SEPTEMBER 2019 | FUTUREOFPERSONALHEALTH.COM
An Independent Supplement by Mediaplanet to USA Today
ENDOCRINE HEALTH
Jaime King
The model and actress opens up about her struggles with endometriosis and infertility
A breakdown of the signs and symptoms of an underactive thyroid Why we need to raise awareness for Cushing’s syndrome
The Endocrine System’s Effects on Aging The many advances we’ve made in modern medicine have dramatically increased the average lifespan in the United States over the past century, but healthful longevity with an excellent quality of life is the goal.
Aaron I. Vinik, M.D., Ph.D., FCP, MACP, FACE Member, American Association of Clinical Endocrinologists (AACE)
onsidering the rapidly growing elderly population, examining the endocrine system’s far-reaching effects in longevity and healthy aging deserve greater attention and understanding.
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including physical frailty, hip fractures, and other injuries. While there are common, non-endocrine causes of sarcopenia, such as inactivity, weight loss without exercise, reduced blood flow, and genetic factors, the muscles are supported by the endocrine system.
Sarcopenia Defined as age-related low muscle function (walking speed or grip strength) in the presence of low muscle mass (muscle wasting), the prevalence of sarcopenia varies widely, with estimates suggesting it is present in up to 13 percent of people ages 60-70, and up to 50 percent in those 80 years of age and older. It is one of the root causes of a host of health issues that plague the elderly,
Thyroid Another area that should be examined is how the aging process affects the thyroid function. Aging is associated with decreased secretion of thyroid-stimulating hormone, which is produced by the pituitary gland in the brain, and directs the thyroid to make and release essential thyroid hormones T3 and T4 into the blood, where they travel to, and are
used by, multiple target organs and systems. T3 and T4 secretions also are impaired as we age. As a result of these changes, there is an increased prevalence of thyroid disease in the elderly, particularly what is known as sub-clinical thyroid disease, a disease that is not severe enough to present definite or readily observable symptoms. Testosterone It is widely known that testosterone concentrations decline with age. It is important to determine in older men if a low testosterone level is simply caused by aging or if it is due to hypogonadism, a disease in which the body is unable to produce normal amounts of testosterone because of a problem with the testicles or
the pituitary gland, which controls the testicles. There are many other endocrine system changes that occur with aging that significantly impact how we age and, thus, deserve greater attention: bone disease, growth hormone therapy, and Type 2 diabetes, as well as the interaction of nutrition and metabolism, just to name a few. As we become more focused on these changes and gain critical insight into the complex association between aging and the endocrine system, the valuable information produced by these efforts will help us enhance function in our aging population and lead to not only longer lives, but better quality ones as well. n
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Why Cushing’s Syndrome Can Be So Difficult to Detect
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or many patients with Cushing’s syndrome, a delayed diagnosis of 6-10 years is not uncommon. It’s hard to believe this is possible considering the information age in which we live. Why is Cushing’s so difficult to diagnose? The answer is almost as elusive as diagnosing Cushing’s itself. There isn’t just one reason for a delayed diagnosis; there are many factors that come into play, all of which work against the patient. Understanding Cushing’s It helps to understand that the glucocorticoid hormone cortisol controls nearly every organ and tissue in the body, and too much cortisol has an adverse effect on every organ and tissue. Cortisol production is regulated by the hypotha4 • FUTUREOFPERSONALHEALTH.COM
lamic-pituitary-adrenal axis in the body. Causation factors for hypersecretion of cortisol can be within the axis, but it can also be ectopic or can be caused by taking corticosteroid medications. As this hormone ravages the body, the clinical manifestation of nonspecific symptoms that overlap with other diseases begin to appear. Complicating diagnosis, oftentimes Cushing’s patients’ symptoms are not textbook. As the illness progresses, it causes a decreased quality of life, hopelessness, and depression. It is believed the average primary care doctor has probably never diagnosed a Cushing’s patient, and the training provided by most medical schools on pituitary-related illnesses is a distant memory to these physicians. Even some endocrinologists can miss the signs of this rare, complex disease.
