Understanding your thyroid and parathyroid with Susan Hagen, MD, FACS
Understanding thyroid disease is personal for Susan Hagen, MD, FACS.
As a surgeon with Boulder Valley Surgical Associates, Dr. Hagen specializes in surgical treatment of thyroid and parathyroid disorders, surgical treatment for breast cancer, and has received national recognition for both surgical leadership and excellence in teaching.
Long before she became a surgeon, however, Dr. Hagen was diagnosed with thyroid cancer after a routine primary care visit uncovered a thyroid nodule she didn't even know she had.
"This subject is especially important to me because I've experienced this as a patient and, of course, much more frequently as a surgeon," Dr. Hagen shared during her recent BCH Community Education lecture.
Her diagnosis led to surgery and two rounds of radioactive iodine treatment, but it also gave her a new appreciation for the trust that patients place in their physicians.
"I learned a lot about being a patient and the vulnerability that comes with that," she said. "Not always knowing who you're seeing. Are they really the best? Do they have your interests at heart? What happens if something goes wrong?"
That perspective continues to shape how Dr. Hagen cares for her patients.
"I am awed every day how patients come in and put trust in us to care and provide what we think is the best care for our patients."
Two glands, two different jobs
Many people assume the thyroid and parathyroid glands work together. They don't.
"The only reason why the parathyroid is called a parathyroid is it lives next door to the thyroid," Dr. Hagen explained. "They actually don't really interact with each other."
The thyroid is the butterfly-shaped gland at the front of the neck that regulates metabolism. It produces hormones that affect nearly every organ system, influencing how the body uses energy, regulates temperature and controls heart rate.
The parathyroid glands, usually four tiny glands located behind the thyroid, have a completely different responsibility: regulating calcium levels in the blood. Although these glands are small, the anatomy of the neck is anything but simple.
"There's a lot of important structures that live near here," Dr. Hagen said. "This is a very busy area of the neck. You've got to have someone who loves being here in order to do the surgery."
Thyroid symptoms aren't always clear
One of the biggest challenges with thyroid disease is that many symptoms can easily be mistaken for everyday life or other medical conditions.
"They may be related to the thyroid and they may not," Dr. Hagen said.
An overactive thyroid, known as hyperthyroidism, can cause symptoms including:
- Heat intolerance
- Anxiety
- Sweating
- Diarrhea
- Increased heart rate
- Hair loss
- Insomnia
Graves' disease, an autoimmune disorder, is one of the most common causes of hyperthyroidism.
When the thyroid is underactive — hypothyroidism — the body's metabolism slows.
"When we think of underactive thyroid, we're thinking fatigue, weight gain, constipation, dry skin, sometimes heavier menstrual cycles, memory issues and difficulty concentrating," Dr. Hagen said.
Hashimoto's thyroiditis is the most common autoimmune cause of hypothyroidism, although thyroiditis, iodine deficiency, surgery and other conditions can also lead to reduced thyroid function.
Because these symptoms overlap with so many other conditions, evaluation usually begins with a primary care provider.
"We often will check the lab for a TSH (thyroid-stimulating hormone) because that's something that we can test blood work for," Dr. Hagen explained. "If it's normal and you have these symptoms, you don't have to despair. It just means we have to go further and look further into it."
Common thyroid conditions
Thyroid disorders are common, affecting an estimated 20 million Americans according to the American Thyroid Association, with women significantly more likely than men to develop thyroid disease.
In addition to hyperthyroidism and hypothyroidism, another common condition is goiter, an enlargement of the thyroid gland. A goiter develops when the body doesn't produce enough thyroid hormone and the gland enlarges in an attempt to compensate.
Thyroid nodules are also common. While many are benign, some require additional evaluation to determine whether they could represent thyroid cancer.
Understanding thyroid cancer
Hearing the words "thyroid cancer" can be frightening, but Dr. Hagen explained that many thyroid cancers have an excellent prognosis.
Papillary thyroid cancer accounts for approximately 80% of cases and is generally the most favorable type. Other forms include follicular, medullary, oncocytic and anaplastic thyroid cancer, each with their own characteristics and treatment approaches.
Diagnosing thyroid disease often begins with blood work and imaging, including ultrasound. Depending on the findings, patients may undergo nuclear medicine imaging or an ultrasound-guided needle biopsy. In some cases, additional molecular testing helps determine whether a thyroid nodule is likely to be cancerous.
"When they look at a biopsy, they're able to say what type of cell is acting up," Dr. Hagen said. "That helps us understand prognosis."
Not every thyroid condition requires surgery
Dr. Hagen is not the first step in a patient’s care.
"I am a surgeon," she said. "I am the last stop."
Many thyroid conditions can be managed with medication, observation or ongoing monitoring. Surgery is typically considered when thyroid cancer is diagnosed, nodules appear suspicious, an enlarged thyroid causes difficulty swallowing or breathing or hyperthyroidism cannot be controlled medically.
Depending on the diagnosis, surgery may involve removing one lobe of the thyroid — lobectomy — or the entire gland — thyroidectomy. Some patients may also require removal of nearby lymph nodes.
Today's approach is also more personalized than it once was.
"We're able to do precision medicine," Dr. Hagen said. "We're able to say, 'Wait, is this a tiny little cancer that's slow growing? Can we save half the gland and monitor?'"
Dr. Hagen provides surgical treatment for thyroid nodules, thyroid cancer, enlarged thyroids (goiters), hyperthyroidism, hyperparathyroidism, parathyroid adenomas and other endocrine conditions. Learn more about BCH's Endocrine Surgery program and when surgery may be appropriate.
Tiny glands that regulate calcium
Most people have four parathyroid glands, although nearly one in five people has a different number.
"They're smaller than a pencil eraser," Dr. Hagen said.
Their role is to carefully regulate calcium levels throughout the body.
"When calcium is low in the blood, the parathyroid ramps up and releases more calcium."
When one or more glands become overactive, a condition known as hyperparathyroidism, calcium levels in the bloodstream rise while calcium is pulled from the bones.
"Bones, stones, groans and psychiatric overtones,” Dr. Hagen emphasized.
The phrase refers to the common effects of elevated calcium levels, including bone pain, osteoporosis, fractures, kidney stones, digestive problems, muscle aches, irritability and memory changes.
About 80% of primary hyperparathyroidism cases are caused by a single overactive gland, while the remainder may involve multiple glands or inherited syndromes. Diagnosis generally includes blood tests measuring calcium and parathyroid hormone levels, followed by imaging to locate the affected gland when surgery is being considered.Most parathyroid operations involve removing only the abnormal gland, allowing calcium levels to return to normal and relieving symptoms.
The steps of endocrine care
Whether symptoms point to the thyroid or parathyroid glands, Dr. Hagen stressed that the first step is talking with your primary care provider.
"The biggest thing is to talk to a primary care physician first," she said. "They are the people who order those basic labs."
Depending on the results, patients may be referred to an endocrinologist for medical management or to an endocrine surgeon when surgery becomes the best treatment option.
Dr. Hagen works closely with primary care providers and endocrinologists to develop personalized treatment plans based on each patient's diagnosis, anatomy and long-term goals.
If you've been diagnosed with a thyroid or parathyroid condition, or have symptoms that need further evaluation, learn more about the BCH Endocrine Surgery program or schedule a consultation with Susan Hagen, MD, FACS, by calling Boulder Valley Surgical Associates at 303-415-4599.