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https://www.londonswissmedical.com/

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27The Guthrie Wing
28King's College Hospital
29Denmark Hill
30London SE5 9RS
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32<script>window.__NUXT__=function(e,t,i,n,o,a,s,l,r,d,m,c,p,y,u,h,C,_,g,f,v,T,w,k,b,D,O,R,E,N,x,S,L,A,U,Y,Q,Z,$,j,F,I,P,H,G,W,M,q,B,z,K,V,J,X,ee,te,ie,ne,oe,ae,se,le,re,de,me,ce,pe,ye,ue,he,Ce,_e,ge,fe,ve,Te,we,ke,be,De,Oe,Re,Ee,Ne,xe,Se,Le,Ae,Ue,Ye,Qe,Ze,$e,je,Fe,Ie,Pe,He,Ge,We,Me,qe,Be,ze,Ke,Ve,Je,Xe,et,tt,it,nt,ot,at,st,lt,rt,dt,mt,ct,pt,yt,ut,ht,Ct,_t,gt,ft,vt,Tt,wt,kt,bt,Dt,Ot,Rt,Et,Nt,xt,St,Lt,At,Ut,Yt,Qt,Zt,$t,jt,Ft,It,Pt,Ht,Gt,Wt,Mt,qt,Bt,zt,Kt,Vt,Jt,Xt,ei,ti,ii,ni,oi,ai,si,li,ri,di,mi,ci,pi,yi,ui,hi,Ci,_i,gi,fi,vi,Ti,wi,ki,bi,Di,Oi,Ri,Ei,Ni,xi,Si,Li,Ai,Ui,Yi,Qi,Zi,$i,ji,Fi,Ii,Pi,Hi,Gi,Wi,Mi,qi,Bi,zi,Ki,Vi,Ji,Xi,en,tn,nn,on,an,sn,ln,rn,dn,mn,cn,pn,yn,un,hn,Cn,_n,gn,fn,vn,Tn,wn,kn,bn,Dn,On,Rn,En,Nn,xn,Sn,Ln,An,Un,Yn,Qn,Zn,$n,jn,Fn,In,Pn,Hn,Gn,Wn,Mn,qn,Bn,zn,Kn,Vn,Jn,Xn,eo,to,io,no,oo,ao,so,lo,ro,mo,co,po,yo,uo,ho,Co,_o,go,fo,vo,To,wo,ko,bo,Do,Oo,Ro,Eo,No,xo,So,Lo,Ao,Uo,Yo,Qo,Zo,$o,jo,Fo,Io,Po,Ho,Go,Wo,Mo,qo,Bo,zo,Ko,Vo,Jo,Xo,ea,ta,ia,na,oa,aa,sa,la,ra,da,ma,ca,pa,ya,ua,ha,Ca,_a,ga,fa,va,Ta,wa,ka,ba,Da,Oa,Ra,Ea,Na,xa,Sa,La,Aa,Ua,Ya,Qa,Za,$a,ja,Fa,Ia,Pa,Ha){return ot.data={},ot.content=[{data:{},content:[{data:{},marks:[],value:"We are trusted private consultants in endocrinology, diabetes and general medicine. ",nodeType:e}],nodeType:t},{data:{},content:[{data:{},marks:[],value:"Your health is our concern.",nodeType:e}],nodeType:t}],ot.nodeType=l,at.data={},at.content=[{data:{},content:[{data:{},marks:[],value:"Endocrinology is the branch of medicine that deals with the endocrine system, a network which includes hormone-releasing glands such as the pituitary, thyroid, parathyroid, pancreas, adrenals, ovaries and testicles. We care for patients with hormone-related diseases associated with these glands, as well as looking after those with diabetes and offering more general medical care.",nodeType:e}],nodeType:t}],at.nodeType=l,pt.data={},pt.content=[{data:{},content:[{data:{},marks:[],value:"Adrenal disease covers a series of conditions that affect the adrenal glands, near the kidneys. They cause the glands to produce too many – or too few – hormones such as cortisol, adrenaline and aldosterone. 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By studying the interactions between hormones and the cardiovascular system, endocrinologists can contribute significantly to a better understanding of cardiovascular disease and the management of disorders related to it.",nodeType:e}],nodeType:t}],wt.nodeType=l,Rt.nodeType=l,Rt.data={},Rt.content=[{nodeType:t,data:{},content:[{nodeType:e,value:"Hypertension or high blood pressure is not unusual – and it is also the most common modifiable condition that increases our risk of cardiovascular disease, which can result in angina, heart attacks, heart failure, stroke, dementia, kidney disease and failure, peripheral vascular disease and erectile dysfunction. It can form part of a complex of metabolic abnormalities alongside polycystic ovarian syndrome, affecting fertility and s
32ometimes causing problems in pregnancy. Most people have hypertension because of the interplay between their genes and lifestyle, and we can help you make the necessary lifestyle adjustments to mitigate this. For others – around 15% of patients – the hypertension is secondary and there is a specific reason for it. We will consider if this is likely and, if needs be, investigate. The treatment always depends on the cause, but the important thing is always to reduce the risk of cardiovascular harm right across your body.",marks:[],data:{}}]}],Nt.nodeType=l,Nt.data={},Nt.content=[{nodeType:t,data:{},content:[{nodeType:e,value:"When treating hypertension, the goal is always to help reduce the harm and damage it causes. There are numerous ways to do this – including looking at how your lifestyle might be improved – and there are several classes of medication available. Depending on the cause of your hypertension, your priorities, lifestyle and other conditions, we can help lower the blood pressure safely and quickly. If there are complications, we can work – with other colleagues if necessary – to diagnose and treat these. Some patients need several different types of medication, each bringing its own benefits, side effects and limitations. What works for one person won’t necessarily work for the next, and our role is always to find the combination that will work for you. This may involve attending to other conditions that affect your cardiovascular risk, such as diabetes or pre-diabetes, lipid and cholesterol disorders, obesity or overweight, sleep apnoea, kidney damage and liver disease, in particular metabolism-associated steatotic liver disease (MASLD), previously known as non-alcoholic steatotic or fatty liver disease (NASH/NAFLD).",marks:[],data:{}}]}],St.nodeType=l,St.data={},St.content=[{nodeType:t,data:{},content:[{nodeType:e,value:"Conn’s syndrome occurs when the adrenal glands produce excess aldosterone, resulting in high blood pressure. We can work with you to diagnose and manage this condition, whether it’s due to unilateral adrenal adenoma or bilateral adrenal hyperplasia. We sometimes work with other professional colleagues to sample the adrenal veins for aldosterone, and work with an endocrine surgeon if a unilateral adenoma is responsible. If you have excess aldosterone caused by bilateral adrenal hyperplasia, we can block that hormone to help control your blood pressure using spironolactone or eplerenone. ",marks:[],data:{}}]},{nodeType:t,data:{},content:[{nodeType:e,value:"Only about 1% of patients with Conn’s syndrome have their condition diagnosed. Aldosterone, the causative hormone in Conn’s, causes problems for the heart and blood vessels above and beyond those caused by high blood pressure, so it cannot be overstated how important it is to explore the cause of your hypertension with an expert or an endocrinologist with a specific interest in this area. As endocrinologists with a specialist hypertension clinic this is an important area of our clinical practice.",marks:[],data:{}}]},{nodeType:t,data:{},content:[{nodeType:e,value:"The current tests to identify Conn’s have to be performed systematically, often withdrawing medication so it doesn’t interfere with the hormonal tests, and then establishing the patient safely on new medication. If this is the correct line of investigation, we will manage this careful balance with you.",marks:[],data:{}}]}],At.data={},At.content=[{data:{},content:[{data:{},marks:[],value:"Phaeochromocytoma and paraganglioma are rare tumours of the autonomic nervous system, which controls the hormones and neurotransmitters adrenaline, noradrenaline and dopamine. These hormones are essential to our health and help the body respond to changes in environment, posture, temperature and food. Tumours in this part of the nervous system can cause severe hypertension, palpitations and sweats. They are usually benign but can be cancerous, and they can run in families. We routinely work with patients to first identify their phaeochromocytoma or paraganglioma using laboratory and diagnostic imaging, and then help them manage their condition in collaboration with expert colleagues. We also consider how the diagnosis might be relevant to other family members.",nodeType:e}],nodeType:t}],At.nodeType=l,Yt.data={},Yt.content=[{data:{},content:[{data:{},marks:[],value:"As we age, our arteries narrow, and this affects the blood supply to the heart, brain and kidneys, as well as that to the lower limbs and erectile function. When the arteries are narrowed – or stenosed – the kidneys can compensate by making hormones to try to increase the blood pressure to in turn increase the blood supply. This makes hypertension in the rest of the body worse. Renal artery stenosis is a particular consideration when there is severe hypertension because it is resistant to many drugs. 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32ssment of the renal blood flow is needed for this diagnosis, using Doppler ultrasound, CT or MR angiography. If a young woman does have stenosis of the renal arteries, we will work with her to consider renal artery angioplasty as well as assess the blood vessels across the body. ",nodeType:e}],nodeType:t},{data:{},content:[{data:{},marks:[],value:"In older patients, treatment can be a complex matter, considering the relative benefits and harms of angioplasty alongside other options. In each case, we look after these conditions with a small team of colleagues to ensure you get the best assessment, advice and treatment. ",nodeType:e}],nodeType:t}],Yt.nodeType=l,Zt.data={},Zt.content=[{data:{},content:[{data:{},marks:[],value:"Lipids and cholesterol travel through the bloodstream attached to proteins. If they are present in high levels, they can have a negative effect on your health. we can advise on what kind of therapy you can take to reduce the risk, when and how you should take it, and assess what the overall risk might be.",nodeType:e}],nodeType:t},{data:{},content:[{data:{},marks:[],value:"Cholesterol is carried through the bloodstream by two types of lipoproteins: low-density lipoprotein (LDL) which can build up on the walls of arteries, and high-density lipoprotein (HDL) which helps remove LDL from the bloodstream. LDL cholesterol is often referred to as ‘bad’ and HDL as ‘good’ cholesterol. When the total amount of cholesterol in the blood (TC) is measured, patients are often given a TC:HDL ratio, which should be as low as possible, although cholesterol ratios should always be considered alongside other factors.",nodeType:e}],nodeType:t}],Zt.nodeType=l,jt.nodeType=l,jt.data={},jt.content=[{nodeType:t,data:{},content:[{nodeType:e,value:"Our lipids give us a clue about what is happening in our heart and blood vessels, liver and kidneys, showing the concentration of particles moving back and forth between the sites in the body where they are used and processed. They are important to our cardiovascular health because if they occur at very high levels – hyperlipidaemia – they are sometimes taken up in the vessel wall, causing a narrowing of the arteries in the heart, brain, penis and peripheral vessels. This condition is known as atherosclerosis.",marks:[],data:{}}]},{nodeType:t,data:{},content:[{nodeType:e,value:"Not everyone’s lipids will cause them problems, but we manage lipids and cardiovascular disease for a wide range of patients and can help you understand the outcomes of any tests, when to test further, when to leave alone and when we might want to offer treatment. The most common lipid abnormalities are associated with being overweight and obese, and with pure hypercholesterolaemia. These conditions can look similar – and we sometimes use similar medications for them – but there are important differences.",marks:[],data:{}}]}],It.nodeType=l,It.data={},It.content=[{nodeType:t,data:{},content:[{nodeType:e,value:"High cholesterol is the most common type of hypercholesterolaemia, a condition where there are high levels of fat (lipids) in the blood. Our cholesterol is controlled by our lifestyle, but also our genetic makeup. In some patients with polygenic hypercholesterolaemia, their high cholesterol levels are caused by genetic problems that cholesterol isn’t broken down or taken out of the blood, leaving it to collect in the arteries.",marks:[],data:{}}]},{nodeType:t,data:{},content:[{nodeType:e,value:"Statins are the backbone treatment if we want to reduce cholesterol and cardiovascular risk, but they are not for everyone. We can help you understand why they might be necessary, when they might not be the correct treatment, and what to do if you have side effects. We can also consider alternatives or consult with specialist dietician colleagues.",marks:[],data:{}}]},{nodeType:t,data:{},content:[{nodeType:e,value:"Single genes causing elevated cholesterol from birth are common, and are known as familial hypercholesterolaemia (FH). In FH the risk of cardiovascular disease is much higher, and sadly most patients are not diagnosed correctly, meaning they do not receive the right treatment. We have experience in helping you decide whether you need testing for FH, arranging for the tests to be made, and then guiding your treatment. We often support your care with specialist lipid clinics where you can access the latest treatments, including alirocumab, evolocumab, or the tablet bempedoic acid.",marks:[],data:{}}]}],Ht.nodeType=l,Ht.data={},Ht.content=[{nodeType:t,data:{},content:[{nodeType:e,value:"In mixed dyslipidaemia, particularly with diabetes or obesity, the high level of lipids is often less dramatic than in pure hypercholesterolaemia but the treatment can be more complex and the risk of cardiovascular disease higher. The need to consider weight, glucose and blood pressure makes finding the right treatment all the more important. Often small adju