Physicians are often taught to focus on the likeliest possibilities instead of looking at the whole constellation of symptoms. The symptoms are treated while the disease does untold damage. Patients see many doctors and are given multiple medications. If diagnosed and treated at this point, recovery will be a long road and some symptoms may be irreversible. Improving the process There is not one definitive test used when Cushing’s is suspected, which further complicates diagnosis. Physicians often run multiple tests depending on causation, which can include MRI, blood assays, urine test, CRH and ACTH stimulation tests, saliva test, dexamethasone suppression test, and the more invasive inferior petrosal sinus sampling.
Cushing’s syndrome causes a wealth of unpleasant symptoms while doing long-term damage to the body, but with no uniform plan for diagnosis, it can take a while to detect. Here’s what we need to do to improve this process.
Future research and development is needed to simplify this process. Ultimately, awareness in the medical community is key to earlier diagnosis. The Pituitary Network Association produces monthly webinars presented by pituitary specialists that are posted to our website, as well as to an educational platform for doctors with over 250,000 subscribing physicians. We also have a Continuing Medical Education program for nurses on our website as we know nurses are often the first people that see patients. Our goal is to help every Cushing’s patient who may be forgotten, abandoned, or, worse yet, undiagnosed after many years of suffering, find the answers for which they are looking. Knowledge is the best defense. n Carol Knudsen, Director of Strategic Planning, Pituitary Network Association
What Is Cushing’s Syndrome and Why Should We Be Concerned About It? Approximately 25,000 Americans are living with Cushing’s syndrome but our understanding of the disease is still lacking. We talked to Fredric Cohen, chief medical officer at Strongbridge Biopharma, about what causes Cushing’s and why it can be so difficult to detect.
Can you give a brief overview on what Cushing’s syndrome is? Cushing’s syndrome is a rare endocrine disorder that is usually not inherited and typically affects adults. It is characterized by a variety of symptoms and physical abnormalities that are caused by excessive amounts of the hormone cortisol. Cortisol is a vital hormone made by the adrenal glands. The body uses cortisol to maintain normal bodily functions of everyday life, like regulating your blood sugar and metab-
olism. For those with endogenous Cushing’s syndrome, the adrenal glands secrete cortisol in a disordered way throughout the day and night, not in response to stress, but due to an internal cause, usually because a tumor is driving the excessive production of cortisol. About how many people are affected by endogenous Cushing’s syndrome? In the United States, approximately 25,000 adults are diagnosed with endogenous
Cushing’s syndrome. In general, more women than men are affected, and the most common cause is a benign pituitary tumor. Why is it important to continue conducting research and clinical studies for Cushing’s syndrome? Significant unmet medical needs remain in the diagnosis and treatment of endogenous Cushing’s syndrome that can be positively impacted by clinical research. Focusing on treat-
ment, we estimate that 4,000 of the approximately 7,000 patients with active Cushing’s syndrome (i.e., experiencing signs and symptoms of Cushing’s syndrome) are either not being treated for excess cortisol or, if they are being treated, continue to be exposed to excess cortisol despite current treatment. Healthcare providers depend on rigorous evidence to support their treatment recommendations, and that evidence is best obtained through established research methods, like clinical trials. n
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What to Consider When Deciding to Treat or Manage Endometriosis Laparoscopic excision surgery is considered the “gold standard” of endometriosis treatment, but there are many reasons to consider delaying or not receiving the procedure.
