The Latest in Diagnosing and Treating Thyroid Problems in Women AM 570 KVI March 19, 2008 Alan Failor, M.D. Tina Stafford.

Transcription

1 The Latest in Diagnosing and Treating Thyroid Problems in Women AM 570 KVI March 19, 2008 Alan Failor, M.D. Tina Stafford Please remember the opinions expressed on Patient Power are not necessarily the views of KVI, our sponsors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. Please have this discussion you re your own doctor, that s how you ll get care that s most appropriate for you. Introduction We re live on KVI. If you have fatigue, constipation, dry skin, brittle hair, and maybe feeling a bit depressed and gaining some weight you could have an underactive thyroid gland. You know, 30 million people could be affected, so you ll have an opportunity to ask questions of a leading UW expert next live on Patient Power on KVI TalkRadio 570. Good morning across sunny and cold western Washington or wherever you may be with us on the Internet. I m Andrew Schorr here every week to help you be a smarter patient and find out about some serious health concerns and get expert medical advice. That s what we do. If you happened to see the just great article that was about Patient Power in a publication called Northwest Prime Time, a lot of people see it around doctors offices or at senior centers, thanks to them for publishing it. Welcome if you re listening to Patient Power for the first time. I think this is our one-year anniversary Rick. Rick, one year we ve been on. Rick is there on the control room board. It s been one year we ve been at this, and we ve done more than 80 hours of discussions with leading medical experts, so I want to thank you so much if you ve been listening regularly. This is where you can call in live and ask questions, and my goal as a fellow who has walked in your shoes; maybe as a patient as an almost-10-year leukemia survivor, and we re going to celebrate that in April, and I hope you can join with me with me when we do; is to help you be smarter and for us as patients and family members to advocate for ourselves and get smart so we can get the best care. So that s what we do every week. Welcome if you re a first-time listener or if you ve been with us a long time, thanks for joining us again. What I want to talk about today deals with the field of endocrinology. So we ve had a number of endocrinologists on the show before, and we ve been talking about what they do most I think, and that s help people manage diabetes, and as you know diabetes is an epidemic in our country unfortunately as we gain weight. So that s certainly an important topic, and all those diabetes programs and all those other programs we ve done are all on my website and listen to that. 1

2 There s something else that endocrinologists deal with. They deal a lot with hormones and maybe if there s time we ll talk about menopause later on, but I began to think about thyroid, and I didn t know anything about it. It s that little gland under your Adam s apple, and when it s not operating right you could have problems, and I mentioned that just as we were beginning the show, and that is you could have fatigue, constipation, dry skin, brittle hair, you may be gaining a little weight, and it can happen at any age. There are 30 million people who could be living with thyroid problems. Now for some people it may be at a very low level and it doesn t affect them, but for others it could be that Aha, if you will, that s what s going on with these symptoms that could be so many other things. So in the studio with me today is Dr. Alan Failor. Alan has been practicing endocrinology for 30 years, and he is an endocrinologist and a clinical associate professor of medicine at the University of Washington Medical Center, which is one of our sponsors, and I thank them for helping make Patient Power here possible every week. I also want to thank Harborview Medical Center and Virginia Mason Medical Center. They really all stepped up to the plate so we can do this for you. Alan, welcome to Patient Power and thanks for strapping yourself in for a conversation about hormone issues that affect so many people, although often we re not aware of the effect it s having on our body. Thank you. Alan, when we talk about thyroid what I put it on my radar was that we have a couple of women who work in the office with me at what I do during the week, HealthTalk and Healthtalk.com, and those women, two women in their 30s, we got to talking. One of them had had a baby, and she just kept being tired and had these issues, was maybe, I don t know if she was worried about postpartum depression as well, and finally when she got the right test it turned out that she had an underactive thyroid. Then another woman in the office maybe a little more straightforward but saying the same thing, and with her gynecologist they figured that out. So, how common is it and how dramatic can it be when someone is affected this way? Hypothyroidism is extremely common. It s actually one of the more common disorders that affect our society actually worldwide. Some estimates up to five percent of all women develop hypothyroidism at some time during their life. For men it s about one percent, or it s about five to six times more common in women than men. What you re describing in the postpartum situation or after having a baby is actually very often a specific disorder called postpartum thyroiditis, which is usually transient and thyroid function eventually returns back to normal and is not necessarily a lifelong condition, but hypothyroidism can occur at any age although somewhat less common in children, but it can occur at any age and very commonly occurs in young adults. 2