32stments over several lines of treatment are necessary, and in these cases it’s beneficial to see a doctor experienced right across metabolic medicine who can take a broad perspective, rather than consult with separate ones.",marks:[],data:{}}]}],Wt.nodeType=l,Wt.data={},Wt.content=[{nodeType:t,data:{},content:[{nodeType:e,value:"Triglycerides are a combination of three fatty acids that are absorbed from food and carried in the bloodstream as a source of energy.",marks:[],data:{}}]},{nodeType:t,data:{},content:[{nodeType:e,value:"Lower elevations of triglycerides usually tell us similar information about the metabolic environment in the liver and blood vessels to those patients with benign cholesterol levels, but coupled with a low HDL level (particularly when the TH:HDL ratio is high), a high level of ApoB (a protein found in ‘good’ LDL cholesterol) can suggest a greater cardiovascular risk. In such cases, we would look closely at your weight, blood pressure and glucose balance to minimise this risk.",marks:[],data:{}}]},{nodeType:t,data:{},content:[{nodeType:e,value:"Higher elevations of triglycerides, particularly in the high teens to 30s, are dangerous right away. There is a risk of pancreatic inflammation (pancreatitis) which can make us extremely unwell, so hypertriglyceridaemia needs prompt diagnosis and assessment in these cases, often requiring admission and specific therapy. We are experienced in identifying this condition and making the triglycerides safe again, while looking at how to prevent them from becoming high again in the context of your wider metabolic health.",marks:[],data:{}}]}],qt.nodeType=l,qt.data={},qt.content=[{nodeType:t,data:{},content:[{nodeType:e,value:"Lipoprotein (a) or Lp (a) is a type of protein that carries cholesterol in the blood. It is mostly inherited, so only needs to be considered once in your life but is much less modifiable than cholesterol, HDL, LDL and triglycerides. With standard measures of cardiovascular risk, it is often not taken into consideration. We can help decide whether we should measure it, integrate this information for you and see how it changes your health – and then offer relevant advice, treatment or investigations. Therapies to lower it to improve cardiovascular health are in development, but until they are proven to work safely they are only relevant to patients in clinical trials.",marks:[],data:{}}]}],zt.nodeType=l,zt.data={},zt.content=[{nodeType:t,data:{},content:[{nodeType:e,value:"Our work includes the diagnosis and treatment of iron, B12 and folate deficiency. We are particularly interested in using safer alternatives to red blood cell transfusion, reducing the side effects of iron therapy and ensuring anaemia is corrected before surgery and before, during and after pregnancy. We are also concerned with the diagnosis and management of pernicious anaemia and dietary B12 deficiency.",marks:[],data:{}}]},{nodeType:t,data:{},content:[{nodeType:e,value:"Dr Kelly chairs the London Regional Transfusion Committee and works closely with colleagues in haematology, gastroenterology and surgery – both nationally and at King’s College London – to ensure patients receive the right treatment to keep them feeling well now and in the future.",marks:[],data:{}}]}],Vt.data={},Vt.content=[{data:{},content:[{data:{},marks:[],value:"Iron deficiency is very common in women of childbearing age who are having regular periods, especially if they are heavy. We work hard to prevent anaemia by identifying the causes of iron loss, or the failure to absorb it early, by spotting deficiencies when it is mild, and sensibly replacing the iron. This often involves intermittent treatment across years or even decades for some patients. We work closely with gynaecology colleagues if we need specific help with menstrual blood loss.",nodeType:e}],nodeType:t},{data:{},content:[{data:{},marks:[],value:"If you need your iron stores improved for pregnancy, breastfeeding, hair and skin health, or just to improve your energy levels, we can help. Iron deficiency not only occurs in younger women; it can occur from childhood to old age. If there’s a possibility that you need iron replacement or a blood transfusion, we will work with you to find the right treatment.",nodeType:e}],nodeType:t},{data:{},content:[{data:{},marks:[],value:"Iron deficiency without good reason can be an indication of more serious problems including coeliac disease, chronic inflammation, diverticular disease, gastric inflammation and ulcers, and can even be an early indication of cancer as we get older. We can help investigate if it is appropriate or direct you to the services and colleagues who specialise in looking for cancer. This often includes gastroenterologists using endoscopy, or radiologists using CT.",nodeType:e}],nodeType:t}],Vt.nodeType=l,Xt.data={},Xt.content=[{data:{},content:[{data:{},marks:[],value:"Safe intravenous iron preparations have revolutionised the health and care of many patients, protecting them from fatigue, poor hair and skin health, transfusions of red cells and even surgery at times. Not all intravenous iron is the same, but we can help you find the right treatment, balancing convenience, health and short- and long-term safety, and if an iron infusion is required we have a team who can help with this.",nodeType:e}],nodeType:t}],Xt.nodeType=l,ei.nodeType=l,ei.data={},ei.content=[{nodeType:t,data:{},content:[{nodeType:e,value:"Medications often have side effects which can be relevant to your therapy. They may be a feature of the drug itself – such as constipation with oral iron or a dry cough with ACE inhibitors – or they may be related to the excipients used to deliver the drug, for example lactose. Some side effects are common and expected because of the mechanism of the drug. Postural dizziness may occur with some blood pressure tablets; tachycardia, bradycardia, cold hands, erectile problems or gum irritation with others. Other side effects, such as muscle aches with cholesterol tablets, are not as common as the press would have us think. ",marks:[],data:{}}]},{nodeType:t,data:{},content:[{nodeType:e,value:"We always consider how each medication works for you, how it might work with other medicines, what it’s for, and the relative benef
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32ot lower the risk of developing cardiovascular disease. This trial supports the results of an earlier study from the USA (published in 2019), called the VITamin D and OmegA-3 TriaL (VITAL). That trial also showed that vitamin D had no effect on the development of heart disease. In both trials, the finding of no effect may possibly be due to sufficient vitamin D status in most participants at baseline.",nodeType:e}],nodeType:t},{data:{},content:[{data:{},marks:[],value:"Vitamin D helps to regulate the amount of calcium and phosphate in the body and may be measured (and treated) by doctors, if a lack is thought to be compromising bone health.",nodeType:e}],nodeType:t}],li.nodeType=l,ri.data={},ri.content=[{data:{},content:[{data:{},marks:[],value:"Diabetes is a group of diseases that occur when the pancreas is not producing enough of the hormone insulin, or if the body becomes unresponsive to the effects of insulin. The high blood sugar levels that result from this can manifest in a host of different symptoms, many of which can lead to further health complications. We manage patients with diabetes as part of our acute physician work at King’s College Hospital.  ",nodeType:e}],nodeType:t}],ri.nodeType=l,yi.nodeType=l,yi.data={},yi.content=[{nodeType:t,data:{},content:[{nodeType:e,value:"We offer diagnostic and therapeutic advice for Type 1 and Type 2 diabetes, and diabetes that is secondary to other conditions – for example, pancreatic disease or surgery – in The Guthrie Wing, at our private clinics at 25 Harley Street and The Shard, or on the ward. Diabetes can also be secondary to pituitary or adrenal diseases such as Cushing’s syndrome or acromegaly, or be associated with an iron overload in haemochromatosis. These possibilities should always be considered otherwise patients will not get the correct treatment. Rarely, diabetes can be due to genetic conditions – which require very specific treatment.",marks:[],data:{}}]}],hi.nodeType=l,hi.data={},hi.content=[{nodeType:t,data:{},content:[{nodeType:e,value:"The management of diabetes is an area of exciting change, with new agents becoming available. We can ensure that the most appropriate treatments are considered. ",marks:[],data:{}}]},{nodeType:t,data:{},content:[{nodeType:e,value:"Lifestyle changes remain important, though, and in medical therapy metformin remains the primary treatment. For patients with a high risk of cardiovascular disease, SGLT-1 inhibitors are helpful if added to metformin. Often DPP-IV inhibitors will be needed, and these are now an established class. For some patients, pioglitazone still has a clear role, especially if liver dysfunction is present. Where weight is troublesome and insulin proves difficult to use, we now have experience with GLP-1 analogues, including established drugs like exenatide (Byetta, Rydurion), dulaglutide (Trulicity) and newer drugs such as semaglutide (orally as Rybelsus, or as an injection in Ozempic, and also found in Wegovy for obesity).",marks:[],data:{}}]},{nodeType:t,data:{},content:[{nodeType:e,value:"If you have pre-diabetes or a family history of diabetes, we can consider how to reduce your chance of becoming diabetic. This may include the specific management of obesity in close liaison with dietetics, medications such as orlistat and GLP-1 agonists, and/or surgery.",marks:[],data:{}}]},{nodeType:t,data:{},content:[{nodeType:e,value:"If you are interested in finding out how newer therapies such as SGLT
32-2 inhibitors can help, for instance if you have heart failure, and whether or not you have diabetes, then please contact us.  ",marks:[],data:{}}]}],Ci.nodeType=l,Ci.data={},Ci.content=[{nodeType:t,data:{},content:[{nodeType:e,value:_i,marks:[],data:{}}]},{nodeType:t,data:{},content:[{nodeType:e,value:gi,marks:[],data:{}}]}],vi.data={},vi.content=[{data:{},content:[{data:{},marks:[],value:"Being overweight is often a critical modifiable risk for diabetes, and by focusing on your weight, you can help to avoid, manage or even put into remission your diabetes. Some treatments can make managing your weight even more difficult, and in every case we can work together to find the right balance between health benefits and side effects.",nodeType:e}],nodeType:t}],vi.nodeType=l,wi.data={},wi.content=[{data:{},content:[{data:{},marks:[],value:"Diabetes, and in particular Type 2 diabetes, can cause sexual dysfunction – for example, erectile dysfunction, which can in turn be a sign of cardiovascular disease or endocrine dysfunction. By improving your general health, and if necessary assessing your pituitary, androgens, thyroid or adrenal hormonal status, we can help. Frustratingly, men are rarely asked about this aspect of their health in their routine care, even though excellent treatments are now available for erectile dysfunction. If they are appropriate to you we can prescribe these treatments, but we also work very closely with colleagues in urology across London for the very specific management of erectile dysfunction if standard treatments do not work. Similarly, we may also consider whether a more detailed look at your cardiovascular or endocrine health is needed.",nodeType:e}],nodeType:t}],wi.nodeType=l,bi.nodeType=l,bi.data={},bi.content=[{nodeType:t,data:{},content:[{nodeType:e,value:"The high blood sugar levels associated with long-standing diabetes can damage the fine nerves in the feet, legs and – more rarely – the fingers and hands, causing numbness and pain. We can design a plan of care to prevent this or, if it is already present, help to make an accurate diagnosis, followed by treatment to make the condition more comfortable.",marks:[],data:{}}]}],Oi.nodeType=l,Oi.data={},Oi.content=[{nodeType:t,data:{},content:[{nodeType:e,value:"Long-standing diabetes can damage the kidneys, particularly if the patient is also suffering from hypertension or high blood pressure. In some patients, the kidney damage can progress, in some cases leading to kidney failure. We always work with you to help manage your diabetes to prevent and/or delay any kidney damage. This can include an accurate diagnosis in the very early stages, where tiny quantities of albumin leak out into the urine. Sometimes this work is done alongside a kidney specialist, depending on what treatment works best for you.",marks:[],data:{}}]}],Ri.nodeType=l,Ri.data={},Ri.content=[{nodeType:t,data:{},content:[{nodeType:e,value:"Diabetes often requires a patient to take several medicines – for good glucose control, to treat blood pressure and lipids, to minimise kidney and/or nerve damage, and to reduce the risk of cardiovascular disease. Many of the medicines have side effects, and sometimes they may not work well with each other, your diet or your lifestyle. Patients taking GLP-1 agonists, for example, often experience nausea which can get better over time, or constipation or diarrhoea which may persist.",marks:[],data:{}}]},{nodeType:t,data:{},content:[{nodeType:e,value:"In every case, we make sure the medication is exactly right for you, both in the short-term and in your longer-term treatment.",marks:[],data:{}}]}],xi.data={},xi.content=[{data:{},content:[{data:{},marks:[],value:"The US Federal Drug Administration (FDA) approves first oral GLP-1 treatment for type 2 diabetes ",nodeType:e},{data:{},marks:[],value:B,nodeType:e},{data:{},marks:[],value:" semaglutide.",nodeType:e}],nodeType:t},{data:{},content:[{data:{},marks:[],value:"Glucagon-like peptide-1 (GLP-1) is a naturally occurring hormone that helps control blood sugar levels and appetite, and this hormone is missing or present in lower levels in patients with T2DM.  Giving medications which act on the GLP-1 receptor (GLP-1 agonists) can reproduce the action of human GLP-1and improve the glucose control and the whole metabolism of patients with T2DM. These drugs have been available in the UK since 2007 as injectable therapy.  They have proved to be very effective for people with T2DM and can also lead to significant weight loss.",nodeType:e}],nodeType:t},{data:{},content:[{data:{},marks:[],value:"More recently, research has shown that GLP-1 agonists may also reduce the risk of cardiovascular disease, eg heart attacks, heart failure and stroke.",nodeType:e}],nodeType:t},{data:{},content:[{data:{},marks:[],value:"Up to now, the medication could only be given as daily or weekly injections under the skin.  In an exciting development, the American Federal Drug Administration (FDA) has recently approved a tablet form of GLP-1 that can be taken once a week, called semaglutide.  Marketing authorisation from the European Medicines Agency has been applied for earlier this year but FDA approval may herald a step-change in how 
