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.
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.
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.
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..
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.
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
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
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
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
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