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Do You Need an Endocrinologist?
Is An Endocrinologist the Best Doctor for All Thyroid Patients

by Mary Shomon

Many people write in asking if they need to see an endocrinologist -- the medical speciality that includes thyroid specialists. If you've been diagnosed as hypothyroid by your primary care doctor, gynecologist, GP, or other doctor, you may wonder if you should you go to an endocrinologist for your thyroid treatment? Or if you have been diagnosed and are being treated for hypothyroidism but still do not feel well, would a second opinion from an endocrinologist offer ideas that would help you feel better? Some of you may also wonder if an endocrinologist would be more likely to know about and prescribe Armour Thyroid, or T3 drugs.

There's no clearcut answer as to whether or not you need an endocrinologist. There are times when an endocrinologist is absolutely called for, and there are other times when an endocrinologist is probably not the type of practitioner that will best serve your interests.

What is an Endocrinologist?

First, let's take a look at endocrinologists. An endocrinologist is a doctor who specializes in the endocrine system. (The thyroid gland is part of that system, which also includes the neuroendocrine glands of the pancreas, the parathyroids, pituitary gland, ovaries, and the adrenal glands.) A typical M.D. will spend some time -- but not much -- during medical school studying thyroid gland physiology and the common disorders of the thyroid. Endocrinologists, by virtue of their continuing specialized education, are required to spend more time studying and focusing on thyroid issues. The main concentration of most endocrinologists, however, continues to be the diagnosis and treatment of diabetes, and research into diabetes treatments and drugs. Many endocrinologists specialize in the treatment of diabetes, and only a small number of them consider themselves specialists in thyroid disease.

Endocrinology is a specialty that tends to be overly reliant on tests and numbers. Tests and results are often the main focus on endocrinology treatment. In particularly, the blood sugar levels of diabetes, and the TSH, T4, T3 and other various thyroid blood test levels, tend to drive the diagnostic and treatment protocols to a large part.

There are good endocrinologists who have excellent patient skills, and who work well in partnership with patients. You will need to be very careful to find the right endocrinologist, however, one who is patient-oriented, open-minded, up-to-date, and who has good bedside manner and people skills. This is not always an easy task. Frequently, patients have complained to me that they are viewed more as a lab value than as an actual person who is suffering with symptoms. This attitude can be a downside of going to endocrinologists, who are sometimes referred to as the "accountants of medicine," given their passion for the test and numbers and levels. Endocrinologists are also more likely to carefully follow the very conservative diagnosis and treatment protocols as outlined by the American Association of Clinical Endocrinologists (AACE), and very few incorporate complementary or holistic approaches to diagnosis and treatment of thyroid disease.

Graves' Disease/Hyperthyroidism

When you have the hyperthyroid autoimmune condition known as Graves' Disease, rather than the care of a GP or primary care doctor, you probably should be under the care of an endocrinologist, and not just any endocrinologist, but one who specializes in Graves' Disease treatment. Graves' Disease and hyperthyroidism management can involve a number of therapies, including antithyroid drugs, radioactive iodine treatment, and even surgery, so you're best off with an up-to-date specialist.

If you are interested in alternative treatment for hyperthyroidism or Graves' Disease, you are not likely to find this among most endocrinologists. You will need to find a holistic M.D., or Doctor of Chinese Medicine, who can monitor your hyperthyroidism carefully, while using holistic and complementary medicine techniques -- in some cases even alongside conventional antithyroid drugs. Be sure that you are working with a practitioner who has experience working with hyperthyroidism before you make your selection.

Thyroid Nodule Evaluation

Thyroid nodules are fairly common, but when your doctor discovers one, it can be a nerve- wracking process for you in terms of deciding how to proceed. Typically, nodules are evaluated using ultrasound, and in some cases, a fine needle biopsy process, to rule out the small chance that the nodule is cancerous. When it comes to evaluating nodules, you really want to make sure that you're in the hands of an expert, so this is a good time to consult with an endocrinologist who specializes in thyroid nodules, needle biopsy, and cancer evaluation. Not all endocrinologists have this expertise, so ask in advance, and pre-interview the doctor if necessary.

"Nodules, Goiter and Enlarged Thyroids" -- discusses how a nodule is evaluated and treated, and how to know if a nodule is actually a sign of thyroid cancer.

Thyroid Cancer

Because it is so rare, with less than 15,000 new cases diagnosed each year -- very few physicians have expertise in thyroid cancer diagnosis and management. For thyroid cancer, it is highly recommended that you find one of the doctors with expertise in working with this condition. Some of the best treatment is found at Johns Hopkins, NIH, MD Anderson, and some of the other major teaching and cancer hospitals.

For basic information related to thyroid cancer or diagnosis of suspicious nodules or tumors, start with my article, "An Introduction to Thyroid Cancer," with more info about the diagnosis, treatment, long-term followup and support for thyroid cancer.

Thyroid Surgery

When it comes to thyroid surgery, you really need to make sure your surgery is performed by an expert thyroid surgeon. Sometimes this is an endocrinologist, sometimes an ENT (ear, nose and throat) specialist, and in some cases, a cardio-thoracic surgeon. The title of the surgeon is not really the relevant issue, the real question is experience in thyroid surgery. You want a surgeon who performs at least 50 thyroid operations per year, to ensure an expert who is up to date on the latest techniques, and ideally, someone who has done at least 500 thyroid surgeries in his/her career to date.

For information on detailed review of what to expect from thyroid surgery, how to find a thyroid surgeon, and surgical followup, see my article, Thyroid Surgery: An Introduction..