32we use these agents.",nodeType:e}],nodeType:t},{data:{},content:[{data:{},marks:[],value:"Dr Martin Whyte is an expert in metabolic medicine and the use of novel therapies for T2DM at London Swiss Medical, King's College Hospital and the University of Surrey, if you want to discuss the management of your diabetes with him, or another member of the team, please make an appointment.",nodeType:e}],nodeType:t}],xi.nodeType=l,Si.nodeType=l,Si.data={},Si.content=[{nodeType:t,data:{},content:[{nodeType:e,value:ce,marks:[],data:{}}]},{nodeType:t,data:{},content:[{nodeType:e,value:pe,marks:[],data:{}}]},{nodeType:t,data:{},content:[{nodeType:e,value:ye,marks:[],data:{}}]},{nodeType:t,data:{},content:[{nodeType:e,value:ue,marks:[],data:{}}]},{nodeType:W,data:{},content:[{nodeType:p,data:{},content:[{nodeType:t,data:{},content:[{nodeType:e,value:he,marks:[],data:{}}]}]},{nodeType:p,data:{},content:[{nodeType:t,data:{},content:[{nodeType:e,value:Ce,marks:[],data:{}},{nodeType:e,value:_e,marks:[],data:{}}]}]},{nodeType:p,data:{},content:[{nodeType:t,data:{},content:[{nodeType:e,value:ge,marks:[],data:{}},{nodeType:e,value:fe,marks:[],data:{}}]}]},{nodeType:p,data:{},content:[{nodeType:t,data:{},content:[{nodeType:e,value:ve,marks:[],data:{}},{nodeType:e,value:Te,marks:[],data:{}}]}]}]},{nodeType:t,data:{},content:[{nodeType:e,value:we,marks:[],data:{}}]},{nodeType:t,data:{},content:[{nodeType:e,value:ke,marks:[],data:{}}]},{nodeType:t,data:{},content:[{nodeType:e,value:be,marks:[],data:{}}]},{nodeType:t,data:{},content:[{nodeType:e,value:De,marks:[],data:{}}]},{nodeType:t,data:{},content:[{nodeType:e,value:Oe,marks:[],data:{}}]},{nodeType:t,data:{},content:[{nodeType:e,value:Re,marks:[],data:{}}]},{nodeType:t,data:{},content:[{nodeType:e,value:Ee,marks:[],data:{}}]},{nodeType:t,data:{},content:[{nodeType:e,value:Ne,marks:[],data:{}}]},{nodeType:t,data:{},content:[{nodeType:e,value:xe,marks:[],data:{}}]},{nodeType:t,data:{},content:[{nodeType:e,value:Se,marks:[],data:{}}]},{nodeType:t,data:{},content:[{nodeType:e,value:Le,marks:[],data:{}}]},{nodeType:t,data:{},content:[{nodeType:e,value:Ae,marks:[],data:{}}]},{nodeType:t,data:{},content:[{nodeType:e,value:Ue,marks:[],data:{}}]},{nodeType:t,data:{},content:[{nodeType:e,value:Ye,marks:[],data:{}}]},{nodeType:t,data:{},content:[{nodeType:e,value:Qe,marks:[],data:{}}]},{nodeType:t,data:{},content:[{nodeType:e,value:Ze,marks:[],data:{}}]},{nodeType:t,data:{},content:[{nodeType:e,value:R,marks:[],data:{}},{nodeType:e,value:$e,marks:[],data:{}}]},{nodeType:t,data:{},content:[{nodeType:e,value:R,marks:[],data:{}},{nodeType:e,value:je,marks:[],data:{}}]},{nodeType:t,data:{},content:[{nodeType:e,value:R,marks:[],data:{}},{nodeType:e,value:Fe,marks:[],data:{}}]},{nodeType:t,data:{},content:[{nodeType:e,value:Ie,marks:[],data:{}}]},{nodeType:t,data:{},content:[{nodeType:e,value:Pe,marks:[],data:{}}]},{nodeType:t,data:{},content:[{nodeType:e,value:He,marks:[],data:{}}]},{nodeType:t,data:{},content:[{nodeType:e,value:Ge,marks:[],data:{}}]}],Li.data={},Li.content=[{data:{},content:[{data:{},marks:[],value:We,nodeType:e}],nodeType:t},{data:{},content:[{data:{},marks:[],value:Me,nodeType:e}],nodeType:t},{data:{},content:[{data:{},marks:[],value:qe,nodeType:e}],nodeType:t},{data:{},content:[{data:{},marks:[],value:Be,nodeType:e}],nodeType:t},{data:{},content:[{data:{},marks:[],value:ze,nodeType:e},{data:{uri:Ke},content:[{data:{},marks:[],value:Ve,nodeType:e}],nodeType:k},{data:{},marks:[],value:Je,nodeType:e}],nodeType:t},{data:{},content:[{data:{},marks:[],value:Xe,nodeType:e}],nodeType:t}],Li.nodeType=l,Ai.nodeType=l,Ai.data={},Ai.content=[{nodeType:t,data:{},content:[{nodeType:e,value:"The menopause occurs when the production of oestrogen and progesterone – the hormones needed for reproduction and the regulation of menstrual cycles – decreases in a woman’s body. This usually happens naturally between the ages of 45 and 55, but can also result from the removal of the uterus and ovaries in a hysterectomy, or due to chemotherapy or radiation therapy. ",marks:[],data:{}}]}],Qi.nodeType=l,Qi.data={},Qi.content=[{nodeType:t,data:{},content:[{nodeType:e,value:"Much of our work is concerned with the diagnosis of perimenopause and menopause, and how both can be managed through either non-hormonal treatment or hormone replacement therapy (HRT). These can help alleviate vasomotor symptoms of menopause (caused by the dilation of blood vessels) such as sweating and flushing, insomnia, cognition problems, fatigue, letharg
32y, and the loss of libido, and improve vaginal, bone and general health.",marks:[],data:{}}]},{nodeType:t,data:{},content:[{nodeType:e,value:"Premature menopause or primary ovarian insufficiency can also occur when the ovaries fail to produce normal levels of reproductive hormones. In the context of hypothalamic-pituitary disease in particular, careful exploration into the causes and consequences of the disease is required, and a consideration of the role of HRT in treating it.",marks:[],data:{}}]},{nodeType:t,data:{},content:[{nodeType:e,value:"We often discuss the use of testosterone to treat female androgen deficiency (FAD) and/or hypoactive sexual desire disorder (HSDD), and monitor your health while on testosterone.",marks:[],data:{}}]}],$i.nodeType=l,$i.data={},$i.content=[{nodeType:t,data:{},content:[{nodeType:e,value:"Menorrhagia – heavy and/or prolonged periods – can cause distress, be uncomfortable, indicate a problem with the womb or hormones, and can lead to iron deficiency. By working together – sometimes with a gynaecologist or expert in female ultrasound – we can often work out what the problem is. Sometimes we will help you or your other doctors to understand whether there is a hormonal component to it; at other times we guide your treatment to lessen the heavy bleeding. If you have iron deficiency, we can also help treat this to prevent you from becoming anaemic.",marks:[],data:{}}]}],Ii.data={},Ii.content=[{data:{},content:[{data:{},marks:[],value:"Menopause Advice and Consultation\n \nI have been at the Society for Endocrinology, British Endocrine Societies Meeting in Glasgow this week. Once again we have had a selection of great talks on the menopause, natural or premature and what it might mean for women. These are the padded out notes from a key session from Nick Panay (Chelsea & Westminster, London) about HRT: Efficacy and Safety. The Women's Health Initiative may have set back the use of HRT for many women, and perhaps unfairly, due to high doses in a relatively elderly population, and that data was applied to younger patients, without considering changes in dosage and formulations of HRT.\n \nThe most salient piece of advice from the talk and from my own practice is ",nodeType:e},{data:{},marks:[],value:B,nodeType:e},{data:{},marks:[],value:" Listen to Your Patients. Do not make decisions for them. Our job is to give the best information to the patient, based on our assessment of their health, to allow them to make the most informed decision. Occasionally we need to strongly advise patients on a course of action, but the patient should have the same information as us or as close as is practical.\n \nHRT protects against cardiovascular disease, cognitive decline and Parkinson’s disease, and averts the symptoms of the menopause and its transition.\n \nThe transition to the menopause starts, in some women, seven years before their last period. During this time one may get symptoms of oestrogen deficiency, flushes, poor sleep, reduced libido and loss of sense of well being and these can be treated with HRT. The cardiovascular benefits of HRT might be larger the earlier it starts, and this might assuage some of the anxiety about using it during the menopause transition if it is right for the patient. We are rarely prescribing HRT as a permanent solution at first, it is often a trial, to see how the patient is, so they can be more informed about continuing or not.\n \nYounger women tend to need higher, more physiological, doses of oestrogen. And we believe modern HRT is safe until the 50 years of age (the age half of women will have had their menopause by), and generally safe for five years beyond, with due consideration of the pros and cons. The decision to stay on or stop should be assessed yearly and of course yearly beyond 55 years.\n \nDo not forget that local symptoms of oestrogen deficiency, such as vaginal dryness and/ or atrophy may respond very well to local oestrogen and this can be continued indefinitely.\n \nWomen with a uterus need a progesterone and the choice of progesterone is important for how the HRT performs and its safety. In the WHI many of the patients were on medroxyprogesterone acetate and this might have contributed to the risks of HRT in that study. Dydrogesterone or micronised progesterone.\n \nThe combined hormonal contraceptive pill used to the menopause is an option, but it has not been studied in comparison to standard dose HRT ",nodeType:e},{data:{},marks:[],value:B,nodeType:e},{data:{}
32,marks:[],value:" obviously there is a contraceptive benefit, but the doses of hormones are much higher, probably with a higher risk of venous clots.\n \nTransdermal oestradiol does not increase the risk of venous thromboembolism. The choice of progestagen is very important; MPA was a troublesome drug in the Women’s Health Initiative! For women who might want an oral preparation dydrogesterone or micronised progesterone is felt to be safer (and the latter is what many of my patients now take, via capsule).\n \nListen to your patients ",nodeType:e},{data:{},marks:[],value:B,nodeType:e},{data:{},marks:[],value:" libido and sexual function are important, the ovaries make testosterone as well as oestrogen and they might benefit from testosterone therapy. Get the standard HRT right and then consider testosterone for interest/ function/ well-being. And try it for 6 months at least.\n \nA GP might be able to advise you on the correct thing to do, but if you need to see a specialist, make an appointment at London Swiss Medical for a consultation.