3 Diagnosing Hypothyroidism Now let s go over what someone would feel because we were hoping to have on the show here in the studio today my friend Tina Stafford who unfortunately got sick. She s come down with the flu, but Tina had complained a couple of years ago of just severe fatigue; I believe she did have the constipation issue, she was worried about being depressed. She finally got to the doctor, and when they got to the bottom of it, it was an underactive thyroid. So that s, maybe describe what you see in the office when people come in with this issue. Certainly fatigue is the most common symptom and as you are aware is also a relatively nonspecific symptom, so it should at least raise the question although there are a number of other things that you should look for as potential symptoms. A given individual may have a different spectrum of symptoms than others, but fatigue, lethargy, depression, intolerance to cold and being cold all the time compared to your peers and the people around you. Dry skin, coarse brittle hair, modest degrees of weight gain all are or can be symptoms of hypothyroidism. Okay, and let s understand what the thyroid is. So I have this image of this little gland that I guess if it s not acting right or if it were inflamed somehow you could feel it I imagine under your Adam s apple, and so what s going on when for so many people it becomes underactive? Is that an autoimmune condition? Is our body fighting against it? What s going on? By far and away the most common cause of hypothyroidism is something called Hashimoto s thyroiditis, which is an autoimmune disorder. There are a number of other causes of hypothyroidism although they are considerably less common that Hashimoto s thyroiditis. Autoimmune disorders mean basically that your immune system has somehow mounted an attack against something that belongs to you which is inappropriate. Most autoimmune disorders are fairly uncommon-to-rare, whereas Hashimoto s thyroiditis is extremely common. In fact, all other autoimmune disorders combined do not equal or anywhere come close to the frequency of Hashimoto s thyroiditis. Why it s so common isn t really understood, but it clearly it is. Hashimoto s is an autoimmune disorder where the immune system usually very slowly and over a long drawn-out period of time gradually destroys the thyroid and replaces it with fibrous tissue. 3

4 Now, if someone has one of those more uncommon autoimmune conditions; psoriasis, psoriatic arthritis, rheumatoid arthritis, Crohn s disease and some of these others; would that make it more likely that they could also have an autoimmune effect on their thyroid? Yes. The presence of one autoimmune disorder makes it more likely that you can have others, and as again Hashimoto s is extremely common, so if you have one of the other autoimmune disorders, Hashimoto s is a not-unlikely eventuality, although the opposite is most people with Hashimoto s thyroiditis do not have other autoimmune disorders. Okay. We re going to talk much more about thyroid issues. Could this be what s going on for you if you have some of those symptoms? How do you get it worked up by the appropriate provider to find out if that is what s going on, and what are the treatments that make sense from Dr. Failor s point of view? We ll be right back with more of Patient Power right after this. Stay with us. Welcome back live on KVI on a beautiful sunny, crisp clear day. I can just sort of see Lake Union out there and let me see if anybody s out in a kayak as cold as it is. You wouldn t want to fall in. You would be an icicle before you know it, but it s a beautiful day. I love this weather. I ll take this any time. If you re up headed to the ski slopes have a great day, bundle up, and have some hot chocolate. Okay, we re talking about thyroid issues live on KVI and Patient Power, and we have with us Dr. Alan Failor. For 30 years Alan has been an endocrinologist and deals with diabetes, but he deals with thyroid issues too which affect maybe as many as 30 million people, and he also helps ladies, some people with menopause issues, and you can call in with questions about that too. I know that comes up in conversation among women as they get older. Medication Treatment Options Okay, about thyroid Alan. We said that if somebody has an underactive thyroid, which is typically what s going on, you need to replace the thyroid hormone, and that s typically done with prescriptions medicines. What are some of those medicines? What are some of the names that maybe people have heard? Maybe the brand name people recognize most commonly is Synthroid, which is a brand name of L-thyroxine, which is the generic component of that. There s also Levoxyl as one of the well known ones, but L-thyroxine I think in the past the generics have been inadequately or inconsistently absorbed, although I think more recently the generics have 4

