Beyond the Thyroid

When Autoimmune Diseases Overlap: Thyroid & Rheumatology with Dr. Celine Lee

• Dana Gibbs • Season 1 • Episode 30

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Beyond the Thyroid – Episode 30:  When Autoimmune Diseases Overlap: Thyroid & Rheumatology with Dr. Celine Lee

In this episode of Beyond the Thyroid, Dr. Dana Gibbs welcomes Dr. Celine Lee, a board-certified rheumatologist and founder of Lotus Rheumatology and Wellness Clinic, to explore the powerful intersection of thyroid disease and rheumatologic autoimmune conditions.

Dr. Lee shares her compelling journey from practicing dermatology in South Korea to becoming a rheumatologist in the U.S., and how her unique perspective helps her approach complex, overlapping conditions such as Hashimoto’s, lupus, and rheumatoid arthritis.

Together, Dr. Lee and Dr. Gibbs discuss:

  • How autoimmune diseases like Hashimoto’s and lupus are connected
  • Why hormonal imbalances often accompany rheumatologic conditions
  • The role of inflammation, diet, stress, and sleep in disease management
  • How to interpret ANA testing and what it reveals about autoimmunity
  • The importance of treating the whole person, not just the labs


You’ll also learn practical strategies for reducing inflammation, managing fatigue and joint pain, and improving your quality of life with chronic illness. 


🩺 Learn more about Dr. Celine Lee:

📑 Join the The Thyroid Clarity Checkup Priority List! 

🩺 Interested in a Discovery Call with Dr. Dana? Click here!

📺 Watch on YouTube


Episode Highlights: 

00:00 – Introduction and Guest Introduction
00:20 – Dr. Lee’s Unique Background
01:25 – Diving into Autoimmune Diseases
03:28 – Understanding Rheumatology
05:45 – Dr. Lee’s Journey to Rheumatology
08:25 – Challenges in Traditional Medicine
09:51 – Overlap in Autoimmune Diseases
10:42 – Hashimoto’s Disease and Rheumatology
15:36 – The Importance of ANA Testing
22:33 – Managing Inflammation Through Lifestyle
27:19 – Avoiding Inflammatory Foods
28:15 – The Importance of Sleep
30:32 – Exercise and Joint Health
32:59 – Differentiating Joint Pain Causes
36:31 – Rheumatologic Symptoms and Diagnosis
47:10 – Impact of COVID on Autoimmune Disorders
49:39 – Conclusion and Contact Information

Let's connect! 🔔
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✉️ Email Dr. Gibbs at drgibbs@DanaGibbsMD.com or visit https://www.danagibbsmd.com/ for more information.


Thank you so much for listening! Tune in on the next episode.


The medical information provided in this episode is intended for informational purposes only and should not be construed as medical advice. Always consult a qualified healthcare provider regarding any medical questions or concerns.

dana-gibbs-md--she-_2_05-28-2025_110717

Welcome to Beyond the Thyroid. This is Dr. Dana Gibbs and we have a guest today. This is somebody I deeply admire, Dr. Jung. Soon, Lee she goes by Celine. She's a board certified rheumatologist and the founder of Lotus Rheumatology and Wellness Clinic in Salt Lake City, Utah. So Dr. Lee really has a totally unique background because she began her career as a dermatologist in the country of South Korea, where she quickly noticed that many skin conditions, were actually signs of deeper autoimmune diseases. And that insight led her to immigrate to the US where she had to start over and do an internal medicine residency and then a fellowship in rheumatology. So she is now board certified in internal medicine, rheumatology and lifestyle medicine, three board certifications. Wow. So she has over 20 years experience in the medical field and has developed a really rare ability to connect the dots between symptoms and underlying root causes. And her practice is grounded in whole person care using essential medications while empowering patients to change lifestyle, to activate their body's natural healing potential. So today we are gonna dive into autoimmune disease and the fascinating overlap between the rheumatologic autoimmune diseases and the hormone related autoimmune diseases like Hashimoto's and Type one diabetes and other chronic inflammatory conditions. So if you've ever felt like your symptoms were dismissed or they didn't really fit neatly into a box, this episode is for you. So let's get started.