\n \nDr Philip Kelly is an specialist endocrinologist who diagnoses and treats the menopause, as well as considering if the symptoms might be from another problem. If you would like an appointment please contact us via email, phone, or booking online. There are other doctors in London who manage the menopause and my obstetric and gynaecology colleagues here in The Guthrie Clinic are also happy to see patients. So do not hesitate to ask for advice about who to see.",nodeType:e}],nodeType:t}],Ii.nodeType=l,Gi.data={},Gi.content=[{data:{},content:[{data:{},marks:[],value:"Testosterone Replacement & Female Androgen Deficiency",nodeType:e}],nodeType:t},{data:{},content:[{data:{},marks:[],value:"Testosterone is an androgen hormone. We commonly think of it as a male hormone but it has an important role in normal female development, behaviour and health; it is important for sexual function and interest, vaginal health, cognition, energy levels and bone strength and health. Half of a woman’s testosterone comes from the ovaries and half from the adrenal glands; testosterone acts on cells and tissues directly but is also converted into oestogens, particularly in fat cells. Some of the actions of testosterone are actually the effects of oestrogens.",nodeType:e}],nodeType:t},{data:{},content:[{data:{},marks:[],value:g,nodeType:e}],nodeType:t},{data:{},content:[{data:{},marks:[],value:"What happens at the Menopause?",nodeType:e}],nodeType:t},{data:{},content:[{data:{},marks:[],value:"The production of testosterone declines in women from the mid-thirties onwards, thought as the menopause progresses there is no sudden drop in testosterone. This is quite different if there is a surgical menopause – when the ovaries are removed – where there is a precipitous drop in testosterone. After the menopause the level of oestrogen falls but the remaining small quantities of testosterone can cause some women to have male type symptoms such as excess hair growth (hirsutism) and sometimes even male pattern hair loss.",nodeType:e}],nodeType:t},{data:{},content:[{data:{},marks:[],value:g,nodeType:e}],nodeType:t},{data:{},content:[{data:{},marks:[],value:"Female Androgen Deficiency Syndrome (FAD) & Hypoactive Sexual Desire Disorder (HSDD)",nodeType:e}],nodeType:t},{data:{},content:[{data:{},marks:[],value:"The lack of testosterone can cause tiredness, lack of energy, difficulty concentrating and a low libido. Together this can be Female Andogen Deficiency Syndrome (FAD), and the loss of libido can be termed Hypoactive Sexual Desire Disorder (HSDD).",nodeType:e}],nodeType:t},{data:{},content:[{data:{},marks:[],value:g,nodeType:e}],nodeType:t},{data:{},content:[{data:{},marks:[],value:"How is FAD or HSDD diagnosed?",nodeType:e}],nodeType:t},{data:{},content:[{data:{},marks:[],value:"Usually the patient’s story is enough to make the diagnosis, a blood test is not always necessary, though sometimes one might be done if there is any uncertainty.",nodeType:e}],nodeType:t},{data:{},content:[{data:{},marks:[],value:g,nodeType:e}],nodeType:t},{data:{},content:[{data:{},marks:[],value:"Indication and License for Use of Testosterone – why is this important?",nodeType:e}],nodeType:t},{data:{},content:[{data:{},marks:[],value:"Normally drugs have a license to be used in a specific situation. No testosterone therapy has a license for use in women for FAD or HSDD. This is despite our National Institute for Health and Care Excellence (NICE) recommending doctors ‘Consider testosterone supplementation for menopausal women with low sexual desire if HRT alone is not effective.’ – from NICE guideline [NG23] published November 2015 (accessed 3/1/18).",nodeType:e}],nodeType:t},{data:{},content:[{data:{},marks:[],value:"The lack of license is not a safety issue, it is merely for commercial reasons. Doctors prescribe many treatments off their labeled indication and license.",nodeType:e}],nodeType:t},{data:{},content:[{data:{},marks:[],value:"Testosterone therapy in this circumstance might not be the usual experience of a GP; not every person treating menopause will have experience considering it and this can explain why some women have difficultly getting help and advice.",nodeType:e}],nodeType:t},{data:{},content:[{data:{},marks:[],value:g,nodeType:e}],nodeType:t},{data:{},content:[{data:{},marks:[],value:"Testosterone – how can it be given?",nodeType:e}],nodeType:t},{data:{},content:[{data:{},marks:[],value:"The most common way to prescribe and give testosterone is currently with transdermal gels. The products change regularly for commercial reasons (and this is written with thanks to the British Menopause Society), and for the most up to date advice one must speak to a doctor with experience of managing the menopause. There is excellent patient advice at ",nodeType:e}
32,{data:{uri:"https://www.womens-health-concern.org/wp-content/uploads/2022/12/22-WHC-FACTSHEET-Testosterone-for-women-NOV2022-B.pdf"},content:[{data:{},marks:[],value:"Womens Health Concern",nodeType:e}],nodeType:k},{data:{},marks:[],value:".",nodeType:e}],nodeType:t},{data:{},content:[{data:{},content:[{data:{},content:[{data:{},marks:[],value:"Testogel [Besins Healthcare UK] (1% testosterone gel in 5.0g sachets containing 50mg testosterone): Starting dose 1/10 of a sachet/day = 5mg/day i.e. each sachet should last 10 days.\u2028\u2028",nodeType:e}],nodeType:t}],nodeType:p},{data:{},content:[{data:{},content:[{data:{},marks:[],value:"Tostran [Kyowa Kirin Ltd] (2% testosterone gel in a canister containing 60g ) : Starting dose 1 metered pump of 0.5g = 10mg on alternate days – each canister should last 240 days.\u2028\u2028",nodeType:e}],nodeType:t}],nodeType:p},{data:{},content:[{data:{},content:[{data:{},marks:[],value:"AndroFeme*[Lawley Pharma] (1% testosterone cream in 50ml tubes with screw cap): Starting dose 0.5ml/day = 5mg /day i.e. each tube should last 100 days.\u2028\u2028\nTestosterone Implants** [Smartway Pharma] (100mg implanted pellets) Unlicensed – imported from USA\u2028\u2028",nodeType:e}],nodeType:t}],nodeType:p}],nodeType:E},{data:{},content:[{data:{},marks:[],value:"* AndroFeme is not currently available in the NHS and is being imported from Western Australia by special license from the MHRA. Designed for female usage.",nodeType:e}],nodeType:t},{data:{},content:[{data:{},marks:[],value:"** Testosterone implants are currently unlicensed in the UK and can only be used privately or through agreement of the local formulary committee with appropriate monitoring of hormone levels and adverse effects. Designed for female usage.",nodeType:e}],nodeType:t},{data:{},content:[{data:{},marks:[],value:"Some patients prefer testosterone by injection, though this is more difficult in women and usually need very specific consideration from someone familiar with both the menopause, the indications for the testosterone, testosterone injections and monitoring the treatment",nodeType:e}],nodeType:t},{data:{},content:[{data:{},marks:[],value:g,nodeType:e}],nodeType:t},{data:{},content:[{data:{},marks:[],value:"How to apply the Testosterone Gel",nodeType:e}],nodeType:t},{data:{},content:[{data:{},marks:[],value:"Testosterone gel is applied to clean dry skin, rub it in and allow to dry before getting dressed. It can be applied on the wrists, arms, thighs, abdomen or shoulders; wash your hands immediately after applying but do not wash the application area for 2–3 hours afterwards. Do not allow skin contact with partners or children and keep the medication out of reach of children.",nodeType:e}],nodeType:t},{data:{},content:[{data:{},marks:[],value:g,nodeType:e}],nodeType:t},{data:{},content:[{data:{},marks:[],value:"Expected effects",nodeType:e}],nodeType:t},{data:{},content:[{data:{},marks:[],value:"The symptoms of fatigue, lethargy, poor cognition and loss of libido should improve.",nodeType:e}],nodeType:t},{data:{},content:[{data:{},marks:[],value:g,nodeType:e}],nodeType:t},{data:{},content:[{data:{},marks:[],value:"Monitoring",nodeType:e}],nodeType:t},{data:{},content:[{data:{},marks:[],value:"Blood tests are not obligatory, it is the response to therapy that is important. However it is usual to check the testosterone, full blood count, renal and liver function every six months and lipids yearly, alongside routine health monitoring.",nodeType:e}],nodeType:t},{data:{},content:[{data:{},marks:[],value:g,nodeType:e}],nodeType:t},{data:{},content:[{data:{},marks:[],value:"Common side effects",nodeType:e}],nodeType:t},{data:{},content:[{data:{},content:[{data:{},content:[{data:{},marks:[],value:"Hirsutism, increased facial or body hair is common.",nodeType:e}],nodeType:t}],nodeType:p},{data:{},content:[{data:{},content:[{data:{},marks:[],value:"Alopeia – male pattern hair loss is less common, as are acne and greasy skin.",nodeType:e}],nodeType:t}],nodeType:p},{data:{},content:[{data:{},content:[{data:{},marks:[],value:"Rarely can the voice deepen and the clitoris enlarge.",nodeType:e}],nodeType:t}],nodeType:p}],nodeType:E},{data:{},content:[{data:{},marks:[],value:g,nodeType:e}],nodeType:t},{data:{},content:[{data:{},marks:[],value:"Who cannot use testosterone gel or replacement?",nodeType:e}],nodeType:t},{data:{},content:[{data:{},marks:[],value:"Do not use testosterone if you are pregnant or breastfeeding, if you have a history of hormone sensitive breast cancer or if you are a competitive athlete and anabolic steroids are banned.",nodeType:e}],nodeType:t}],Gi.nodeType=l,Mi.data={},Mi.content=[{data:{},content:[{data:{},marks:[],value:"Osteoporosis is a disease that weakens your bones, making them less dense – and therefore more susceptible to fracture – than they would be otherwise. It tends to be more common in older women as their oestrogen levels fall during menopause and beyond, but it can also be linked to other aspects of a person’s health, including their testicular or ovarian function, parathyroids, vitamin D or magnesium levels, connective tissue, alcohol and smoking habits.",nodeType:e}],nodeType:t}],Mi.nodeType=l,Ki.data={},Ki.content=[{data:{},content:[{data:{},marks:[],value:"In the early part of your life, we can help you to understand if you are on track to establish peak bone mass and whether your health is good enough to maintain it, anticipating potential problems with osteoporosis or osteopenia, a condition involving low bone density which may lead to osteoporosis.",nodeType:e}],nodeType:t},{data:{},content:[{data:{},marks:[],value:"We consider whether you should increase your calcium intake, either in the diet or through supplements, or take vitamin D, when to use DXA scanning and how often, and the use of agents such as bisphosphonates and denosumab (and its newer cousins) to help strengthen the skeleton.",nodeType:e}],nodeType:t}],Ki.nodeType=l,Ji.data={},Ji.content=[{data:{},content:[{data:{},marks:[],value:"The four small parathyroid glands are located next to the thyroid. They secrete a hormone (the parathyroid hormone) that regulates calcium levels in a person's body. Parathyroid disease is a condition where they either produce too much or too little of this hormone, causing an imbalance of calcium in the blood.",nodeType:e}],nodeType:t},{data:{},content:[{data:{},marks:[],value:g,nodeType:e}],nodeType:t}],Ji.nodeType=l,tn.nodeType=l,tn.data={},tn.content=[{nodeType:t,data:{},content:[{nodeType:e,value:"Hyperparathyroidism is a common parathyroid disease where too much of the hormone is produced. This usually (but not always) causes the amount of calcium in the blood to rise, and this elevation of the serum calcium – sometimes known as hypercalcaemia – is often only found when a blood test is done for some other reason. Hypercalcaemia can leave people feeling unwell in very vague ways.",marks:[],data:{}}]},{nodeType:t,data:{},content:[{nodeType:e,value:"The commonest cause of primary hyperparathyroidism is a single benign tumour of the parathyroid – an adenoma – and if it can be successfully removed the patient can be cured. However, there are a series of diagnostic considerations to be made that usually require a trained endocrinologist, and a key decision then is to find a good surgeon who operates regularly on the parathyroids. ",marks:[],data:{}}]},{nodeType:t,data:{},content:[{nodeType:e,value:"Many patients benefit from having an endocrinologist involved in their post-operative care, and we can arrange for you to have your operation at a hospital of your choice, with the best surgeon for you. Those we work with most closely are Mr Jonathan Hubbard, who practices at The London Bridge Hospital, and Professor Fausto Palazzo at The Cromwell Hospital. ",marks:[],data:{}}]},{nodeType:t,data:{},content:[{nodeType:e,value:g,marks:[],data:{}}]}],on.nodeType=l,on.data={},on.content=[{nodeType:t,data:{},content:[{nodeType:e,value:"Secondary hyperparathyroidism occurs when too much parathyroid hormone is produced to compensate for some other problem in the body. It can often be caused by Vitamin D deficiency but it can also be seen in renal disease. For this reason, it’s important to re