Endometriosis is a disease of menstruation. It occurs when tissue similar to the lining of the uterus, or endometrium, migrates outside of the womb, where the tissue should not be. The result is inflammation, as the tissue responds to the monthly fluctuations of a woman’s menstrual cycle. 6 • FUTUREOFPERSONALHEALTH.COM
The disease affects an estimated 200 million women worldwide, and many women often experience a decade-long delay in diagnosis. Currently, the only known cause is a person’s genetic makeup. The disease is highly treatable, although there is no finite “cure.” The most important thing to understand about treating and managing endometriosis is that managing the disease only treats the symptoms. It does not eliminate the disease. No alternatives will rid you of long-term pain as effectively as excision surgery. Some sup-
posed treatments (whether it’s managing the disease through synthetic hormones or maintaining a healthy diet) may help to slow the disease growth, but they aren’t going to kill or shrink the tissue that has already implanted inside your body. Treatment The “gold standard” of endometriosis treatment is timely intervention by laparoscopic excision surgery. This type of surgery leaves a completely disease-free environment where organs can function properly without scar tissue. The tissue
can then be examined under a microscope and confirmed for a definitive diagnosis. Management Managing endometriosis focuses on eliminating pain and associated symptoms of the disease, and is not a treatment. Management can consist of using oral contraceptives to halt ovulation and minimize the menstrual flow, thus eliminating the pain associated with uterine cramps. This can temporarily eliminate your pain by stopping your menstrual flow, but it does not remove the endometriosis lesions in your body. Making sure So why do we suggest alternatives to excision surgery? For several reasons. One is that not every girl with one or two symptoms of endometriosis should undergo surgery at 13 or 14. It is crucial to first establish the level of pain a young girl is experiencing, and whether that pain prevents her from performing well in school, extracurriculars, or social engagements before surgical intervention occurs. Furthermore, they should take birth control pills. The good news is that many adolescents benefit from the use of oral contraceptives for many years, as the pill controls the progression of the disease. In addition, some women are afraid to have invasive surgery and want to exhaust all avenues for treating symptoms. There are also women who have recently gone through a pregnancy or have had multiple endometriosis surgeries and, for now, want to give their bodies time to heal. n Tamer Seckin, M.D., Endometriosis Surgeon, Lenox Hill Hospital; Founder, Endometriosis Foundation of America (EndoFound)
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Silent disease In her 20s, King, who started her career modeling for Armani, Calvin Klein, and Victoria’s Secret, started unexpectedly gaining weight despite eating well, exercising, and being holistic. Doctors misdiagnosed her with a thyroid problem. “I really didn’t understand what was wrong with me,” she said. “It was very isolating.” When she was 28, Dr. Randy Harris diagnosed her with endometriosis. The condition, which involves tissue similar to the uterus’ lining growing outside of the uterus, affects 6.5 million women in the United States. During that appointment, Dr. Harris told King she was pregnant, but two weeks later, she was in severe pain, was bleeding, and later miscarried. She was distraught. “I was going through it very privately,” King said. “Nobody talked about this.” Now the actress, who plays Rosie on Netflix’s “Black Summer,” is speaking out so other women don’t feel so alone. “I have to share what happened to me,” she said. “The idea
that other women are suffering in silence like this kills me.”
Model and Actress Jaime King Shares Her Journey Through Endometriosis and Infertility Model and actress Jaime King has struggled with endometriosis, polycystic ovary syndrome, and infertility, including undergoing numerous fertility treatments and having 15 miscarriages. Now she’s sharing her story, advocating for awareness, and supporting other women.
PHOTO: COURTESY OF JEFF VESPA, VESPA PICTURES
or years, Jaime King, now 40, had painful periods that lasted a week, as well as migraines, exhaustion, and other symptoms that made her life difficult. She thought it was normal because that’s all she’d ever known. Over the years, she’d been to nine doctors, each of whom gave her a different diagnosis. “Women are not supposed to be in pain,” she said, “but women don’t always know that.”
Managing her disease King says she never knows how she’s going to feel each day, which makes it difficult to manage symptoms. She takes a birth-control pill daily to suppress her periods, explaining not getting her period prevents scar tissue from forming in her uterus. She encourages all women experiencing painful periods and infertility to get checked out and diagnosed. She’s also an advocate for freezing your eggs. “The sooner you can get diagnosed, the better,” King said. “The more you can suppress the endometriosis, the more you protect and preserve your fertility.” Currently, the options for treating endometriosis are to take birth control to suppress fertility, taking a drug to induce menopause, or having a hysterectomy. “That’s not acceptable to me that those are the only options,” King said. Not alone After years of ongoing infertility, King and her filmmaker husband Kyle Newman now have two children, Leo Thames, 6, and James Knight, 4. She wants other women to know an endometriosis diagnosis doesn’t necessarily mean you’ll have fertility problems. Still, she encourages women on the journey to find a good doctor, and to have the support of friends and family. “Get a second opinion, a third opinion,” she said. “Really feel out what’s right for you. Know that you are not alone.” n Kristen Castillo FUTUREOFPERSONALHEALTH.COM • 7
Hypothyroid treatment doesn’t have to be full of obstacles. Taking thyroid medication and still don’t feel right? You’re not alone. Nearly half of patients taking traditional thyroid medicines have factors that can negatively affect how well their medicine works.1 Food allergies, stomach conditions, and the use of common nonprescription drugs are often to blame.1
Learn more at www.Tirosint.com
Traditional thyroid medicines come in tablet form and can contain fillers like gluten, lactose, dyes, and preservatives.2 These can cause irritation or interfere with how your medicine might work. With so many hurdles, it can feel like there’s a lot standing between you and feeling better.
