What Do You Do For Post-Partum Hashimoto’s Thyroiditis?

 

Like all thyroid disease, post-partum thyroid conditions seem to be on the rise – and often they rewrite the rule book when it comes to thyroid pathology & its management. Therefore for many of us it can add an extra element of uncertainty about how to help these clients.

One of our graduate practitioners has a great example of this, a 33yo female who developed late gestational diabetes and is now struggling with a new baby and an autoimmune thyroid disease!  What would you do?  Does post-partum thyroiditis have unique triggers/drivers that require specific treatment? What can you/should you be doing differently because she is still breastfeeding?  What’s the likely progression/prognosis?

This is your invitation to come along and find out the answers to these questions and more.  During our live graduate mentoring session on Monday 15th June at 3.30pm AEST we’ll work through all aspects of the case, from history to presentation and from looking for clues in her pathology results to where to start with treatment. (more…)

Who gives an RDW about RDW?

Ever noticed that thing called RDW (red cell distribution width) reported in your patients’ haematology results? Given that this parameter is currently regarded as one of the most important & earliest markers of a wide range of serious diseases, you might start paying some more attention to it from now on!

Dr. Michael Hayter, cleverly refers to RDW as being a reflection of the ‘Quality Control’ of an individual’s red blood cell synthesis.

As it’s a measure of how similar or dissimilar our rbcs are in terms of size, smaller values (suggesting homogeneous rbcs) are regarded as healthy, while higher RDWs suggest that some part of  rbc synthesis and/or clearance process is faulty.

This makes perfect sense in the context of nutritional anaemias like iron and B12/folate which all produce elevated RDW results but new research proposes that this rbc size disparity is also a common linking feature in just about every major disease, often predating diagnosis or in cases of established pathology signalling progression and warning of imminent poor outcomes for the individual.

There have been 100s of papers published just in the past 4 years on this topic and the findings are nothing if not dramatic. One of the biggest things I’ve realised is that, while Australian pathology companies suggest that all RDW results < 16% are acceptable, in the light of these new associations, a more accurate cut-off is probably around 13.5%! The big question now to answer is, is the increased RDW a passive marker of pathology or actively involved in the pathogenesis of these major diseases. For now, we should be scrutinising our patients’ RDW results more closely and being alert to what these markers are telling us about our clients threats & risks. I’ve recorded a 30min audio summarising all the information I’ve come across on this topic and how to apply it in your patients which you can access here.

Alternatively, if you’re happy to chomp into some juicy journal articles yourself then check out these ones to start with

https://jaha.ahajournals.org/content/3/4/e001109.full

https://www.researchgate.net/profile/Fabian_Sanchis-Gomar/publication/269930590_Red_blood_cell_distribution_width_A_simple_parameter_with_multiple_clinical_applications/links/5499b0e50cf2d6581ab15143.pdf

Learning the Language of Men’s Endocrine Health

 

We should all be as skilled in investigating & treating male hormone imbalances as we are female ones, yet this is often not the case.  A lack of confidence in this area, which seems to be an issue for many, in particular will compromise our ability to question male clients comprehensively and effectively about their reproductive health and ultimately reduce our capacity for making good clinical decisions and achieving the best outcomes for them.  If you’re female, how would you feel seeing a male practitioner who doesn’t ask you about your menstrual cycle in detail?

Many of us are at risk of committing similar crimes but we need not be. (more…)

Managing Your Random-Regulars

So often in mentoring I hear about patients practitioners have struggled to treat primarily because of irregular points of contact….you know the type, the client who is an Irregular Regular or Random Regular, booking in to see you just once or twice a year or just in acute situations & never doing the follow-up you so want them to do, in order to address the real underpinning causes.  A case I heard the other day would sound familiar to many of us, about a patient who saw the practitioner only when she experienced cramping.  Each time she’d have an appointment, buy some magnesium which relieved the issue and then disappear again, only to re-emerge with the same issue at a later time.  During one of these subsequent visits, the patient mentioned that she was ‘exhausted’.  Following the practitioner’s insistence that the patient bring in any pathology she had had done, the practitioner realises much to her horror, the patient has been suffering from macrocytic anaemia for some years but no one had bothered to tell the patient and accordingly, the practitioner has been none the wiser as well.  The practitioner of course felt terrible because she’s thorough and conscientious but is she to blame?  Where does the patient’s autonomy end and the practitioner’s duty of care begin?