32cognise the condition, both to understand why it is there and to treat it accordingly. We can help you understand if it is present, why and what to do about it.",marks:[],data:{}}]}],sn.data={},sn.content=[{data:{},content:[{data:{},marks:[],value:"Hypoparathyroidism – when too little of the parathyroid hormone is produced – is most often a consequence of thyroid surgery. It can also occur after radiotherapy, or as a result of damage from the immune system – and magnesium deficiency is also increasingly recognised as a cause. All of these conditions can cause low calcium, muscle cramps, weakness and instability of the heart. Ensuring that you maintain your calcium, magnesium and phosphate levels is critical as all of them contribute to your bone and kidney health for decades to come.",nodeType:e}],nodeType:t}],sn.nodeType=l,rn.nodeType=l,rn.data={},rn.content=[{nodeType:t,data:{},content:[{nodeType:e,value:"The hypothalamus controls several endocrine functions and if it is damaged, the functioning of the pituitary gland will also be affected. Pituitary disease itself is rare, but like hypothalamic disease, the symptoms vary widely and it’s essential to consult an expert for diagnosis and treatment. ",marks:[],data:{}}]}],yn.nodeType=l,yn.data={},yn.content=[{nodeType:t,data:{},content:[{nodeType:e,value:"Pituitary disease includes a group of conditions that affect the pituitary gland and the hormones it produces. Disorders can happen when the gland produces too much or too little hormone. ",marks:[],data:{}}]},{nodeType:t,data:{},content:[{nodeType:e,value:"Pituitary tumours are often found incidentally on a general MRI or CT scan. Small tumours are naturally more common than larger ones, but all have to be understood. They are usually benign and cause problems because they produce hormones, squash normal hormone-producing cells, cause headaches, put pressure on the nerves to the eyes or – more rarely – those controlling eye movements or facial sensation. We have a wealth of experience diagnosing and treating pituitary tumours and work with a group of experts who can also help. Tumours and/or inflammation can affect sexual function, fertility, energy, growth and weight, and must be diagnosed quickly and accurately.",marks:[],data:{}}]},{nodeType:t,data:{},content:[{nodeType:e,value:"Hypothalamic tumours are rarer, but much of our general health relies on this part of the brain functioning well. The effects tend to be more subtle than with pituitary tumours and require very specialist assessment, which usually involves radiology, the laboratory, eye specialists and oncologists – a collaboration which we can help you to navigate.",marks:[],data:{}}]}],hn.data={},hn.content=[{data:{},content:[{data:{},marks:[],value:"Prolactinoma is a common clinical problem which occurs when the pituitary gland produces excessive prolactin. It causes menstrual irregularities or inappropriate breast milk production, and infertility in both men and women, and is sometimes associated with polycystic ovarian syndrome (PCOS). Following diagnosis, which usually happens quickly, the usual treatment is a dopamine agonist such as cabergoline.",nodeType:e}],nodeType:t}],hn.nodeType=l,_n.nodeType=l,_n.data={},_n.content=[{nodeType:t,data:{},content:[{nodeType:e,value:"Benign tumours in the pituitary are often too small to cause any harm, but sometimes it’s useful to make a detailed asse
32ssment of the pituitary function and carry out ongoing surveillance to find out whether they are stable or changing over time. Larger tumours can squash the cells that make normal pituitary hormones, and this in turn can affect your energy, temperature, breast health, periods, erections and/or fertility, growth, skin condition and mood. As these benign tumours can grow very slowly the changes are often insidious and the tests difficult to interpret. Often they are picked up by an optician, or by a scan for something else.",marks:[],data:{}}]},{nodeType:t,data:{},content:[{nodeType:e,value:"The larger tumours can get close to – or even squash – the optic nerve, or other nerves used for vision. This must be diagnosed quickly and the pressure relieved, usually by an operation. More rarely, tumours can affect the nerves associated with eye movement and facial sensation.",marks:[],data:{}}]},{nodeType:t,data:{},content:[{nodeType:e,value:"Whatever the situation, we have experience in assessing and diagnosing pituitary disease and helping you decide on the right treatment for you, connecting you where necessary with a close network of trusted colleagues experienced in these conditions too. ",marks:[],data:{}}]}],fn.data={},fn.content=[{data:{},content:[{data:{},marks:[],value:"If a tumour or inflammation in the pituitary and/or hypothalamus affects the central control of your adrenals, it can be difficult to diagnose. Secondary adrenal failure, when hormones are not produced correctly, can affect your energy, wellbeing, blood pressure and weight. Our depth of understanding of how the hypothalamic-pituitary-adrenal (HPA) axis works means that we can quickly work out what the best tests are if you become unwell suddenly, how to replace hormones if they are deficient, and how to avoid becoming unwell.  ",nodeType:e}],nodeType:t}],fn.nodeType=l,Tn.nodeType=l,Tn.data={},Tn.content=[{nodeType:t,data:{},content:[{nodeType:e,value:"Thyroid health is more difficult to maintain when pituitary disease is present. The clinic picture becomes more complex and the normal rules for interpreting thyroid blood tests often don’t apply. Decisions about therapy must be made by a thyroid specialist used to dealing with pituitary disease with or without multiple hormone deficiencies. ",marks:[],data:{}}]}],kn.nodeType=l,kn.data={},kn.content=[{nodeType:t,data:{},content:[{nodeType:e,value:"If the signals received by your hypothalamus indicate that you might be underweight, it will change the signals it sends out to regulate your libido, periods, erections, energy and sleep, affecting your function in these areas, but also other parts of the body including your skeleton, breasts and womb. While the condition can be difficult to recognise in some patients, we can help you understand what is happening and what can be done about it. Often this is about ensuring your body has the right hormonal environment while we consider your weight and energy balance. It may also involve looking at whether we can improve some co-existing disease that is affecting you – for example, your mental health, cancer or immune problems, coeliac or inflammatory bowel disease.",marks:[],data:{}}]}],Dn.nodeType=l,Dn.data={},Dn.content=[{nodeType:t,data:{},content:[{nodeType:e,value:"The hypothalamus, located close to the pituitary in the base of the brain, controls nearly all our endocrine function. It is very sensitive to the body’s energy balance, and if this balance is upset the symptoms can be seen elsewhere.",marks:[],data:{}}]},{nodeType:t,data:{},content:[{nodeType:e,value:"Rarely, tumours or inflammation of the pituitary gland and/or hypothalamus can interfere with the important centres in the brain which control the adrenals, thyroid, testes and ovaries. Sometimes a tumour makes it clear that we should focus on these areas, but making the right diagnosis can often be more difficult. We are used to interpreting tests of these hormonal axes in pituitary disease and treating dysfunction across them. The effects might be felt in your mood, energy, weight, muscle and fat distribution, libido, periods, erections, fertility, temperature and general wellbeing.",marks:[],data:{}}]}],Rn.nodeType=l,Rn.data={},Rn.content=[{nodeType:t,data:{},content:[{nodeType:e,value:"PCOS is a common condition that affects how a woman’s ovaries work. Because some of the symptoms of PCOS – for example, irregular or heavy periods – are also associated with other conditions, it’s important to exclude these and clarify what type of PCOS you have so that we can help you plan your short- and long-term treatment.",marks:[],data:{}}]}],xn.nodeType=l,xn.data={},xn.content=[{nodeType:t,data:{},content:[{nodeType:e,value:"Irregular periods are common outside of PCOS and patients often visit a GP or gynaecologist for help. Ensuring you also have good metabolic and endocrine health is important though, because improving your health in these areas can often greatly improve your periods – and help with regular ovulation. If the peri
32ods are irregular because of your transition into menopause, we can also help with this. More rarely irregular periods are due to pituitary or hypothalamic dysfunction, and this requires specific testing which we can do if necessary.",marks:[],data:{}}]},{nodeType:t,data:{},content:[{nodeType:e,value:"We often work with female ultrasound experts and gynaecologists if we need to know more about the health of your ovaries to help classify and diagnose PCOS.",marks:[],data:{}}]}],Ln.nodeType=l,Ln.data={},Ln.content=[{nodeType:t,data:{},content:[{nodeType:e,value:"Heavy periods are common and again, most women start by visiting their GP or gynaecologist. However, there are many aspects of your assessment and care that we can help with as endocrinologists. We can make sure you do not have thyroid disease and if so treat it; we can ensure your iron stores are satisfactory, and treat and maintain them if not. We can also help with treatments to make the heavy periods less troublesome. If you have fibroids and want to consider having them treated, it is usually better to see a gynaecologist while they are still small to consider your options.",marks:[],data:{}}]}],Un.data={},Un.content=[{data:{},content:[{data:{},marks:[],value:"Before and after ovulation, and into the early part of menstruation, some women have disabling symptoms that affect their mental health. At one end of the spectrum is severe PMS, but some patients also have intrusive thoughts of self-harm or harm to others, and this is known as pre-menstrual dysphoria disorder. We have experience in helping you understand if this might apply to you – and if so, in helping you find the right diagnosis. Sometimes treatment involves specific psychological medicine, but it should always be with a doctor who understands the context of hormonal changes across the cycle.",nodeType:e}],nodeType:t}],Un.nodeType=l,Yn.data={},Yn.content=[{data:{},content:[{data:{},marks:[],value:"Thyroid hormones affect the way nearly every organ in the body works, and in turn influence the health of both mother and developing baby during pregnancy. During the first trimester, the baby depends on the mother’s supply of thyroid hormones through the placenta, so maintaining thyroid health is essential for both. ",nodeType:e}],nodeType:t}],Yn.nodeType=l,Fn.nodeType=l,Fn.data={},Fn.content=[{nodeType:t,data:{},content:[{nodeType:e,value:"For women planning to embark on a cycle of IVF, the thyroid function must be working as well as possible. Thyroid hormones affect the production of reproductive hormones, and these are essential for successful ovulation and implantation – as well as foetal development.",marks:[],data:{}}]}],Pn.data={},Pn.content=[{data:{},content:[{data:{},marks:[],value:"Maintaining thyroid health before and during pregnancy forms an important part of our work at London Swiss Medical. We work with you to get you as well as possible for conception – whether natural or assisted – and plan ahead so your thyroid health is controlled during pregnancy, breastfeeding and motherhood. If you become pregnant and have thyroid disease, please call us as soon as possible so we can check you are in good health. Doses of thyroxine should often be reconsidered if you are planning a pregnancy, so it is vital to consult with your thyroid specialist.",nodeType:e}],nodeType:t}],Pn.nodeType=l,Hn.nodeType=l,Hn.data={},Hn.content=[{nodeType:t,data:{},content:[{nodeType:e,value:Gn,marks:[],data:{}}]},{nodeType:t,data:{},content:[{nodeType:e,value:g,marks:[],data:{}}]},{nodeType:t,data:{},content:[{nodeType:e,value:Wn,marks:[],data:{}}]},{nodeType:t,data:{},content:[{nodeType:e,value:g,marks:[],data:{}}]},{nodeType:E,data:{},content:[{nodeType:p,data:{},content:[{nodeType:t,data:{},content:[{nodeType:e,value:Mn,marks:[],data:{}}]}]},{nodeType:p,data:{},content:[{nodeType:t,data:{},content:[{nodeType:e,value:qn,marks:[],data:{}}]}]}]},{nodeType:t,data:{},content:[{nodeType:e,value:g,marks:[],data:{}}]},{nodeType:t,data:{},content:[{nodeType:e,value:Bn,marks:[],data:{}}]},{nodeType:t,data:{},content:[{nodeType:e,value:g,marks:[],data:{}}]},{nodeType:E,data:{},content:[{nodeType:p,data:{},content:[{nodeType:t,data:{},content:[{nodeType:e,value:zn,marks:[],data:{}}]}]},{nodeType:p,data:{},content:[{nodeType:t,data:{},content:[{nodeType:e,value:Kn,marks:[],data:{}}]}]},{nodeType:p,data:{},content:[{nodeType:t,data:{},content:[{nodeType:e,value:Vn,marks:[],data:{}}]}]},{nodeType:p,data:{},content:[{nodeType:t,data:{},content:[{nodeType:e,value:Jn,marks:[],data:{}}]}]}]},{nodeType:t,data:{},content:[{nodeType:e,value:g,marks:[],data:{}}]},{nodeType:t,data:{},content:[{nodeType:e,value:Xn,marks:[],data:{}}]},{nodeType:t,data:{},content:[{nodeType:e,value:g,marks:[],data:{}}]},{nodeType:E,data:{},content:[{nodeType:p,data:{},content:[{nodeType:t,data:{},content:[{nodeType:e,value:eo,marks:[],data:{}}]}]},{nodeType:p,data:{},content:[{nodeType:t,data:{},content:[{nodeType:e,value:to,marks:[],data:{}}]}]},{nodeType:p,data:{},content:[{nodeType:t,data:{},content:[{nodeType:e,value:io,marks:[],data:{}}]}]},{nodeType:p,data:{},content:[{nodeType:t,data:{},content:[{nodeType:e,value:no,marks:[],data:{}}]}]}]},{nodeType:t,data:{},content:[{nodeType:e,value:g,marks:[],data:{}}]},{nodeType:t,data:{},content:[{nodeType:e,value:oo,marks:[],data:{}}]},{nodeType:t,data:{},content:[{nodeType:e,value:ao,marks:[],data:{}}]}],so.data={},so.content=[{data:{},content:[{data:{},marks:[],value:lo,nodeType:e}],nodeType:t},{data:{},content:[{data:{},marks:[],value:ro,nodeType:e}],nodeType:t},{data:{},content:[{data:{},marks:[],value:mo,nodeType:e}],nodeType:t},{data:{},content:[{data:{},marks:[],value:co,nodeType:e}],nodeType:t},{data:{},content:[{data:{},marks:[],value:po,nodeType:e}],nodeType:t},{data:{},content:[{data:{},marks:[],value:yo,nodeType:e}],nodeType:t},{data:{},content:[{data:{},marks:[],value:uo,nodeType:e}],nodeType:t}],so.nodeType=l,Co.data={},Co.content=[{data:{},content:[{data:{},marks:[],value:"Sodium and water balance disorders are closely related, as sodium plays an important role in the movement of water into and out of cells. Water balance disorders arise when there is an imbalance in the body’s water content, presenting problems with thirst or the production of too much urine. Although common, such disorders are often poorly controlled or undiagnosed.",nodeType:e}],nodeType:t}],Co.nodeType=l,fo.data={},fo.content=[{data:{},content:[{data:{},marks:[],value:"Many thirst disorders are difficult to diagnose, particularly when they are not severe. An endocrinologist can help to differentiate between problems where the patient produces too much urine – diabetes insipidus – and is thirsty to compensate, and those where the patient drinks too much – primary polydipsia – and produces too much urine to compensate. ",nodeType:e}],nodeType:t},{data:{},content:[{data:{},marks:[],value:"Diabetes insipidus (DI) may require a supervised water deprivation test in hospital as it is a specialist area even within endocrinology. It is important to differentiate cranial DI – which responds to DDAVP – from nephrogenic DI, which does not. A very similar clinical picture can often occur from primary polydipsia (drinking too much), which some call dipsogenic DI.",nodeType:e}],nodeType:t}],fo.nodeType=l,To.nodeType=l,To.data={},To.content=[{nodeType:t,data:{},content:[{nodeType:e,value:"Hyponatraemia – a low level of sodium in the blood – is also extremely common and again, very easy to misdiagnose and mistreat. In many patients it requires specialist attention much earlier than 