You're listening to the Beyond the Thyroid podcast. I'm your host, Dr. Dana Gibbs. I'm an ENT surgeon and hormone specialist. For years, I struggled with my own unrecognized thyroid problems before and even after I was regularly performing thyroid surgeries. Then, one day, I learned something that turned my health around and opened my eyes to the limits of mainstream medicine in treating more subtle thyroid abnormalities. I spent the next 20 years fine tuning my hormone expertise in disorders like Hashimoto's disease, perimenopause, and stress related illness. Come join me as I share this new approach to hormones that empowers you to take control of your own thyroid and hormone imbalances. Let's dive in.

dana-gibbs-md--she-_1_05-16-2025_171001

Hi everybody. Welcome to Beyond the Thyroid Podcast. Today I have a special guest with me today. This is my friend, Dr. Celine Lee, and Dr. Lee is a rheumatologist in direct care practice in salt Lake City, Utah, and we are gonna have such a fun time'cause we are gonna talk about the overlap between rheumatologic and hormonal based diseases like Hashimoto's Disease. So welcome Dr. Lee. It's so good to have you here. Why don't we start with, what rheumatologists do and what is a rheumatologist, because I'm not sure that everybody even knows what kind of diseases you treat and what a rheumatologist is.

celine-lee--md_1_05-16-2025_161001

Yes. The rheumatology is the kind of weird long name that most people usually don't even know that it exists until they develop some type of symptoms that will require rheumatoid evaluation. I have many patient told me that they never heard the terminology of rheumatology until they develop these symptoms. So rheumatology is a specialty that treat diagnosed and treat. Systemic autoimmune disorders such as rheumatoid arthritis or lupus, or SHO syndrome, sclero, myositis, and those diseases are the immune dysregulation disorders that where their own immune cells attack the healthy tissues of the person that can cause inflammation. As you know, are many autoimmune disorders. To the thyroid. MS is more to the CNS type one diabetes is more the pancreatic beta LS cells. But in rheumatology, we usually treat the disease that is more multi-organ disease, like a systemic disorder. For example, lupus can go to almost any organs in the body. So we treat those disease particularly.

dana-gibbs-md--she-_1_05-16-2025_171001

Okay. That's, that's a great way of putting it,'cause I was gonna ask you about that since type one diabetes seems to be the purview mostly of an endocrinologist, but then they don't really have experience in multi-organ system autoimmune disease. The same goes with Hashimoto's disease. And so I'm sure, I think the reason you and I got to really know each other is because so many people get diagnosed with the antibodies for Hashimoto's disease and end up in your clinic with a oh my gosh. I have a rheumatologic or you know, I have an autoimmune disease. What kind of doctor treats an autoimmune disease and they end up in your office because of that

celine-lee--md_1_05-16-2025_161001

That's, yeah, that's right. There's a lot of overlap.

dana-gibbs-md--she-_1_05-16-2025_171001

Yeah, there's a lot of overlap, but it seems like some of those diseases are kind of orphan diseases. You mentioned already some of what kind of the diseases you treat. So tell me in particular, how did you get interested in rheumatology and how did you decide to open a direct care rheumatology practice?'Cause I know there's a big story there.

celine-lee--md_1_05-16-2025_161001

Yeah. So I started actually as a dermatologist. So I was trained in dermatology, and I'm actually a birth certified dermatologist back in South Korea. And I was mostly interested in rheumatic skin disorders such as a lupus rash, psoriasis, m myositis, rashes, sarcoidosis. So those are the skin disorders that really excited me in intriguing and discovering what's more. In the person's immune system because often those skin rashes are just the tip of the iceberg. There's signals, there's something going on inside of the body. So whenever we see those rashes, I, I was always thinking about what's causing this rash? What's happening in the body that caused this rash? And did that always like leading to the deeper like investigation and often those rashes. From autoimmune disorders a lot of lupus patients and even psoriasis patient as well. So that's kind of how I started it. You know, doing my interest in autoimmunity and when I moved to United States I was thinking, you know, because I have so much interest in the rheumatoid skin disorders and I was kind of wanting to do more because as a dermatologist we really cannot treat the systemic. You know, those symptoms. So for example I cannot treat lupus nephritis when I'm a dermatologist. And I was kind of thinking, right, okay, why can't I just treat that too? So yeah. So that's the reason why changed my specialty to rheumatology.

dana-gibbs-md--she-_1_05-16-2025_171001

I see. And did you have to do more specialty training when you came to the US? They would not accept your Korean specialty training, would they?

celine-lee--md_1_05-16-2025_161001

Oh, yes. I had to do another. So I have 11 years of postgraduate medical training. So I did six years in South Korea, so two years of transitional years, four years in dermatology residency. And then after coming from to United States I had to do another internal medicine residency for three years and then two years of rheumatology fellowship. So 11 years

dana-gibbs-md--she-_1_05-16-2025_171001

oh my goodness. I don't guess I realized that they made you do internal medicine over again, so. You're probably one of the most hyper educated people I know. Oh my goodness. Okay and how did you decide that direct care practice was what you wanted to do?