Take steps toward feeling like yourself again. Pure and consistent. Tirosint® (levothyroxine sodium) gel capsules are a unique thyroid medication that doesn’t contain filler ingredients that can cause problems or negatively affect your therapy.3 It’s proven to provide consistent control for a wide variety of patients, even those taking antacids or who have stomach problems that are known to interfere with traditional thyroid tablet medications.4,5
Relief at an affordable price Nine out of 10 patients with commercial insurance can pay as little as $25 for a month’s supply of Tirosint with our new copay card. No insurance or have high deductibles/copays? Go to www.Tirosint.com to learn about Tirosint Direct to get the lowest cash price. Avoid the hurdles. Ask your doctor about Tirosint today.
References. 1. McMillen M, et al. Comorbidities, concomitant medications and diet as factors affecting levothyroxine therapy: results of the CONTROL Surveillance Project. Drugs in R&D. 2015;16(1):53-68. 2. Levothyroxine sodium package insert. Princeton, NJ: Sandoz Inc.; 2008. 3. Tirosint package insert. Lugano, Switzerland: Institut Biochimique (IBSA); 2017. 4. Seng Yue C, et al. When bioequivalence in healthy volunteers may not translate to bioequivalence in patients; differentiated effects of increased gastric pH on the pharmacokinetics of levothyroxine capsules and tablets. Journal of Pharm Sci. 2015:18(5):844-858. 5. Santaguida MG, et al. Thyroxin softgel capsule in patients with gastric-related T4 malabsorption. Endocrine. 2015:49 (1):51-57. IBSA Pharma Inc., 8 Campus Drive, Suite 201, Parsippany, NJ 07054 © 2019 IBSA Pharma Inc. All rights reserved. IB-CRP-19-0021
IMPORTANT SAFETY INFORMATION WARNING: NOT FOR THE TREATMENT OF OBESITY OR FOR WEIGHT LOSS • Thyroid hormones, including TIROSINT, either alone or with other therapeutic agents, should not be used for the treatment of obesity or weight loss. • In euthyroid patients, doses within the range of daily hormonal requirements are ineffective for weight reduction. • Larger doses may produce serious life-threatening manifestations of toxicity when given with other weight loss drugs. INDICATIONS AND USAGE TIROSINT is L-thyroxine (T4) indicated for adults and pediatric patients 6 years and older with: • Hypothyroidism - As replacement therapy in primary (thyroidal), secondary (pituitary), and tertiary (hypothalamic) congenital or acquired hypothyroidism.