32it is often received. Some patients may have transient low sodium alongside a critical illness, but if it persists, or is more severe, a thorough assessment will be needed to come to a diagnosis and plan treatment.",marks:[],data:{}}]}],ko.nodeType=l,ko.data={},ko.content=[{nodeType:t,data:{},content:[{nodeType:e,value:"One of the causes of hyponatraemia is the syndrome of inappropriate ADH secretion (SIADH or SIAD). Diagnosis is essential because it can be associated with tumours in the brain or lung, or other diseases across the body. New treatments such as vaptans have revolutionised its treatment, but they must be used under specialist supervision.",marks:[],data:{}}]}],Do.data={},Do.content=[{data:{},content:[{data:{},marks:[],value:"Concerns about testosterone are common; testosterone affects our sense of self, our libido, and the sexual function in both men and women. It is essential for the proper completion of puberty, and the development and maintenance of the skeleton, and the management of testosterone problems is important as it can also affect fertility. ",nodeType:e}],nodeType:t}],Do.nodeType=l,xo.data={},xo.content=[{data:{},content:[{data:{},marks:[],value:"Testicular failure – or hypogonadism – is characterised by low levels of testosterone and/or sperm production. If you are deficient in testosterone (or other androgens), a fast and accurate diagnosis is vital so that you can be monitored and/or given an appropriate treatment to restore your testosterone levels. This will always include a detailed clinical assessment, often including tests of blood or semen samples, and occasionally an MRI scan of the hypothalamus and pituitary gland.",nodeType:e}],nodeType:t}],xo.nodeType=l,Lo.nodeType=l,Lo.data={},Lo.content=[{nodeType:t,data:{},content:[{nodeType:e,value:"One of the main functions of the testes is to produce healthy sperm. However, many endocrine conditions can affect the precise interplay of hormones necessary for this. We have experience in diagnosing these conditions and then treating them to restore sperm production. If the hormonal system is damaged by a tumour or inflammation in the hypothalamus or pituitary, we can replace the hormones to stimulate sperm production.",marks:[],data:{}}]},{nodeType:t,data:{},content:[{nodeType:e,value:"If the testes themselves are damaged – by tumour, inflammation, childhood trauma or injury, or by developmental defect – adjusting the hormones from the brain will have less effect. In these cases we may refer you to a very specialist male fertility doctor to see if any sperm retrieval can be performed directly.",marks:[],data:{}}]}],Uo.nodeType=l,Uo.data={},Uo.content=[{nodeType:t,data:{},content:[{nodeType:e,value:"In some men, hypogonadism occurs when there is an upset in their metabolism. This is usually because the body’s energy balance has been disturbed, either from weight loss, over-exercise (both cardiovascular and bulk) or by attempting to reduce body fat below a normal level. Other causes are psychological upset and mental health problems. In response, the hypothalamus suppresses testosterone production. Our experience in diagnosing such problems means we can work with you to find a route back to overall health – and more healthy sperm production.",marks:[],data:{}}]}],Qo.nodeType=l,Qo.data={},Qo.content=[{nodeType:t,data:{},content:[{nodeType:e,value:"Erectile dysfunction is a common problem, treated by many doctors and health practitioners, but it is not a symptom in isolation. We usually consider how it relates to your hormones, whether it might be a symptom of testosterone deficiency or a manifestation of cardiovascular disease, as well as looking at how it affects you and what we can do to improve it. We have extensive experience in finding the right treatment for erectile dysfunction and, if things are very difficult, work closely with experienced urologists to get specialist help.",marks:[],data:{}}]}],Zo.data={},Zo.content=[{data:{},content:[{data:{},marks:[],value:"Conditions affecting the thyroid gland are very common. Some of the symptoms – fatigue and weight gain – are also very common though, and it can take skill to determine whether the thyroid might be responsible. Our approach is holistic, looking at the whole patient so that we can rule out other causes before investigating the thyroid function in more detail.",nodeType:e}],nodeType:t}],Zo.nodeType=l,Fo.nodeType=l,Fo.data={},Fo.content=[{nodeType:t,data:{},content:[{nodeType:e,value:"An underactive thyroid gland (hypothyroidism) can be very difficult to diagnose because the symptoms can also be associated with other conditions, and deciding whether to have therapy is a serious decision best discussed with an expert. For women of childbearing age planning to embark on a cycle of ovulation induction, IVF or embryo transfer, it’s imperative that the thyroid function is working as well as possible.",marks:[],data:{}}]}],Po.nodeType=l,Po.data={},Po.content=[{nodeType:t,data:{},content:[{nodeType:e,value:"Sub-clinical hypothyroidism, which occurs when levels of thyroid-stimulating hormone (TSH) are above the normal range, is often – but not always – associated with women of childbearing age. We offer advice and guidance on how to manage it, particularly during pregnancy.",marks:[],data:{}}]}],Go.nodeType=l,Go.data={}
32,Go.content=[{nodeType:t,data:{},content:[{nodeType:e,value:"An overactive thyroid is also known as hyperthyroidism or thyrotoxicosis. The most common cause is Graves’ disease, an autoimmune disease that affects the thyroid. Hyperthyroidism is most common in – but is not restricted to – younger patients. We can help to make your diagnosis and decide on the right treatment for you.",marks:[],data:{}}]}],Mo.nodeType=l,Mo.data={},Mo.content=[{nodeType:t,data:{},content:[{nodeType:e,value:"Some people make antibodies that can stimulate the thyroid, causing hyperthyroidism. This is known as Graves’ disease. Hyperthyroidism must be treated, and there are many options available. For most patients, medicine is prescribed to get things under control, but for others, radio-iodine or surgery may be more appropriate. Often a 12-to-18-month course of medicine will be enough to allow the production of antibodies to fall and put Graves’ disease into remission, with no further treatment needed. Graves’ disease often causes a swelling of the thyroid – known as thyroid eye disease or Graves’ ophthalmopathy – and much more rarely it can affect the skin, nails or joints.",marks:[],data:{}}]}],Bo.data={},Bo.content=[{data:{},content:[{data:{},marks:[],value:"Thyroid eye disease (TED) can only be identified through a detailed ophthalmological assessment. We work in a small team alongside specialist ophthalmology, radiology and neurosurgery colleagues to manage both TED and Graves’ ophthalmology, making us uniquely placed to consider treatments ranging from the use of selenium, steroids and immunosuppressants through to cosmetic surgery and orbital decompression.",nodeType:e}],nodeType:t}],Bo.nodeType=l,Ko.nodeType=l,Ko.data={},Ko.content=[{nodeType:t,data:{},content:[{nodeType:e,value:"Hyperthyroidism can also be caused by a multi-nodular thyroid gland – a condition that becomes more common as we get older and causes swelling to the neck. Like all hyperthyroidism, it has to be treated and the options available include medicine, radio-iodine and/or surgery. Unlike Graves’ disease, where the antibodies can go away, the nodularity usually persists and, even after 12-18 months of tablets, toxic multinodular goitre is rarely cured or put into remission. Patients can still have tablet treatment, however, and together we can consider what is the best ongoing treatment for you.",marks:[],data:{}}]}],Jo.nodeType=l,Jo.data={},Jo.content=[{nodeType:t,data:{},content:[{nodeType:e,value:"A single nodule – a toxic adenoma – can also cause thyrotoxicosis. Its treatment can be quite different to other forms of hyperthyroidism so it is particularly important to get an accurate diagnosis.",marks:[],data:{}}]}],ea.nodeType=l,ea.data={},ea.content=[{nodeType:t,data:{},content:[{nodeType:e,value:"Viruses can inflame the thyroid for a short time and cause dramatic hyperthyroidism, often followed by a period of calm and then either transient or permanent hypothyroidism. This can often come and go within 6 months. The condition must be recognised because the treatment is completely different to other causes of hyperthyroidism: often a nuclear medicine uptake scan is needed for diagnosis, followed by blood tests while the inflammation is treated.",marks:[],data:{}}]}],ia.data={},ia.content=[{data:{},content:[{data:{},marks:[],value:"While thyroid nodules are very common, thyroid cancer is rare, and most cases are curable if treated promptly. We work closely with a multidisciplinary team including ultrasonographers, pathologists, cytologists, doctors of nuclear medicine and specialist nurses so that the best decisions can be made about your treatment. Very often this is to exclude cancer, but sometimes it is to give a prompt diagnosis and work out who is best placed to help you.",nodeType:e}],nodeType:t}],ia.nodeType=l,oa.data={},oa.content=[{data:{},content:[{data:{},marks:[],value:"Pregnancy is a natural process, and we avoid making any medical intervention unless it is absolutely necessary. Keeping the thyroid functioning perfectly is particularly important during the first twelve weeks of pregnancy and in the time preceding conception. However, it can also be more difficult to treat at this time; in the second and third trimesters it is usually easier. Most women don’t need routine testing before or during pregnancy, but if your thyroid is abnormal, was abnormal in a previous pregnancy and/or you need it to be functioning perfectly for assisted conception, ovulation induction, embryo transfer or IVF, we can help manage this for you. The thyroid often changes during pregnancy, and we can readjust things for you after delivery to help you and your baby, however you are nursing.",nodeType:e}],nodeType:t}],oa.nodeType=l,sa.data={},sa.content=[{data:{},content:[{data:{},marks:[],value:"Just as the immune system changes after pregnancy, so the thyroid function can also change. Patients can become unwell and attribute their feelings of exhaustion or depression to becoming a new mother. The risk of post-partum thyroiditis is higher for some women, and for those patients we would consider arranging a blood test and routine reviews rather than waiting for you to become unwell. We will advise you on what is best for your individual case.",nodeType:e}],nodeType:t}],sa.nodeType=l,da.nodeType=l,da.data={}