Sometimes patients themselves can be a big barrier to their own wellness for all sorts of reasons and we can’t always resolve this but perhaps we need to consider introducing clinic protocols to try and better manage the Irregular Regulars.   (more…)

Increasing Off-label use of Anti-psychotics – Should we be worried?

I regard myself as integrative which means working collaboratively with other health professionals to get the best outcomes for our shared patients, sometimes that means my patients are taking psychiatric medications & there have been instances where I have seen the necessity and benefit of the right drug at the right time.  This might be in the form of short term use of atypical antipsychotics, so a recent article linking higher rates (approx. 50%) of diabetes with the use of atypical antipsychotics specifically in teenagers, caught my eye.  (more…)

A Great Time To Be A New Practitioner

“Health issues are rarely one individual textbook condition like they were during my studies.  The interaction of the body is complex, and Rachel has given me valuable insight into how to link various pathology markers & physical aspects together.  Test interpretation has been a huge focus for me.  The letters and numbers now mean something, and I can work with “true” reference ranges, and see how different values affect others. The sessions have been great to get assistance with cases and learn how to break things down & prioritise treatment, and also to connect with other practitioners, and hear their cases as well.   I really feel like my career has received an invaluable leg up, and I’m so thankful for Rachel’s knowledge and assistance.”

Rohan Smith, Graduate Group Mentoring Participant, Adelaide.

We began our Graduate/New Practitioner Group Mentoring sessions in March 2014 with just a few keen newbies but the sessions have gone from strength to strength since then, with an ever-growing group of new graduates participating in case presentations every month.  Every session I’m reminded that people are now graduating with much more sophisticated knowledge than I did.  Not because the education standards have improved (ouch!) but actually because the research-backed knowledge base of our whole industry has progressed & improved so dramatically… & that is really exciting & changing the marketplace for all of us.  (more…)

Do you mind if I record our appointment?

I read an interesting news item in Medical Observer this week about the increasing number of patients either overtly or covertly recording medical appointments on their smart phones.  Have some of your patients already asked if they could do this?  Mine have and I’m also aware of some patients getting into hot water when asking their ‘old-school’ medical specialists if they could do the same thing. For me, I have always understood the patient’s desire to do this, as the information they’re being given might be complex, considered critical and they may need to hear it several times in order to grasp the details, instructions etc. In other situations I’ve experienced it’s because the patient needs someone else, who couldn’t be present at the appointment, to hear the discussion ‘firsthand’ e.g. another parent, a partner.  In my mind this all makes good sense.  Does it make me speak differently, think more carefully about my words etc…You bet it does!  (more…)

Optimal Thyroid Function In Pregnancy?

Thyroid function is critical to successful conception, healthy pregnancies, babies and mum’s post-partum wellbeing, so we need to take the time to ensure we’re monitoring it properly.

First of all you need the right tool for the right job & that means we need trimester specific reference ranges – which unfortunately many pathology companies don’t use in Australia.  Due to the thyrotropic action of HCG (acting a bit like TSH), TSH should actually decrease in the 1st trimester and while TSH is less affected in 2nd and 3rd trimesters it should still actually sit lower than in non-pregnant females. (more…)

Is This Your Month to Start Mentoring?

We’re ready to begin another year of group mentoring from this Tuesday and we’ve got just 6 spots in total still available across all our time slots! Maybe you’ve heard the buzz about the sessions from some of our mentees over the past few years & are tempted but have been holding back or deliberating…now’s the perfect time to join in, while we’re all coming back from a break and the groups are reforming and settling.  To boot we’re offering newcomers, a special 6 month package to get you started: attend yourself (or if necessary receive an audio recording when you’re unable to) all sessions from January to June at a reduced price https://rachelarthur.com.au/product/special-6mth-group-mentoring-package/ (more…)

What to make of long-term low CRP

Ever had those patients… young, slim, fit…I won’t go so far as to say ‘well’ or otherwise they probably wouldn’t be seeing us right?  But not overtly inflamed and yet when you measure their CRP, it registers.  The average CRP of ‘healthy’ adult populations is reported to be between 1 and 3 mg/L but we know that even values within this range positively correlate with long-term CVD risk and most of us believe that unless there’s a good reason for immune activation at the time of the test, we’d like to see values < 1mg/L.

I saw one of my patients who fits this bill just the other day – an updated CRP and there it was again bubbling away at 1mg/L.  This guy is young (20s), slim (BMI of 19 kg/m2), non-smoker (another classic driver of this sort of brewing CRP), doesn’t report any acute illness e.g. URTI, at the time of each test (we would expect a much higher value with this anyway)…so why is there any CRP?  (more…)

PCOS families – are your male patients affected?