• Pituitary Thyrotropin (Thyroid-Stimulating Hormone, TSH) Suppression - As an adjunct to surgery and radioiodine therapy in the management of thyrotropin-dependent well-differentiated thyroid cancer. LIMITATIONS OF USE • Not indicated for suppression of benign thyroid nodules and nontoxic diffuse goiter in iodine-sufficient patients
• Not indicated for treatment of transient hypothyroidism during the recovery phase of subacute thyroiditis Monitoring TSH and/or Thyroxine (T4) Levels Persistent clinical and laboratory evidence of hypothyroidism despite an apparent adequate replacement dose of TIROSINT may be evidence of inadequate absorption, poor compliance, drug interactions, or a combination of these factors. In adult patients with primary hypothyroidism, monitor serum TSH levels after an interval of 6 to 8 weeks after any change in dose. Warnings and Precautions • Cardiac Adverse Reactions in the Elderly and in Patients with Underlying Cardiovascular Disease: Overtreatment with levothyroxine may cause an increase in heart rate, cardiac wall thickness, and cardiac contractility, and may precipitate angina or arrhythmias, particularly in patients with cardiovascular disease and in elderly patients. Initiate TIROSINT therapy in this population at lower doses than those recommended in younger individuals or in patients without cardiac disease. • Myxedema coma: Use of oral thyroid hormone drug products is not recommended to treat myxedema coma. • Acute adrenal crisis in patients with concomitant adrenal insufficiency: Treat patients with adrenal insufficiency with replacement glucocorticoids prior to initiating treatment with TIROSINT. • Prevention of hyperthyroidism or incomplete treatment of hypothyroidism: Over- or under-treatment with TIROSINT may have negative effects on growth and development, cardiovascular function, bone metabolism, reproductive function, cognitive function, emotional state, gastrointestinal function, and on glucose and lipid metabolism. • Worsening of diabetic control: Carefully monitor glycemic control after starting, changing, or discontinuing thyroid hormone therapy. • Decreased bone mineral density associated with thyroid hormone over-replacement: Increased bone resorption and decreased bone mineral density may occur as a result of levothyroxine over-replacement, particularly in post-menopausal women. Adverse Reactions Notify your healthcare provider if you experience any of the following symptoms: rapid or irregular heartbeat, chest pain, shortness of breath, leg cramps, headache, nervousness, irritability, sleeplessness, tremors, change in appetite, weight loss, vomiting, diarrhea, excessive sweating, heat intolerance, fever, changes in menstrual periods, hives or skin rash, or any other unusual medical event. This is not a comprehensive list. Adverse Reactions in Children Pseudotumor cerebri and slipped capital femoral epiphysis have been reported in children receiving levothyroxine therapy. Hypersensitivity Reactions Hypersensitivity reactions to inactive ingredients have occurred in patients treated with thyroid hormone products. These include urticaria, pruritus, skin rash, flushing, angioedema, various GI symptoms (abdominal pain, nausea, vomiting and diarrhea), fever, arthralgia, serum sickness and wheezing. Use in Specific Populations Pregnancy Experience with levothyroxine use in pregnant women, including data from post-marketing studies, have not reported increased rates of major birth defects or miscarriages. Since thyroid-stimulating hormone (TSH) levels may increase during pregnancy, TSH should be monitored and TIROSINT dosage adjusted during pregnancy. Lactation Limited published studies report that levothyroxine is present in human milk. Pediatric Use Closely monitor infants during the first two weeks of TIROSINT therapy for
cardiac overload, arrhythmias, and aspiration from avid suckling. Closely monitor children during the first two weeks of TIROSINT therapy for cardiac overload or arrhythmias. Geriatric Use Atrial fibrillation is the most common of the arrhythmias observed with levothyroxine overtreatment in the elderly. Overdosage The signs and symptoms of overdosage are those of hyperthyroidism. In addition, confusion and disorientation may occur. Cerebral embolism, shock, coma, and death have been reported. Seizures occurred in a 3-year-old child ingesting 3.6 mg of levothyroxine. Symptoms may not necessarily be evident or may not appear until several days after ingestion of levothyroxine sodium. Distribution Thyroid hormones do not readily cross the placental barrier. Patient Counseling Information Patients should notify their healthcare provider should they become pregnant or are thinking of becoming pregnant while taking TIROSINT. Important Information • It may take weeks before you notice your symptoms getting better. Keep using this medicine even if you feel well. • Notify your healthcare provider if you are taking any other medications, including prescription and over-the-counter. • Notify your healthcare provider of any other medical conditions, particularly heart disease, diabetes, clotting disorders, and adrenal or pituitary