5 kind of come up to snuff if you will, and the generics are reasonable. So L-thyroxine is the substance that s usually prescribed. There s also a form of what s called T3; the brand name most people might recognize is Cytomel; that is used sometimes, and whether you should use that in routine thyroid replacement is one of the more controversial areas of thyroid treatment or treatment of hypothyroidism. It s probably more controversial amongst patients and their access to various types of other information regarding thyroid disease other than mainstream endocrinologists. I think the issue is not nearly so controversial among endocrinologists who believe that probably adding this form of T3 does not add much to the therapeutic efficacy. Okay, we re going to talk about that in a second. So take these drugs Synthroid and Levoxyl, was that the other one? Yes. The ones that people may know. They come in different dosages. So there you are. You ve had a test with your doctor. So then the question is do you take a medicine, and it sounds like probably so because you need the hormone, and your thyroid gland wasn t doing it. How do you decide on dosage, and then how often does somebody have to take these medicines, and do they have to take them for life? The dosage is usually based up on lean body mass, and there is an equation for how many micrograms of thyroid hormone to give per lean body mass. That s a place to at least start, and so you need to kind of tailor the dose for each individual, and you use the blood test, the TSH result, just as you do for screening for thyroid hormone for thyroid disorders as a means of deciding what the appropriate dose is. So you make a guesstimate based upon lean body mass and thyroid requirements, and then you adjust based upon the blood tests. Okay, so if somebody starts on one of those medicines, do you do periodic blood tests or follow-up blood tests to see if you got it right? Yes. How often would those tests be? 5

6 Thyroid hormone, as opposed to many other hormones that are very evanescent and literally in and out of your circulation within minutes, thyroid hormone is very long lived. So the half-life is what s called seven days. So it actually takes at least a month for everything to re-equilibrate in a given dose, and so usually people wait a month to six weeks and then recheck the value and adjust from there. So if somebody today had some of these symptoms, and they saw their doctor maybe not tomorrow, it s a holiday, but this week, and then was prescribed one of these medicines; if that s what s going on and everything is accurate, when would they start to feel better? They d usually start feeling better within a few days to a week; they d start noticing an improvement. Usually it would be a month to slightly longer before they d really kind of have the full benefit of the particular dose they would start it on. But your experience is when somebody is properly diagnosed and the medicine dosage is right that these problems of fatigue and weight gain and brittle hair and dry skin and maybe some feelings of depression, that those get better? Yes. Listener Questions That s good news. Okay, well Betty has called in from Mount Vernon. Betty, welcome to Patient Power on this sunny and cold Sunday. What s your question or comment for us? Good morning. The history of my thyroid is pretty, oh like a nightmare. Years and years and years ago we moved to Bozeman, Montana from Livingstone, Montana, and they had whatchamacallit in the water; I can t think of the word; you know, to help with your teeth. Fluoride. Fluoride, yes. Okay, and I developed a real allergy to that, and my thyroid started acting up. I started getting shaky, and my whole body was, and my skin kind of turned brown, and I got really skinny, and then I would get real heavy and then real skinny; not real heavy but, 6

7 and it was very hard for me because I would burst into tears at the smallest thing, and I had all kinds of weird symptoms, and I put off and put off what the doctor wanted to do, which was to kill most of the thyroid. I put it off for 20 years until my eyes started feeling like magnets were pulling them out of my head, and I finally capitulated, and they gave me a huge dose of radioactive iodine. They put me on Synthroid, and that caused me to get heart problems; not real bad ones but weird situations; and so they finally allowed me to go on Armour, and I am doing better, but I do have very dry skin and kind of brittle hair, but I m skinny because I exercise a whole bunch. Betty, how old are you? Do I have to tell you? No, you re 39, Betty. No 80, I am 80 years old. Well let s see what Alan says about this. Did you have a specific question though? Well, I wonder why my voice has dropped probably an octave, and it s hard for me to sing, and sometimes it s hard to talk. I think that s just getting sexier in your older age. I don t drink or smoke at all. Okay, well let s find out. Alan, I mean she s been through a lot, so let s just take that step by step for a second. Is there a connection between fluoridated water for some people and hormonal issues? Can some people react to that? Fluoride itself has no effect upon the thyroid, so although there may have been an issue with the fluoride at that point, I would have a hard time explaining what happened with your thyroid as a result of that. 7