Hypothyroidism Diagnosis

Typical hypothyroidism diagnosis for an endocrinologist will involve assessment of the TSH level. If the level is above the normal range (at most U.S. labs, the top end of normal is from 4.0 to 5.5), then hypothyroidism is diagnosed. (Note, however, that since 2003, some endocrinologists have recommended that thyroid disease be diagnosed and managed according to a new, narrower range of .3 to 3.0.) Some endocrinologists are so cautious that they don't even believe in treating TSH levels under 10, a level at which many patients report significant and debilitating symptoms.

Where you will not necessarily get much help from an endocrinologist is if you suspect you have hypothyroidism, and have numerous symptoms of the condition, as well as a family history, but test in the "normal range" TSH-wise.

There are doctors who believe that the TSH level is only one factor in diagnosis, and that other levels, symptoms, family history, and other clinical factors can be more important in making a thyroid diagnosis. These doctors do offer options you can pursue, including antibodies testing, treatment for TSH levels above 2 that are accompanied by significant hypothyroidism symptoms, detailed T4/T3 testing, and TRH tests to help identify low-level or subtle hypothyroidism.

Most endocrinologists, however, will not be willing to pursue these types of options with you. You will need to find one of the growing number of general practitioners and holistic/alternative MDs who focus on diagnosing and treatment hypothyroidism.

Hypothyroidism Treatment

After permanent treatment for hyperthyroidism, or after diagnosis and treatment for autoimmune hypothyroidism, many people continue to have symptoms that may be related to the thyroid, symptoms such as such as weight gain, depression, brain fog, hair loss, swelling, shortness of breath, intolerance to heat and cold, muscle aches and joint pains, constipation, carpal tunnel, high cholesterol, infertility, fibromyalgia, chronic fatigue syndrome, and more. If you are with a doctor who has told you that there's no more that he or she can do to help you, as your thyroid is being sufficiently treated, you may wonder if it's time to see an endocrinologist.

Unless you have a personal recommendation from someone who has found a very innovative and open-minded endocrinologist, an endocrinologist may not be the best course. You will likely find that if your TSH is in the normal range, and you're being treated with levothyroxine (i.e., Synthroid, Levoxyl), few endocrinologists will offer any variation on this particular treatment.

Your best course of action is to look for a doctor -- it may be a family practice, holistic M.D., alternative M.D., or osteopath -- who focuses on a more holistic treatment of the thyroid, and who considers lab values only one part of the overall diagnostic and treatment picture, and who is willing to work T3 drugs, rather than relying solely on levothyroxine as the only treatment.

Generally, you'll need to find if too high or low a TSH or a lack of T3 hormone is preventing you from feeling well. A growing number of doctors -- but few endocrinologists -- believe that a TSH level of around 1 - 2 is optimal for most people to feel well and avoid having hypothyroid or hyperthyroid symptoms. (NOTE: this TSH is usually kept even lower than 1-2 for thyroid cancer survivors to help prevent recurrence.) For some people, even if the TSH level is normal, or even in some bases, low normal, there may still be a situation where one is hypothyroid at a cellular level, due to conversion problems or inadequate T3 hormone, or other factors. This can result in continuing symptoms. Inability to properly convert can also result in fluctuating TSH, as the system struggles to keep balancing an out of what T4 and T3 level, sending TSH levels up and down to compensate. Some patients do best on the addition of T3 -- such as in the form of the prescription drug Cytomel, or via compounded time-released T3 -- to their levothyroxine, others take the synthetic T4/T3 drug Thyrolar, and still others seem to do best on Armour, the natural thyroid hormone replacement. But few endocrinologists work with these T3 drugs, despite the February 11, 1999 research report in the New England Journal of Medicine which found that many patients feel better on a combination of T4 and T3, not T4 (i.e., Synthroid) alone.

Finding the Best Doctor for You

Thyroid Top Doctors Directory: For patient-recommended thyroid practitioners -- including holistic experts, endocrinologists, and general practitioners -- see Mary Shomon's Top Docs Directory. The Directory organizes doctors by state and country around the world, and new practitioners are added monthly.

Conventional Endocrinologists: For conventional endocrinologists, visit AACE's "Find an Endocrinologist" Search Service. Remember that not all endocrinologists specialize in thyroid treatment, however, so call and ask about the doctor's focus ahead of time -- and what percentage of their patients have thyroid problems, vs. diabetes -- before you make an appointment.

Thyroid Surgeons: For top thyroid surgeons, Columbia Presbyterian's New York Thyroid Center in New York is considered one of the nation's best thyroid surgery centers. They also offer referrals to doctors in other places in the U.S. who are experienced thyroid surgeons. For a referral, contact:
New York Thyroid Center
Herbert Irving Pavilion
161 Fort Washington Avenue, 8th Floor
New York, NY
Phone: 212.305.0442 / Fax 212.305.0445
PATIENTS LINE: 9am-5pm, 800.543.2782, After 5pm, 800.227.2762

ONLINE REFERRAL CENTER

Web: http://www.cumc.columbia.edu/dept/thyroid/
Email: surgery@columbia.edu

Thyroid Cancer Specialists: For thyroid cancer doctors, go to the Thyroid Cancer Survivor's Association (ThyCa). ThyCa sponsors an annual conference of thyroid cancer survivors, and their website, located at http://www.thyca.org, also features information on how to sign up for their support listserv. This organization -- with their support group meetings and listserv -- is a good way to find a top thyroid cancer doctor in the U.S.


Sticking Out Our Necks and this website are Copyright Mary Shomon, 1997-2009. All rights reserved. Mary Shomon, Editor/Webmaster
All information is intended for your general knowledge only and is not a substitute for medical advice or treatment for specific medical conditions. You should seek prompt medical care for any specific health issues and consult your physician or health practitioner before starting a new treatment program. Please see our full disclaimer.