper IUD injuries." Directions are given for contacting other lawyers who handle IUD cases.

Trial contains a sizable number of advertisements which offer expert medical testimony by hundreds of board-certified specialists in all fields of medicine, surgery, dentistry, pharmacology and hospital care . One such service, headquartered in Washington, D.C. and Monterey, California, describes itself as "A Physician-Run Service for Plaintiff and Defense Counsel." Another service in Pompano Beach, Florida offers "Insightful ability to 'read between the lines'," and a third in Albuquerque, New Mexico headlines, " MALPRACTICE--Record Review and Case Analysis--$234. (Price slightly higher for rush service.) All reviews are conducted by a practicing atto rney-medical doctor."

Both the articles and the ads in this publication which is widely read by lawyers strike me as so valuable that I feel both you and I (and medical students) should be spending more time perusing the learned journals of the legal profession .

Dr. Mendelsohn's book, "Confessions of a Medical Heretic," is now available in paperback (Warner Books, $2.75) .

7

The People's Doctor Newsletter

P.O . Box 982 Evanston, Illinois 60204

© The People"s Doctor Newsletter, Inc.

Published monthly. Subscription rate: $18.00annually.

RobertS. Mendelsohn, MD, Editor Vera Chatz, Assoc iate Editor

by Marian Tompson President, La Leche League

International

During the nine months which followed the nuclear accident at Three Mile Island last year, there was a tenfold increase in the incidence of hypothyroidism among infants in Pennsylvania. The heaviest concentration of cases occurred in Lancaster County which is immediately downwind of the TMI reactor. While public health officials were reluctant to attri­bute this unusual clustering to TMI without further epidemiological investigation, it is known that a large release of radioactive iodine into the atmosphere from a nuclear reactor can produce acute, continuing or late thyroid effects when inhaled, ingested or otherwise absorbed. Because of the inverse relationship between iodine uptake and a ge, the unborn baby is at particular risk in this kind of situation.

Congenital hypothyroidism, if not reco gnized and treated early, can severely retard both physical and mental development in children. It is difficult to diagnose at birth because early signs such as arrested growth, reduced appetite, constipation and bloating may not be apparent for months. Damage usually has occurred by the time a diagnosis is made. Thus, it was exciting a few years ago to learn that fresh mother's milk contained varying amounts of thyroid hormones. Acting on this informa­tion, pediatrician Alfred Tenore, M.D. , and a team of researchers reviewed the records of 109 patients with congenital hypothyroidism who had been admitted to Children's Hospital, Philadelphia, during the past 25 years. The investigators found that, at the time of diagnosis, which averaged about nine months, the breastfed infants had greater bone maturity than did the formula-fed infants. In addition, those who were breastfed had achieved 90 per cent of the length expected for their age, while those who were fed arti ficially had achieved only 50 per cent of expected growth . Even more striking was the discovery that 20 of 32 patients raised on formula suffered brain damage, while none of the 15 who were breastfed showed any signs of intellectual impairment.

Screening newborns for hypothyroidism is becoming mandatory in many states. If we've learned anything from the history of other kinds of routine exams, it is that the more widespread the testing the greater the possibility of inaccurate results through human error and sometimes just plain sloppiness. Therefore, it seems that the best way to protect all babies against the more severe effects of this disease would be breastfeeding them, preferably for two years at which time the danger of brain damage from hypothyroidism diminishes.

But what if a breastfeeding mother has a thyroid problem? Can the thyroid medication she t akes harm her nursing baby? Thyroxine taken by the hypothyroid mother is absent or present in insignificant amounts (in human milk) and there are no known harmful effects. Thyroid-deficient mothers report better milk supply and feel better when taking thyroid supplements. A hyperthyroid mother probably would take propylthiouracil (PTU) which is "not concentrated in human breast milk and recommended dosages to the mother result in minimal and presumably clinically insig­nificant doses to the suckling infant" (Kampmann et a l., "Propylthiouracil in Human Milk," Lancet 1:736-37, 1980). This reference and others can be found in "Breastfeeding and Drugs in Human Milk" by Dr. Gregory White and Mary Kerwin \.-7hite, reprinted from Veterinary and Human Toxicology, Vol. 23, Supplement 1, 1980 available for $5 .00 from La Leche League International, 9616 Minneapolis Avenue, Franklin Park, Illinois 60131.

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