We now suspect that many of the drivers behind PCOS are heritable components – a genetic vulnerability passed from parents, possibly one but often both. This growing understanding has identified a phenomenon referred to as ‘PCOS families’ i.e. a family in which at least one female has confirmed PCOS.

Being a primary biological relative of someone with PCOS, it would seem, suggests a shared risk, even if you are a son, or brother or father. 

So beyond the very high rates of undiagnosed PCOS in sisters of someone already diagnosed, there is much talk now about a male PCOS phenotype equivalent. (more…)

End of Year CD Clearance

As we head rapidly towards the change over of our calendars we would like to offer you a special on the very best educational recordings from 2014 – buy 2 CDs before Jan 31st and receive one complimentary Premium Audio Recording of your choice  OR purchase 4 CDs and receive a 3 month Premium Audio subscription for free

It’s been a busy year during which Rachel has delivered 7 very successful new seminars in the area of mental health and  beyond, most notably fortifying her role as a leader in the field of diagnostics and pathology interpretation.  This has included collaborations with ACNEM, Biomedica, Health Masters Live, MINDD and Nutrition Care, however, each recording is classic Rachel – full of fresh perspectives on diagnosis & treatment, colourful analogies  & humour.  In case you missed some of these this year or want a copy for keeps – here’s a quick summary of the 2014 recordings included in this end of year offer: (more…)

Recognising A Tendency to Iron Overload Earlier

We’ve just had another mentoring case in which a 40 something female with deficiencies of almost all other minerals but ‘pretty normal ferritin levels’  presented with a range of endocrine problems and arthralgia.  Sounds as if iron’s not the problem right?  Except that in this case her iron studies also tell us that her transferrin saturation % on last check was 48%.  The diagnostic criteria for hereditary haemachromatosis  (HH) necessitates elevated ferritin – to indicate that the iron stores are reaching saturation, however, while this becomes evident at relatively young ages in men (20s-40s), who have no specific excretory pathway for iron, is this still appropriate in menstruating female, whose monthly periods may mask the HH tendency with regard to ferritin?  I’m guessing you know what my answer is already! 😉

Some would argue that HH, in spite of being an inherited disorder, is only clinically meaningful once the ferritin is elevated ( earlier and more potent elevations are seen in people possessing the C282Y genotype) but again this is very much up for debate in the current scientific literature, with a lot of research concluding that the transferrin saturation (also referred to as the transferrin ratio) being an important prognostic indicator for various chronic diseases including CVD.

When we go back to basics and remember the higher the transferrin percentage the more iron is being delivered to tissues around the body (whether they like/want it or not! so we refer to this as being ‘iron dumping’) and the higher the serum iron, the more unbound iron is in the system – a key source of oxidative stress..it becomes patently clear that these two parameters are important early warning signs of a tendency to iron overload, increased risk of heavy metal toxicity and already active mineral imbalance.  So in future keep your eyes open for women with fasting transferrin saturation values that consistently sit above 35% and men, > 40% and if you do see a series of suspicious values – consider the genotype test through mainstream labs.

Mental Health – The Real Story

“Two great speakers – inspirational in the first half and bang on in the second – I now know how much I don’t know”

Just out now in time for Christmas…no seriously though… this year I had the good fortune to team up with Biomedica and in particular Rachel McDonald and we delivered a 3 hour seminar called Mental Health in Holistic Practice.  The intention behind this collaboration was to shift the education focus for practitioners from a prescription based approach, to one really about the clinical reality of managing mental health clients.  Probably most of you will agree that the ‘treatment’ counts for only a portion of the positive outcomes in your patients and this is particularly true in clients challenged with mental health issues. After more than 20 years in practice working in this area, I’m keen to share what I’ve learned so other practitioners can get there much much faster! (more…)

Low T3 Syndrome & The Hibernation Effect

Apologies for having a one-track mind currently but yes I’m still banging on about the thyroid this week.  You see, this year in my own clinic I connected up some dots I hadn’t connected before via a series of young female patients.  Each of these women presented with some hypothyroid features, most notably, low basal body temperatures, fatigue and weight gain and while their thyroid hormones (TSH, T4 and T3) were all technically ‘within range’, their T3 levels were very low (low 3s) and the TSH seemed to sit low as well (<1.5).  Normally of course, when T3 levels drop we expect TSH secretion from the pituitary to rise in response, as a means to correcting this dip, however, this part of regulation appeared ‘blunted’ or even ‘broken’ in these women.