8 Okay, and the color of her skin that Betty described? Would that be any sign, the actual color? Betty talked about brown skin. It s back to normal now, the color. Okay. Hypothyroidism can be associated with kind of a yellowish tinge to the skin, a more bronze type of discoloration is more oftentimes associated with adrenal insufficiency and can also be associated with a disorder called hematochromatosis, which is a disorder of iron absorption, but it would not be something that I would easily be able to attribute to the thyroid. But it sounds like there could well have been hormonal issues going on for Betty possibly? There certainly could have been. It sounds like what you re describing is that you had hyperthyroidism and not hypothyroidism. Yes, it was a toxic exophthalmic goiter. That s what they said it was. Did you get a swelling? Because with goiter you think about Only when they gave me some sort of medicine. Then it went way out to my chin, my neck did, and I couldn t swallow hardly. The term goiter literally means the thyroid is enlarged. It doesn t mean anything beyond that. There are different types of goiters. So to call something a goiter means by definition the thyroid is enlarged in size. Typically what you re describing would also be referred to as Graves disease and maybe is something that people would more commonly recognize that term. Yes. 8

9 Betty, just hold on for one second. Betty had mentioned about her eyes too. Isn t there a condition that relates where your eyes kind of pop out a little? That s called Graves ophthalmopathy and is associated with Graves disease. Graves disease is an autoimmune disorder where there are antibodies that actually instead of destroying the thyroid as it does in Hashimoto s thyroiditis, it actually stimulates the thyroid. In some percentage of people, and it varies depending on where you read, a group of those people also have involvement of their eyes, and what it is, is an inflammation behind the eyes that pushes the eyes forward. So it s not the eyes directly themselves that are affected but the tissues behind the eyes that are inflamed and push the eyes forward. One last thing is Betty asked about her voice. Would any of these be connected with her voice? Well, if she s hypothyroid, hoarseness is a symptom of hypothyroidism or an underactive thyroid, so if you re not getting adequate doses of thyroid hormone, that could be the cause of that, although there are certainly other causes of hoarseness also. Betty, I hope you re in direct consultation with your doctor in Mount Vernon. Yes, I get my prescription once a year, but the lids of my eyes are always red. My eyes always look red. Well talk with Alan as you listen off the air, but it sounds like these issues, and as you get older, let s say 80, you want to be in a direct conversation with your doctor, and I m glad you exercise, and today s a good day to do it Betty, but it sounds like you re pretty spunky. I just think this is an active conversation with your doctor to see what s related and what isn t. Thank you. Thank you for listening and calling in. Have a great weekend. 9

10 Thank you. You too. Thank you. She s 80 and active. I love it. Let s take a call from Susan in Shoreline. Susan welcome. Let me press the right button here and put you on the air. Thanks for being with us today. What s your question? I have Hashimoto s disease and was put on Armour Thyroid 15 milligrams, actually 45 milligrams a day, and when I got diagnosed with it some of my sensations were really unusual, what I would call sinister sensations happening in my mouth. My teeth would tingle. I had a symptom that the previous woman was talking about in terms of her eyes feeling like magnets were pulling them. I got all the tests, and they put me on this, and on 45 milligrams a day I still get, especially if I m under a little stress, I will still get those funny sensation in my mouth. So once in a while, or actually quite a bit, I will up my dosage. I ll either take four or five Armour pills, and I m just wondering should I be doing that? Alan? I think that it all depends on what your levels are. Armour Thyroid is a preparation that is basically ground up pig and cow thyroids, and it s not the fact that it s pig and cow thyroids as why I would have some objection to using that as a thyroid hormone replacement. I do have some patients who take that somewhat against my druthers, but it depends I can tell you what my numbers are if that would help you. It would help but although those numbers would change if you re taking more of it, but the number of milligrams that you re taking is quantified by the amount of iodine in the preparation and not actually the amount of active thyroid hormone. So there are several studies showing that different batches of Armour Thyroid and other forms of desiccated thyroid like that actually vary considerably from one batch to the next in terms of how much active hormone they have. Now is Armour Thyroid a prescription medicine? 10

