In this episode of PodMD, specialist general surgeon Dr Michael Ng will be discussing the topic of Hyperthyroidism, including what hyperthyroidism is, how a patient would typically present, the risks of the condition, treatment options, when to refer and more. This podcast is the first part in a two-part series. The second podcast will be discussing surgery for hyperthyroidism.

  • Transcript
    Please note this is a machine generated transcription and may contain some errors.
    *As always, all in this PODMD podcast is intended for health professionals and the comments are of a general nature. Information given is not intended as specific medical advice pertaining to any given patient. If you have a clinical issue with one of your patients please seek appropriate advice from a colleague with expertise in the area.

    Today I’d like to welcome to the PodMD studio Dr Michael Ng

    Dr Michael Ng is a specialist general surgeon with special interests in Endocrine (Thyroid and Parathyroid) surgery and Thoracic surgery.

    Michael completed his medical degree at the University of Melbourne and became a Fellow of the Royal Australasian College of Surgeons in 2012 by completing his postgraduate surgical training via the Austin Hospital, Western Hospital and Royal Melbourne Hospitals. Aside from consulting at the Specialist Centre Ballarat, Michael also consults in Maryborough, Metropolitan Melbourne and is currently in the process of commencing consulting in Melbourne’s North and East.

    Today, we’ll be discussing the topic of Hyperthyroidism, which is the first part in a two-part series. The second podcast will be discussing surgery for Hyperthyroidism.

    *We do hope you enjoy this podcast but please remember that the advice here is of a general nature and is not intended as specific advice about a given patient. The views and opinions expressed in this podcast are those of the doctor, not PodMD.
    If you do have a patient on whom you require specific advice, then please seek advice from a colleague with appropriate expertise in that area.

    Michael, thanks for talking with us on Pod MD today.

    Michael: Thanks for having me. It’s good to be here.

    Question 1
    The topic of today’s discussion is Hyperthyroidism. Michael, Can you describe for our listeners what Hyperthyroidism is?

    Michael: Well, essentially hyperthyroidism is the excess hormone production, particularly from the thyroid. The thyroid produces thyroid hormone and really this can be due to a variety of reasons including goitres, autoimmune conditions, viral illness, tumours, medication and very rarely cause from the pituitary gland, but that is certainly less common.

    Question 2
    How would a patient with Hyperthyroidism typically present?

    Michael: Hypothyroidism is certainly a common disease and incidence is estimated between one and 5% of the population. It can present in a variety of ways, one of the common presentations, obviously, is asymptomatic disease and picked up via routine screening as part of a blood panel.

    It can also present more obviously with weight loss, palpitations, hair loss and thin skin. It can also manifest as particularly heat intolerance and sweating, but patients can also have a mental manifestations such as anxiety and irritability.Patients with large goitres can also be hyperthyroid, although goitre itself does not mean that a patient is hypothyroid.

    Question 3
    What are the treatment options?

    Michael: So, so the treatment options are multiple, and we’ll start particularly with observation. In many cases, hyperthyroidism can be what we call subclinical or not overt, in which case we can just observe with time and see how things evolve and progress. In certain disease states such as Hashimoto’s disease, initial treatment is medical, but in the long term hyperthyroidism from this cause actually turns into hypothyroidism, so it is important to note the reason for hyperthyroidism and be able to understand what the natural history is.

    We move onto medication for hyperthyroidism and particularly control of the excess hormone production and there are really 2 main types of medication to control thyroxine production and that is carbimazole and the other drug we generally use is propylthiouracil. Now part of the problems with these are they can have side effects and in particular agranulocytosis.

    Moving on there is option for use of radioactive iodine ablation of the thyroid gland.Which is good and useful, the downside however, being that in a significant proportion of cases we actually take the radioactive iodine ablation a bit too far and patients actually end up hypothyroidism, which is the opposite effect to hyperthyroidism and lastly, surgery can be indicated in hyperthyroidism, particularly in specific cases and we can discuss that at a subsequent podcast.