32,da.content=[{nodeType:t,data:{},content:[{nodeType:e,value:"Thyrotoxicosis is common, it affects about 1 in 100 people, it is six - ten times more common in women than men. There are two main causes in the UK: ",marks:[],data:{}}]},{nodeType:W,data:{},content:[{nodeType:p,data:{},content:[{nodeType:t,data:{},content:[{nodeType:e,value:"The immune system making antibodies that stimulate the thyroid and the patient becomes hyperthyroid - this is Graves' thyrotoxicosis.",marks:[],data:{}}]}]},{nodeType:p,data:{},content:[{nodeType:t,data:{},content:[{nodeType:e,value:"There is benign nodularity in the thyroid - a multinodular goitre. ",marks:[],data:{}}]}]}]},{nodeType:t,data:{},content:[{nodeType:e,value:"The following conditions are less common, but still not rare, their treatment is completely different and thus them being diagnosed and distinguished from Graves' thyrotoxicosis is critically important - a single nodule can cause thyrotoxicosis and in some people a viral inflammation of the thyroid can cause sudden hyperthyroidism.",marks:[],data:{}}]},{nodeType:t,data:{},content:[{nodeType:e,value:g,marks:[],data:{}}]},{nodeType:t,data:{},content:[{nodeType:e,value:"Graves' thyrotoxicosis",marks:[],data:{}}]},{nodeType:t,data:{},content:[{nodeType:e,value:"In Graves' disease the body makes antibodies that stimulate the TSH receptor causing thyroid over-reactivity and the production of excess thyroid hormones - thyroxine (T4) and liothyroinine (T3). These hormones attach to thyroid hormone receptors all round the body causing the symptoms of thyrotoxicosis. Robert Graves was a Dublin physician who wrote one of the first descriptions of this form of thyrotoxicosis.",marks:[],data:{}}]},{nodeType:t,data:{},content:[{nodeType:e,value:"The features of Graves' disease are: hyperthyroidism with a smoothly enlarged fleshy thyroid - a goitre.",marks:[],data:{}}]},{nodeType:t,data:{},content:[{nodeType:e,value:"The antibodies can also attach to other parts of the body causing the other features of Graves' disease. ",marks:[],data:{}}]},{nodeType:E,data:{},content:[{nodeType:p,data:{},content:[{nodeType:t,data:{},content:[{nodeType:e,value:"The muscles of the eyes - causing protrusion of the eye, Graves' ophthalmopathy, or thyroid eye disease (TED); this is much more common in cigarette smokers.",marks:[],data:{}}]}]},{nodeType:p,data:{},content:[{nodeType:t,data:{},content:[{nodeType:e,value:"The skin - most commonly on the leg, over the shin, called pre-tibial myxoedema, or Graves' dermopathy; rare.",marks:[],data:{}}]}]},{nodeType:p,data:{},content:[{nodeType:t,data:{},content:[{nodeType:e,value:"The nails and the bones of the wrist - causing digital clubbing and pain at the wrist - thyroid acropachy; very rare.",marks:[],data:{}}]}]}]},{nodeType:t,data:{},content:[{nodeType:e,value:"\nThe diagnosis of Graves' disease is supported by the presence of thyroid antibodies in the bloodstream. Very commonly anti-thyroid peroxidase antibodies (anti-TPO Ab) are elevated, most UK Hospital laboratories measure these and the result comes back quickly. Antibodies agains the TSH-receptor (TRAb) are also elevated, they define Graves' disease, the result tends to come back a one to two days to a fortnight after being taken. TRAb should be measured to diagnose and monitor the patient's condition, they are very useful to predict the course of therapy and whether the patient is more likely to relapse after treatment.",marks:[],data:{}}]},{nodeType:t,data:{},content:[{nodeType:e,value:"Graves' disease may rarely not be associated with thyrotoxicosis, the patient might not be thyrotoxic or hyperthyroid and the thyroid function tests (TFT) might be completely normal but the patient still have TED, dermopathy or acropachy.",marks:[],data:{}}]},{nodeType:t,data:{},content:[{nodeType:e,value:"The mainstay of treatment for Graves' thyrotoxicosis is antithyroid medication - carbimazole and propylthiouracil (PTU) these are discussed in the resources page. The patient can expect to be treated for 12 - 18 months before making a decision on stopping, to see whether they are cured, or whether they will relapse. Factors that favour Graves' thyrotoxicosis relapsing are high titre of TRAb, male sex, large goitre, difficult to control thyrotoxicosis and extra-thyroidal Graves' disease. If it does relapse off treatment it is not a problem to take carbimazole or PTU again and many patients are controlled on small doses for many years or decades, or the patient might decide to have radiodine, or a thyroidectomy.",marks:[],data:{}}]},{nodeType:t,data:{},content:[{nodeType:e,value:g,marks:[],data:{}}]},{nodeType:t,data:{},content:[{nodeType:e,value:"What if the patient relapses after a course of treatment?",marks:[],data:{}}]},{nodeType:t,data:{},content:[{nodeType:e,value:"Many endocrinologists used to say that a patient who had relapsed would need definitive, or permanent, therapy for Graves', try to guarantee a cure of the thyrotoxicosis;
32 these treatments are radioactive iodine (RAI) or surgical thyroidectomy- discussed in patient resources. Some patients are treated with RAI as first line therapy, it is a respected strategy in many units around the world and promoted in the UK by NICE Guidance; much more rarely is surgery used as a primary treatment; surgery carries more risk in a thyrotoxic patient, and there is a small but predictable risk of damaging the nerves controlling the voice box or the parathyroid glandsthat control calcium and phosphate balance across the body.",marks:[],data:{}}]},{nodeType:t,data:{},content:[{nodeType:e,value:"However many endocrinologist did not agree with a permanent treatment at the outset as this would usually leave the patient dependent on thyroid hormone therapy for life. They give the patients the option of what to do, and may patients choose to maintain themselves on low doses of carbimazole (or PTU) for life as long as they are tolerated and work. Long-term antithyroid medication has generally been a strategy I have supported in the majority of patients and this has now become a more accepted strategy internationally, with support from the American Thyroid Association.",marks:[],data:{}}]},{nodeType:t,data:{},content:[{nodeType:e,value:"Gender, family plans, pregnancy, breastfeeding, child care responsibilities and co-existing medical conditions all have to be taken into account before deciding on what is best by each individual patient.",marks:[],data:{}}]},{nodeType:t,data:{},content:[{nodeType:e,value:"General Practitioners in the UK are generally reluctant to manage hyperthyroidism themselves, particularly Graves' thyrotoxicosis. It is usual that patients are referred to an endocrinologist, though some GPs will have experience of managing the condition and local practice varies.",marks:[],data:{}}]},{nodeType:t,data:{},content:[{nodeType:e,value:"It is important is that the patient sees someone experienced in the diagnosis and management of thyroid disease, who is able to accurately diagnosis the condition, counsel the patient on treatment options and supervise treatment appropriately AND that the patient and doctor have a relationship based on mutual trust.",marks:[],data:{}}]},{nodeType:t,data:{},content:[{nodeType:e,value:"Hyperthyroidism, if not treated well, is associated with ill-health, and before effective treatment used to shorten patients' lives, and it still retains the potential to do so even with modern treatment. 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Obesity is the most common manifestation, with excess body fat often leading to additional health issues. Consulting with someone who can asse
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Disease","Diabetes","Weight Management","Lowering Liver Fat","hyperlink","Thyroid Disease","Page","Pregnancy","- ","unordered-list","Menopause","Post-Partum / Post-Pregnancy Thyroiditis","Thyroid Medications – Carbimazole & Propylthiouracil Advice for Patients","Homepage","Mounjaro and Wegovy","mounjaro-and-wegovy","2024-07-01T00:00:00.000Z","The GLP-1 analogues tirzepatide in Mounjaro and semaglutide in Wegovy and Ozempic are available from LondonSwissMedical. Dr Philip Kelly describes how they benefit patients, help weight loss, diabetes and glucose control, lipids and overall cardiovascular health.","lowering-liver-fat","2019-10-18T00:00:00.000Z",null,"Map","How we 
32can help",1147,1344,"Drug intolerance and side effects","ordered-list","Hypoglycaemia","T2DM Update – Major Therapeutic Advance – New Oral Treatment for Type 2 Diabetes","–",1263,"Menopause – Listen to Your Patients","Testosterone and The Menopause",1455,1149,1090,"post-partum-post-pregnancy-thyroiditis","2021-03-19T00:00:00.000Z","thyroid-medications-carbimazole-and-propylthiouracil-advice-for-patients","2019-08-08T00:00:00.000Z","Graves' thyrotoxicosis: information for patients & their doctors",!1,"HomepageIntroText","HomepageHowWeCanHelpText","Journal","SettingsNavigationCollection","Wegovy and Ozempic are the brand names for semaglutide, and Mounjaro is the brand name for tirzepatide.","Semaglutide is a GLP-1 (glucagon like peptide 1) agonist and tirzepatide is a dual-agnoist for GLP-1 and GIP (gastric inhibitory polypeptide, also known as glucose dependant insulinotropic polypeptide).","WHAT DO GLP-1 AGONISTS DO?","GLP-1 (glucagon-like peptide-1) agonists are a class of medications primarily used to treat type 2 diabetes and, more recently, obesity. They mimic the action of the natural hormone GLP-1, which is involved in the regulation of blood sugar levels and appetite. Here’s how they work:"," STIMULATE INSULIN SECRETION: GLP-1 agonists enhance the secretion of insulin from the pancreas in response to meals, this helps to lower blood glucose levels and store protein, dietary fats, minerals and micronutrients effectively.","INHIBIT GLUCAGON RELEASE",": They reduce the release of glucagon; glucagon is a hormone that raises blood sugar levels by promoting the release of glucose from the liver. In health, glucagon and insulin acts in balance with each other.","SLOW GASTRIC EMPTYING",": Slowing stomach emptying helps to reduce the rate glucose enters the bloodstream, leading to better post-meal blood glucose control.","PROMOTE SATIETY",": GLP-1 agonists adjust the communication from the gut to the brain to promote a feeling of fullness, this can help with weight loss.","Overall, these effects help to improve blood glucose control and reduce body weight in individuals with type 2 diabetes or obesity.","HOW IS A DUAL AGONIST, LIKE TIRZEPATIDE IN MOUNJARO, DIFFERENT?","Tirzepatide and semaglutide both help manage type 2 diabetes and promote weight loss, but they have distinct mechanisms of action and effects due to their different molecular targets:","1. DUAL RECEPTOR AGONISM:\n   - Tirzepatide: Acts as a dual agonist for both the GLP-1 receptor and the GIP receptor. This dual agonism may provide additional benefits in glucose control and weight loss by leveraging the complementary actions of both incretin hormones.\n   - Semaglutide: Acts solely as a GLP-1 receptor agonist.","2. GLUCOSE CONTROL:\n   - Both medications lower blood glucose, but the dual action of tirzepatide on GLP-1 and GIP receptors may offer superior glucose control for some patients.","3. WEIGHT LOSS:\n   - Clinical studies have suggested that tirzepatide may lead to greater weight loss than semaglutide; this is likely due to its dual mechanism which enhances satiety and reduces appetite more effectively.","4. INSULIN SENSITIVITY:\n   - Tirzepatide has been shown to improve insulin sensitivity more  than semaglutide, possibly due to the combined effects of GLP-1 and GIP receptor activation.","5. GASTROINTESTINAL SIDE EFFECTS:\n   - While both medications can cause gastrointestinal side effects such as nausea, vomiting, and diarrhea, the specific profile and severity of these side effects may vary between the two drugs. Some patients may tolerate one better than the other.","In 
32summary, tirzepatide's dual receptor agonism offers potential advantages in glucose control, weight loss, and insulin sensitivity over semaglutide, which targets only the GLP-1 receptor.","WHAT IS THE AVERAGE WEIGHT LOSS WITH SEMAGLUTIDE?","The average weight loss with Wegovy/ semaglutide, based on clinical trial data, is:","- Around 15% of initial body weight: In the Once-Weekly Semaglutide in Adults with Overweight or Obesity trial, participants taking Wegovy lost an average of 15% of their initial body weight over a 68-week period.","- Approximately 15-20 kg (33-44 lb): This corresponds to an average weight loss of about 15 to 20 kg (33 to 44 lb), depending on that patient's initial weight.","Wegovy can be a highly effective treatment for obesity, leading to substantial weight loss when combined with lifestyle changes such as diet and exercise.","WHAT IS THE AVERAGE WEIGHT LOSS WITH TIRZEPATIDE?","The average weight loss with Mounjaro/ tirzepatide based on clinical trial data is shown in the SURMOUNT-1  - Tirzepatide Once Weekly for the Treatment of Obesity trial.  The average weight loss with tirzepatide varies based on the dosage and the duration of treatment. Here are the key findings:","Around 15 - 18% of initial body weight: In the Tirzepatide Once Weekly for the Treatment of Obesity trial, participants taking Mounjaro lost and average of between 15 - 18% of their initial body weight over a 72-week period.","Weight Loss in kilogram (pounds): In the same trial, the weight loss ranged from about 8.2 kg (18 lb) for the 5 mg dose to 11.3 kg (25 lb) for the 15 mg dose.","Higher Doses and Longer Duration: - In the SURMOUNT-1 trial,  The average weight loss for those on the highest dose (15 mg) was up to 22.5% of their initial body weight over 72 weeks, which equates to an average loss of about 24 kg (53 lb).","These results indicate that tirzepatide can lead to substantial weight loss, often exceeding the results seen with other medications for weight management, including semaglutide. The dual action on GLP-1 and GIP receptors likely contributes to these significant outcomes.","These drugs are exciting, already helping very many patients under the care of Dr Philip Kelly and Professor Martin Whyte  at LondonSwissMedical. They both work closely with specialist dieticians, experienced in the  supervision of patients taking these medications, this can help patients make the most of these medications.  are also supported by excellent laboratories in London, and across the UK, to help you understand how these medications would work for you, whether that is your weight and body mass index (BMI - height in kilogram, divided by the square of your height in meters), waist circumference, HbA1c and plasma glucose, cholesterol and lipids, liver fat and enzymes in metabolism dysfunction associated liver disease (MASLD - previously called non-alcoholic steatohepatitis/ NASH), your sleep, libido and erections, or your periods and fertility. There is so much more to your health, and we look after the whole of you.","If you want to know more about your health book an appointment.","Your Health is Our Concern.","With increasing abdominal weight gain comes a greater chance of fats being produced and stored in the liver. This is associated with diabetes, cardiovascular and in some cases, liver cirrhosis.","Ordinarily, the liver will not produce fat during or immediately after eating.  This is because the insulin release triggered by the food acts on the liver to stop it.  However, in conditions of ‘insulin resistance’ (often a part of type 2 diabetes), the liver doesn’t act on the insulin stop-signal.  Some of the fats that are produced find their way into the blood, but others remain in the liver – compounding the problem.","This condition is known as non-alcoholic fatty liver disease (NAFLD) and is thought to affect up to 30% of people in the UK.  It is far more common in individuals who are overweight or obese. As such, weight loss by any means will help, although exercise seems to have an additional benefit and is strongly encouraged. ","Drugs that act on the glucagon-like peptide 