11 Yes. Okay, but you re saying it s somewhat inconsistent? Yes. The quantification, the number of milligrams you report taking is actually how many milligrams of iodine is in it and not how much active hormone. Active thyroid hormone has iodine in it. Iodine is part of the thyroid hormone molecule. So for Susan then if she s playing around with her dose to see what works for her, is that something she should do on her own or do with testing or do with her doctor? When I take the four or five, the funny mouth sensations go away. The sensations you have in your mouth are not something I would ordinarily attribute to your thyroid, and when you take excess thyroid hormone like that if indeed the level is too high at that, it will be days to weeks before your levels actually come back down to normal. So over the long run you do increase your risk of osteoporosis. You also increase your risks in the short run of arrhythmias because of the elevated levels of thyroid hormone that may be occurring with that kind of practice. So how does Susan get it right to make sure she s not, you know, there s not another shoe that s going to drop? She should have her levels checked on her usual dose, and if they re where they should be on her usual dose, to take more than that is going to raise them above that, and one, the fact that the sensations in your mouth go away it may be because you ve increased your thyroid hormone, although it may be just a matter of time and even if you didn t take excess thyroid hormone those same symptoms would go away. So whether there s a true cause and effect relationship there, I would question, and even if there is, again, you re taking some risks by taking too much thyroid hormone if indeed that s what you re doing. Okay Susan, I know this complicates it for you, but you heard from an expert here, okay? 11

12 All right. Thank you for calling in. Thank you. Okay. Rick, is it time for a break? He s looking around here. I lose track. I get involved in the, we ve got some time I think. Alan, so related to these issues, so hormones, and I want to just broaden the discussion a little bit. When we think about hormones beyond thyroid, we also think for a lot of people estrogen, progesterone. There was some news that came out this week related to I think it was an estrogen patch? Am I right about that? It s a birth control patch. Yes, so I know we re talking about a different population there, but these are not trivial substances. What was the concern about the patch? An increased risk of blood clots and the sequelae from blood clots such as clots going to the lungs, pulmonary emboli associated with the use of birth control patches. Hmm, okay, and what s your thought about the patches versus other birth control at this point. Actually, increased risk of clots has been associated with virtually all forms of birth control tablets where they use estrogen/progesterone for that, so the patch is a different way of delivering that which though it might have some advantages in terms of lower incidence, but it turns out that maybe that s not the case. So the risk is still very tiny, but it s not zero, and it s usually in young women who are otherwise healthy, so those sequelae when they do occur, although relatively uncommon to rare, can be pretty serious consequences. Okay, we re going to talk more about hormones and get back on track specifically with thyroid with Dr. Alan Failor, endocrinologist at the University of Washington Medical Center. We ll be right back. More with your calls on Patient Power. 12

13 Thanks for joining us this sunny Sunday live on KVI. Andrew Schorr here with Patient Power. You know, it s funny folks. I ve been doing this show for a year, and so it sort of takes the second half hour, everybody wakes up. Somebody calls somebody and says, Patient Power is talking about what you ve got. And so we start to get the calls and then I say oh an hour is too short. Send me an to Andrew@patientpower.info, and if you want more programs on this topic or related topics say so because my job is to do this for you. I m not selling anything thanks to UW, Harborview, Virginia Mason, and Evergreen Medical Center who has been helping what we do on KOMO during the week, those Patient Power Minutes, and we will do it for you. Let s take a call from Susan. Susan you re on the air from Duvall. Welcome. What s your question? Hi. I have Graves disease, but I have a normal thyroid. In 1990 it started out with my eyes. First they thought it was conjunctivitis, and then they diagnosed it as Graves disease. I went on steroids for about six months and then had radiation to my eyes, and it brought the eye down, but I guess I m confused that I have my thyroid checked every year and it s normal. So is this something that you have Graves disease forever and that it can activate again? Dr. Failor? The simple answer is yes. What you have is what s called Graves ophthalmopathy, euthyroid Graves ophthalmopathy, which means the eye involvement of Graves disease without the thyroid involvement, and that s relatively uncommon. You re not alone out there, but that s a fairly uncommon situation for Graves disease, and most people who do have that eventually become hyperthyroid but not all of them. So to watch your thyroid levels and follow them carefully over time is an appropriate thing, but it could occur at any time, and again Graves disease is an immunologic disorder. It s not specifically a disorder of the thyroid gland. The thyroid gland is just one of the things that is involved in most people with Graves disease. But apparently not Susan. Not all people. 13