gland problems, as the dose of medications used to control these other conditions may need to be adjusted while taking TIROSINT. If you have diabetes, monitor your blood and/or urinary glucose levels as directed by your physician and immediately report any changes to your physician. If you are taking anticoagulants, their clotting status should be checked frequently. • Notify your physician or dentist that you are taking TIROSINT prior to any surgery. Do not take TIROSINT: • If your adrenal glands are not working well and you have not been treated for this problem. Before you take TIROSINT, tell your doctor about all of your medical conditions. Your doctor should do certain blood tests while you are taking TIROSINT and may change your daily dose of TIROSINT as needed. Keep taking TIROSINT unless your doctor tells you to stop or to change your dose. TIROSINT may cause serious side effects, including: • Heart problems. You may experience an increased heart rate, chest pain and irregular heartbeat. Your risk of developing heart problems may be greater if you are elderly, you have heart problems, or you take too much TIROSINT. • Worsening diabetic control: If you are a diabetic, it may be harder to control your blood sugar levels causing hyperglycemia, while taking TIROSINT. Check your blood sugar levels closely after starting, changing, or stopping treatment with TIROSINT. • Weak or brittle bones: Your risk of developing weak or brittle bones may be greater if you are post-menopausal or you take too much TIROSINT. Need more information? • This information does not replace talking to your healthcare provider about your hypothyroidism symptoms. • Go to Tirosint.com
Identifying the Signs and Symptoms of Hypothyroidism and Hashimoto’s Thyroiditis Hypothyroidism is a serious condition that can cause many unpleasant symptoms, and can progress if undiagnosed and untreated. Here’s how to spot the signs: Women experience thyroid problems in far greater numbers than men. It is estimated that 1 in 8 women will develop a thyroid condition in their lifetime. Autoimmune disorders are also more common in women and are related to immune system dysfunction, which leads to inflammation and damage within organs and glands, such as the thyroid. The autoimmune disorder Hashimoto’s thyroiditis can lead to hypothyroidism, or thyroid underactivity, as the antibodies react against and damage the thyroid. While not everyone with the thyroid antibodies of Hashimoto’s thyroiditis develops hypothyroidism, research indicates the presence of these antibodies is associated with 11 • FUTUREOFPERSONALHEALTH.COM
a 5 percent risk of developing hypothyroidism each year. The symptoms of hypothyroidism include, but are not limited to, fatigue, feeling cold, unexplained weight gain, dry skin, depressed mood, memory issues, constipation and menstrual changes, and infertility. While being a common disorder, experience indicates some patients may go undiagnosed for long periods of time. What you should do If you have the symptoms of hypothyroidism, simple blood tests called a TSH and Free T4 can help determine whether your thyroid is underactive. TSH, a hormone secreted by the pituitary, which is part of your brain, provides a measurable signal within the blood to help assess thyroid health. In the most common forms of hypothyroidism, TSH promptly rises when thyroid hormone becomes insufficient. If your thyroid blood test results suggest hypothyroid-
ism is present, your healthcare team will advise you whether additional testing is warranted. In regards to management recommendations, sometimes close monitoring with serial thyroid blood tests will be advisable, while in other cases, oral thyroid hormone replacement therapy may be indicated. As recommended by the American Thyroid Association (ATA), the majority of patients with hypothyroidism can successfully manage the condition with an oral medication called levothyroxine. Choices include either a generic or brand name forms of this medication, which need to be taken once daily. Your healthcare team can advise you further about these options. Investigating the issue If hypothyroidism is the cause of the symptoms, they should gradually resolve once thyroid hormone levels are back in the normal range. However, if symptoms persist despite
appropriate thyroid levels, it is possible they are related to another underlying condition and not your thyroid. Further evaluation for other potential causes of the symptoms is then warranted. In addition, special attention to managing thyroid levels and thyroid hormone replacement is necessary in women with infertility and during pregnancy. More specific recommendations can be obtained through your OB/GYN, reproductive endocrinologist, or other thyroid specialist. Furthermore, patient educational material about these topics is available on the ATA website, as well as published guidelines for clinicians related to the management of thyroid disorders to include those encountered during pregnancy. n Victor J. Bernet, M.D., FACP, FACE, Secretary and Chief Operating Officer, ATA; Chair, Division of Endocrinology, Mayo Clinic Florida MEDIAPLANET