321 receptor and also the ‘thiazolidinedione’ class of drugs (Pioglitazone, also known as Actos) have demonstrated beneficial effects in patients with diabetes and NAFLD but there is no accepted pharmacological treatment for these patients. ","A new class of medication generating particular interest is the ‘SGLT2 inhibitor’.  These medications lead to glucose loss is the urine and so reduce the total calorie load. ","https://diabetesjournals.org/care/article/43/2/298/36104/Empagliflozin-Effectively-Lowers-Liver-Fat-Content","A recent trial"," has shown that they can lead to fat loss from the liver – interestingly even without major weight loss. Further, confirmatory studies are required but this may prove to be a useful addition to diet and exercise","If you would like to discuss your diabetes, lipids and or metabolism and how to improve your cardiovascular, liver and general health, then do make contact with the team here at LondonSwissMedical. Dr Martin Whyte is a Consultant Diabetologist and Physician with LondonSwissMedical and King's College Hospital and Senior Lecturer in Metabolism at the University of Surrey. He is an expert in the metabolic abnormalities underlying NAFLD,  non-alcoholic steatohepatitis (NASH) and in the management of patients with NAFLD, NASH, type 2 diabetes, metabolic dyslipidaemia/ hypercholesterolaemia, hypertension and obesity and overweight.","SettingsSpecialtiesCollection","SettingsFooterLinks","SettingsContactDetails","Settings",{},{},"Who we are","who-we-are","How we charge","how-we-charge","journal","Adrenal Disease",{},"https://images.ctfassets.net/7khqj3oh9qlw/43rEyRi2bBLR91xa9UMRrL/7ae741a00a104a3ed93ef557f5b1b782/LSM_Adrenal_Disease.jpg","Cushing’s syndrome and Cushing’s disease",{},"Conn's Syndrome",{},"Addison’s disease",{},"Secondary adrenal failure and steroid stewardship",{},{},"https://images.ctfassets.net/7khqj3oh9qlw/Av3dHJ9wXdh7eiLGYYFKB/e006e34b543fc2461f4575bcfce94248/LSM_CardiovascularDisease.jpg",0,0,"Hypertension – diagnosis of secondary hypertension or essential hypertension",{},"Hypertension – treatment",{},"Conn’s syndrome",{},"Phaeochromocytoma and paraganglioma",{},"Renal artery stenosis and fibromuscular hyperplasia",{},"Lipids and cholesterol",{},"Hyperlipidaemia",{},"Hypercholesterolaemia",{},"Mixed dyslipidaemia or the dyslipidaemia of diabetes and/or obesity",{},"Hypertriglyceridaemia",{},"Elevated lipoprotein (a)",{},"Anaemia",{},"Iron deficiency and iron deficiency anaemia",{},"Intravenous iron therapy and alternatives",{},{},{},{},"Vitamin D – do you need it for your heart?","vitamin-D-do-you-need-it-for-your-heart","2022-07-18T00:00:00.000Z","Vitamin D — do you need it for your heart?",{},{},"https://images.ctfassets.net/7khqj3oh9qlw/78Ebd9TdlQXiQ13cvK2vig/39b3b131bae11e2f7622372fcd81cc6a/LSM_Diabetes.jpg",0,0,"Type 2 diabetes, Type 1 diabetes and secondary diabetes",{},"New agents for diabetes: GLP-1, agonists, semaglutide (Rybelsus and Ozempic), SGLT-2 inhibitors",{},{},"Hypoglycaemia – where your blood sugar levels fall below the normal range – needs prompt investigation, whether it occurs on fasting, after meals or unpredictably. Whether you are certain you have hypoglycaemia or are concerned that it might be responsible for your symptoms, we can assess the majority of patients quickly and safely as an outpatient.","If you have hypoglycaemia in the context of Type 1 diabetes and/or insulin therapy please email us first so we can have you seen by the right person straight away.","Obesity and overweight",{},"Diabetes and erectile dysfunction",{},"Peripheral neuropathy",{},"Diabetic nephropathy/ renal disease/ albuminuria",{},{},"t2dm-update-major-therapeutic-advance-new-oral-treatment-for-type-2-diabetes","2019-10-02T00:00:00.000Z",{},{},{},{},"https://images.ctfassets.net/7khqj3oh9qlw/5B2te0J8KlUzqXG03FEKwx/fc0b997dd3f8cbd1dc97421fac764381/LSM_Menopause.jpg",0,{},"Menorrhagia",{},"menopause-listen-to-your-patients","2018-11-14T00:00:00.000Z",{},"testosterone-and-the-menopause","2020-06-01T00:00:00.000Z",{},"Osteoporosis",{},"https://images.ctfassets.net/7khqj3oh9qlw/HtIYwxYML7FdqNQnbBu9r/0eb8d4d63bed73b18d8a7cf709cfd86b/LSM_Osteoporosis.jpg",0,"Osteoporosis and osteopenia",{},"Parathyroid Disease",{},"https://images.ctfassets.net/7khqj3oh9qlw/1kIGt06AN8niMA48Kg20qA/e55299fb1a369ff46e9680d09d5e3f80/LSM_ParathyroidDisease.jpg","Primary hyperparathyroidism",{},"Secondary hyperparathyroidism",{},"Hypoparathyroidism",{},"Pituitary and Hypothalamic Disease",{},"https://images.ctfassets.net/7khqj3oh9qlw/6BMBSTvtWbkPQrf6Ey69ei/67316d77473dd6bde123419ce3cf9978/LSM_PituitaryDisease.jpg",0,0,"Pituitary disease, tumours, hypofunction and hyperfunction",{},"Prolactinoma and prolactin excess",{},"Non-functioning pituitary tumour",{}
32,"Secondary adrenal failure and hypoadrenalism",{},"Secondary hypothyroidism",{},"Weight-related amenorrhoea",{},"Hypothalamic thyroid, adrenal or testicular dysfunction",{},"Polycystic Ovarian Syndrome (PCOS)",{},"https://images.ctfassets.net/7khqj3oh9qlw/3fX8hhfx87ngrGoFWMCsq2/648a2c1b854e47533d64e624e9385ec0/LSM_PCOS.jpg","Irregular periods",{},"Heavy periods",{},"Pre-menstrual syndrome (PMS) and pre-menstrual dysphoria disorder",{},{},"https://images.ctfassets.net/7khqj3oh9qlw/3FPSDN4eaxm0bWXopUjwPh/9d417e6087d726324bdcc25cc2922a60/LSM_Pregnancy.jpg",0,0,0,{},"Thyroid and pregnancy",{},{},"The body and immune system go through enormous changes post-delivery of a baby, and changes in how mothers feel is common. Post-partum thyroid dysfunction is very common, especially so in the following groups.","Very High Risk and should be routinely monitored:","Previous episode of post-partum thyroiditis","have thyroid disease such as Hashimoto's thyroiditis or take thyroid hormone replacement","High risk and monitoring recommended:","type 1 diabetes mellitus","chronic hepatitis C","Positive thyroid peroxidase antibodies","Previous autoimmune non-thyroid disease","Increased risk, consider monitoring:","systemic lupus erythematosis (SLE)","had gestational diabetes mellitus","if there is a family member with thyroid disease, whether autoimmune or not","if there is a family member with a non-thyroid autoimmune condition.","Post-partum thyroiditis can easily be missed, or mis-diagnosed, often as depression. It is essential to have a clinical assessment and blood test to diagnose it, and consider the differential diagnoses, such as Graves' thyrotoxicosis or toxic adenoma. It can cause problems caring for and bonding with the baby, difficulties in breast feeding and if undiagnosed can cause difficulties for subsequent pregnancies, especially if the mother was to conceive and carry with undiagnosed and untreated hypothyroidism.","If you, or a patient has any symptoms that could be attributable to thyroid dysfunction in the year after delivery it is important to be checked. If you or your patient are part of the higher right groups you might consider routine monitoring as above, and/ or arrange a review with an endocrinologist and London Swiss Medical would be happy to advise you.",{},"Carbimazole is the usual first line medication to control overactivity of the thyroid gland in patients with hyperthyroidism; in some patients propythiouracil (PTU) is used particularly if carbimazole has caused side effects or you are pregnant. They are effective in reducing the production of thyroid hormones in the majority of patients with hyperthyroidism and side effects of these drugs are rare. If you have Graves' disease you will normally be offered treatment for between 6 months and 2 years in the first instance, this results in long-term remission in about one third to one half of patients once the drug is stopped.","Both drugs have  common side effects of rash and joint pains, but more rarely (less than 1 in 500 patients) a serious reduction in the circulating white blood cells (agranulocytosis) occurs during treatment and/or a reduction in the blood platelets (needed to form clots).","The earliest sign that the drugs may be affecting the white blood cells is a sore throat, mouth ulcers, excessive bruising, fever or a rash – if these occur then you must stop taking your carbimazole or PTU immediately. You may need to attend your surgery, your doctor's office or hospital emergency department to arrange a blood test, usually the next working day stating the drug you are taking. If the white cells and platelets are fine then you should continue taking your carbimazole or PTU.","Sore throats, mouth ulcers and rashes are common and it is more likely that if you get these it is not due to the carbimazole or PTU. However the only safe thing to do is stop the medication temporarily and wait for the result of your blood test.","Very rarely, serious liver injury has been reported in patients, including children, taking PTU, especially during the first six months of taking the drug. Your doctor should monitor you for symptoms and discontinue the PTU if liver injury is suspected or found. If you develop loss of appetite, nausea, vomiting, fatigue, abdominal pain, notice any yellowing of the eyes or skin or dark urine or develop itchy skin you should see your doctor immediately.","Carbimazole is not suitable in the first 12 weeks of pregnancy and it is not recommended in women who might get pregnant and/or are planning pregnancy – we would normally switch to  PTU in these circumstances.","If you are ever in any doubt contact your doctor and/or the doctor who has started the treatment.","Sodium and Water Balance Disorders",{},"https://images.ctfassets.net/7khqj3oh9qlw/T8p57anICFgXJmu99iJpJ/bbb8737b9056b24675f1de390e89f43
32c/LSM_WatBalDisorder.jpg","Thirst disorders – polyuria and diabetes insipidus/primary polydipsia",{},"Hyponatraemia",{},"Syndrome of inappropriate ADH secretion",{},"Testicular Failure",{},"https://images.ctfassets.net/7khqj3oh9qlw/5zN1Ou67Mwqr248OsaZpfr/f323f0a4ddc616291499854c2081d75a/LSM_TesticularFailure.jpg",0,0,"Testicular failure and androgen deficiency",{},"Spermatogenesis induction",{},"Hypothalamic hypogonadism",{},"Erectile dysfunction",{},{},"https://images.ctfassets.net/7khqj3oh9qlw/3kTCsQb9763nFD5lBPE0TW/4f2407579692ecc0f7f6773d8b65dc71/LSM_Thyroid_Disease.jpg","Hypothyroidism",{},"Sub-clinical hypothyroidism",{},"Hyperthyroidism",{},"Graves' disease",{},"Thyroid eye disease and Graves’ ophthalmology",{},"Toxic multinodular goitre",{},"Toxic adenoma",{},"Thyroiditis/de Quervain's thyroiditis",{},"Benign/indeterminate thyroid nodules and thyroid cancer",{},"Thyroid disease during conception, pregnancy and breastfeeding",{},"Post-partum thyroiditis/post-pregnancy thyroiditis",{},"graves-thyrotoxicosis-information-for-patients-and-their-doctors","2019-10-21T00:00:00.000Z",{},{},{},{},"https://images.ctfassets.net/7khqj3oh9qlw/4G4azZhKh5pLcgX8GacCxs/0ced5f9fb09f7722e014bb2c28adc097/LSM_Obesity.jpg",0,0,"Obesity, metabolism and diabetes",{},{},"Medication for obesity – GLP-1 analogues, liraglutide (Saxenda), orlistat",{},"Preparation and/or consideration of surgery",{},"Post-operative problems – post-prandial hypoglycaemia",{},"Metabolic dysfunction-associated steatotic liver disease (MASLD) or NASH",{},"Anorexia nervosa and bulimia nervosa",{},"Relative energy deficit and sport (RED-S)",{},{},{},"www.linkedin.com/in/drphilipkelly","https://www.facebook.com/londonswissmedical","https://www.instagram.com/londonswissmedical/",{},0,{},0,"PageCollection","PageIntroText","PagePeopleCollection","PageAccordionBlocksCollection")</script>
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