14 Then I understand that I had the radiation done once, and that was like a one-time deal. If it came back again I wouldn t have that option? There are risks to taking too much radiation, so I think that s what they were telling you is they gave you as much as they could give you without causing other associated problems by giving you more. Okay, well I appreciate it. I know some people said it was stress related, but it was just an odd thing because I didn t feel any stress, but all of a sudden all this stuff came on. It s not necessarily stress related, although all immune related disorders have some relationship to stress. It s kind of hard to define that very clearly since it s kind of hard to define and measure stress, but yes there is some relationship but not necessarily. We re going to do that show another time on stress. Susan, thanks for calling in. Thank you. Bye bye. Rick, can I take one other quick call? Okay, I m going to take Sheila here who s holding from Normandy Park. We re running low on time, but Sheila, what s your question? I have a mother who lives in Chicago who just recently as of last week had a goiter burned out by some type of nuclear medicine. She s not really clear what happened. She s had thyroid problems for years. I guess goiter is part of a family hereditary problem, so I was just wondering what we could expect now that she s had this done? Most certainly what she had was radioiodine treatment where the radioiodine treatment is kind of like the ideal form of radiation treatment where the iodine is virtually exclusively taken up by the thyroid so the radioactivity is concentrated there. The usual reason for doing that is hyperthyroidism. The most common source of that is Graves disease, which we have recently been talking about. What it will do is basically ablate her thyroid gland so that it is unable to make thyroid hormones. So she will go from being overactive to underactive over some period of time, but it s an average of about three months from the time that you get the radioactivity to the time that you need to be started on thyroid hormone. 14

15 Then she ll take a medicine for that? She will take thyroid hormone supplements from then on, yes. Okay, so this basically will eliminate the thyroid problems that she s had in the past, which they ve really had problems getting a handle on? Presumably if that s hyperthyroidism that would be the expectation, yes. As far as hereditary, what will this do for us? Well, there is a hereditary predisposition. It s not like some disorders where if she had it 50% of her kids are going to have it or 25%, but individuals in the family have a higher likelihood of developing it also, yes. Because now it s been grandmother and mother, so Yes, you ll have to keep an eye on that. Unfortunately I ve got to run Sheila. Thank you for calling in. Bye. That s okay. Thank you. Let s take a quick break then we ll see if we have a final comment from you Alan. We ll be back with another show on this soon. We ll be right back. Wow, we are running out of time. I am going to do another program on thyroid issues, and maybe then we ll get to menopause and other hormones. We ve got to do it Alan, so I m going to have you back, Dr. Alan Failor who is an endocrinologist at the University of Washington. If you want to call the endocrinology clinic at the University of Washington Medical Center here s the number: (206) , and we ve been listening to Dr. Alan Failor who s an endocrinologist at the University of Washington. I want to thank UW and Harborview and Virginia Mason for all being sponsors of Patient Power. 15

16 Alan, quickly, and maybe we ll have to do another show on this. People go to the health food store, they see an ad, and it says, oh we can help with thyroid. In your experience, 30 years as an endocrinologist, beyond these prescription medications to replace the thyroid hormone, what s your experience with food or so-called natural substances or over-the-counter supplements, etc.? The only thing that fits into that that s been shown to have any effect is iodine or dietary iodine. In many parts of the world that s a huge issue regarding thyroid function is iodine deficiency. In this country it s actually a very rare problem where people are iodine deficient. So very commonly people are told to take kelp and various other things that have a lot of iodine in them. It really doesn t make much sense in this country because rarely are people iodine deficient in that it s the cause of the thyroid dysfunction. There are really no other food sources or food additives or over-the-counter types of things that are going to fix the kind of problem that people with thyroid disease have. And pills, health food store stuff helpful, not helpful? There s no evidence that they re helpful. Again, what it would have to be is thyroid hormone, and if you take some kinds of thyroid extract there may be thyroid hormone in there, but then you re taking it in a very unregulated fashion. Okay, this is all controversial. We will talk about it some more. Thank you for being with us Dr. Alan Failor from the University of Washington. Next week we re going to talk about women and heart problems with Dr. Terry Block from Valley Medical Center. Thanks for being with us. Have a great week. Please remember the opinions expressed on Patient Power are not necessarily the views of KVI, our sponsors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. Please have this discussion you re your own doctor, that s how you ll get care that s most appropriate for you. 16