So why would their pituitary be sleeping on the job, allowing them effectively to experience long term suboptimal thyroid function? (more…)

T3 resistance?

Just been speaking on the thyroid at ACNEM last week and am finding that practitioners across the board are getting more and more curly thyroid cases.  One scenario that we increasingly see is something that might be described as ‘T3 resistance’, when your patient’s T3 value looks healthy but they continue to manifest the signs and symptoms of hypothyroidism.  There are several differentials to consider of course (more…)

What have you learned in 2014?

I’ve learned a lot (!) and as always that learning has principally driven by my clients – their pathology, the diagnostic investigations we’ve employed to better understand the drivers behind their conditions, their response to various treatment approaches & of course a million other subtle thing we’re learning along the way.  The other teachers are the many practitioners I interact with on a daily basis as part of our individual or group mentoring sessions – whether it’s some curly question or problem they bring that throws me into the scientific literature searching for answers or a fabulous bit of wisdom they bring to the table themselves, it’s a great reciprocal learning environment.  You know, the most common thing I hear from naturopaths is the frustration they feel at the limitations of their under-graduate education and how it is only since graduating that they’re ‘learning all this stuff” but in reality, as with most health professions, the bulk of the learning has to happen on the ground.

I’ve been in practice for about 20yrs (ouch!) and I don’t think my rate of learning has slowed at all.  It’s great if we can view this as the eternal fountain of inspiration that keeps us motivated and engaged in our profession…no not every minute of every day…let’s be realistic now…but overall it’s a strength not a weakness 🙂

Over the next month I’m being let loose on the major capital cities thanks to Nutrition Care to for a series of evenings of case study discussions – bringing together quick teaching points from all the things my clients have taught me this calendar year.  Whether it’s from a diagnostic or  treatment & management perspective I’ve got some juicy morsels to share!  I hope you can come along and  we can learn from each other yet again as a nice way to reflect on the year and our ever –growing profession…. If you’re interested in attending contact your local Nutrition Care representative for more information or call them on (03) 9769 0811

  • Brisbane – 12th November
  • Melbourne – 20th November
  • Sydney – 26th November
  • Adelaide – 27th November

 

Knowing your (Se) Numbers in Thyroid Patients

I’ve been re-reading lots of studies for a talk I’m delivering at ACNEM in Melbourne, investigating the relationship between selenium and a myriad of thyroid pathologies: from hypo- to hyperthyroidism and from subclinical thyroiditis to cancer.  The sheer number of trials is overwhelming & increasing, in fact I think there’s more every time I go back and look (!) and the bulk of the findings keep telling us yes! yes! yes!…selenium plays a pivotal protective & corrective role unmatched by any other nutrient. Whether it’s buffering the oxidative stress that comes with high TPO antibodies or lowering antibody titres, preventing or minimising the orbitopathy associated with Grave’s or simply maintaining a better level of T3 in euthyroid individuals, there are numerous potential positive effects from selenium supplementation …in the right patient… and therefore this is the bit we need to be clear about: while the majority of both epidemiological and interventional studies all concur that low selenium levels equate with a greater risk of thyroid issues in all our patients & poorer outcomes in patients with already established thyroid disease, the big question is how low are we talking?? (more…)

Roaccutane, depression & nutrition – the links

We’re all aware of the reported link between Isotretinoin (aka Roaccutane, Accure, Oratane), originally listed by the FDA in 1982 for the treatment of severe treatment refractory cystic acne, and depression & suicidality in some individuals.  Any suggestion of causality however remains hotly debated by the manufacturer of course & there is a recent small RCT not only refuting a relationship but claiming that via effectively resolving acne, patients’ depressive features decrease on this drug (Marron, Tomas-Aragones, Boira.  Anxiety, depression, quality of life and patient satisfaction in acne patients treated with oral isotretinoin. Acta Derm Venereol. 2013 Nov;93(6):701-6.). However most of us have read the media reports regarding tragic case studies, are aware of the warnings listed on the package insert and have met patients whose mental health problems appear to have been precipitated by use of the drug.  (more…)

When I grow up

When I grow up I’d like to be a few different things, forget any ballerina or astronaut aspirations, my list includes a clinical psychologist, an integrative psychiatrist and last but by no means least, an endocrinologist.  I’m fascinated by hormones, their regulation & incredible interconnectedness and the longer I’m in practice and the more patients I see with hormonal issues, the deeper I dive into the endocrinology texts (Endocrinology by Greenspan & Baxter is an absolute favourite of mine and you can now purchase this as a download to your computer which is super handy).  I think (more…)

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