    Question 4
    Are there any warning signs a GP or their patient can look out for?

    Michael: So that that’s a good question, and I suppose part of the problem with hyperthyroidism and particularly most endocrine diseases are that symptoms can, on the whole, be quite subtle sometimes and particular and not specific at all. But common manifestations of hyperthyroidism include unexplained loss of weight, worse heat intolerance or worsening heat intolerance, excessive sweating, a new onset of atrial fibrillation.

    Other manifestations that would prompt investigation, particularly into the thyroid and hyperthyroidism would also include a neck lump or a goitre and also some eye signs, and in particular the characteristic look of graves ophthalmopathy.

    Question 5
    What is the likelihood of recurrence of the condition?

    Michael: The recurrence of the condition does depend, obviously, on the cause of the disease and and the subsequent treatment thereof. So, for example, in Hashimoto’s disease which is an autoimmune condition, the Natural History is of initial hyperthyroidism followed by a subsequent burnout phase where the patient becomes hypothyroid, which is why it’s important in treating Hashimoto’s that we know what the cause of the hyperthyroidism is and the likely Natural History of it. So, in the initial treatment of Hashimoto’s, we will treat with medication ,but then keeping an eye on it, knowing that you will end up with a burnout phase.

    Other causes of hyperthyroidism obviously include tumours and particularly Graves’ disease. Graves’ disease can be controlled or tumours for that matter, can be controlled medically. However, that will obviously be a long-term medication management regime and we would have to monitor that over the long term. Surgery for particularly tumours causing hyperthyroidism and Graves’ disease should be curative. The downside, obviously, is that patients are can be rendered hypothyroid, which will require thyroxine replacement for the rest of their life.

    So that’s really a slightly complicated answer. It just does depend very much on the the cause of the disease.

    Question 6
    When should a GP refer?

    Michael: Look, I think the there are three main reasons I feel that GPs should particularly refer for hyperthyroidism. I will start off by saying that a lot of mild hyperthyroidism is quite happily managed at the General Practitioner level with medication, however, failure of medical management or or worsening hyperthyroidism despite medical management, should really prompt a referral to other endocrinologists or a surgeon.

    Graves’ disease are particularly when patients are experiencing eye signs and worsening eye symptoms should prompt a referral to an endocrinologist or endocrine surgeon. And lastly, hyperthyroidism due to tumours or goitres should also be referred on for further potential definitive management.

    Question 7
    What role does the GP play in the treatment of the condition?

    Michael: Like many chronic conditions, I think GPs play a crucial role in management and treatment and I think particularly the primary diagnosis and management of Hyperthyroidism and as I said, many cases of hyperthyroidism are mild and management at the General practitioner level is certainly more than adequate, but also particularly ongoing monitoring and care of patients who do have hyperthyroidism, as it can be a chronic disease.

    Concluding Question
    Thank you for your time here today in the PodMD studio. To sum up for us, could you please identify the three key take home messages from today’s podcast on Hyperthyroidism?

    Michael: So firstly, I would say that hyperthyroidism is a common problem with many common symptoms and and there are significant overlaps with other conditions and so we need to be vigilant and mindful that hyperthyroidism can manifest in many ways.

    Secondly, the cause of hyperthyroidism is particularly important in management of hypothyroidism, as knowing the Natural History and cause of the disease will dictate what sort of management is most appropriate for the patient.

    And lastly, we should consider a surgical treatment for hyperthyroidism, especially in the case of patients with diagnosed Graves’ disease.

    Thanks for your time and the insights you’ve provided.

    Michael: Thanks for having me

*As always, all in this PODMD podcast is intended for health professionals and the comments are of a general nature. Information given is not intended as specific medical advice pertaining to any given patient. If you have a clinical issue with one of your patients please seek appropriate advice from a colleague with expertise in the area.