celine-lee--md_1_05-16-2025_161001

So I always have this feeling a little bit of like you could almost say like guilt when I was working in the the more traditional setting of medicine because. As you know in the treasury medicine, in the US healthcare, the time is always, you know, lacking. So when the person have autoimmune disorder, usually it's a multisystem disease. So we need to ask a lot of the almost all organ system, we need to evaluate if the person have, you know, any CNS symptoms, skin symptoms, pulmonology, cardiology, nephrology. So we need to ask a lot of question and do the evaluation. But in traditional system the time was really strained factor. I could not spend sufficient time with a patient. Always felt like I'm not doing enough for the patient because there's so much things that I need to evaluate. So much things that I need to talk to the patient and counseling of a lifestyle modification, how the diet can impact their immune disorders, all of those things. But when you see like 20 patient per day, it's really difficult to do that, you know? And I felt that I can do more outside of the traditional system. So that's the reason why I changed to direct care and I think that was the right decision.

dana-gibbs-md--she-_1_05-16-2025_171001

Oh, I'm right there with you. And, and it's funny what you're, what you're saying about that.'cause it's making me think about another person that we both know that I heard talk earlier this week and she said, you know, there are diseases that no specialty claims because they're like, oh, I have to stay in my lane. I have to just do these multi-system rheumatologic diseases. I have to do just a gynecology I have to do, and, and she's a urologist, so she was like, well, I'm teaching hormone treatments to the hormone doctors. And I was like, oh my goodness. Mind-blown. Because there is overlap. There's overlap and it's amazing how many different conditions, particularly in women's health, are just kind of like, nobody treats that. Sorry, go away, you know? And Hashimotos is kind of one of those. So tell me how you got interested in treating Hashimoto's Disease.

celine-lee--md_1_05-16-2025_161001

Oh, yes. So Hashimoto Disease is, so we, in rheumatology fellowship, we actually don't learn about Hashimoto's disease. We just learn that there's some possibly a in Hashimoto disease, and that's about it. We don't get trained about how to treat Hashimoto disease, about oral replacement therapy, things like that. We just hear about it and that's it. But in real life after I became attending, I see these patients with positive TP antibody, quite high titer, have symptoms. And fatigue and joint achiness and stiffness, but without room to disorder evidence. And when I refer a lot of patients were told that, oh, their TSH is normal. So you know, just like observation was the only thing that they were able to get advice. And I thought that there's maybe there's a little bit more story and because I see these patients and they come to me, asking for answers and because there's a shortage of endocrinologists too, and I was thinking, why can't I just learn about a little bit more of Hashimoto's disease because this is a disease that is autoimmunity and autoimmunity is, I think it's a part of rheumatology.

dana-gibbs-md--she-_1_05-16-2025_171001

​I think probably there isn't anybody who knows more about autoimmune disease than rheumatologists. So, yeah, that makes total sense to me. And you know, coming from the world of ENT, I had the same thing. People would come in, they've got these lumps in their neck. I do a biopsy, it comes at a chronic lymphocytic thyroiditis. And I, you know, it's funny, I'm thinking back to when I was first an attending. And I got that diagnosis. You know, the second or third time I got chronic lymphocytic thyroiditis, I was like, oh, well these are not cancers. And what is this chronic lymphocytic thyroiditis? And I looked it up and it was like, oh, this is Hashimoto's disease. What the heck? And then I was like, okay. And I didn't even realize at that time, I mean, and this is 25 years ago, of course, I didn't even know there was a test for Hashimoto's disease. I didn't even know that's how bad, you know, here I am taking out people's thyroid glands left and right, and I didn't even know there was a test for Hashimoto's disease when I first started out. It's very frustrating to me for people to come in and be like, oh, well my, my endocrinologist said that I don't need any treatment. Or my endocrinologist said, here, take this levothyroxine, but I don't feel any better. So yeah, absolutely. The getting outta your lane thing is I don't know. I think it's part of the direct care movement a little bit. It's like, let's look at the whole person and treat the whole person a lot more than the specialties who are, you know what, I got enough work to deal with in what I know to do. I'm not gonna focus on anything that I don't know to do.

celine-lee--md_1_05-16-2025_161001

Yeah, and I think that it, it is important for us to recognize that even though though there's a lot of advances in medicine, we still don't know a lot of things about human body. And I think the subspecialization kind of almost make a forget that all our body organ is connected. Also our mind is connected to our body and as you know, in more in the hormones how the stress can impact the hormonal system. And our hormone system can cause joint, you know, in the muscles. They're all connected.

dana-gibbs-md--she-_1_05-16-2025_171001

​Joint and muscle pain. That's, that's another thing that I was that interview with Rachel the other day, and she was like, you know, I'm a urologist. What am I doing treating all this joint pain? And I was thinking my, you know, I was thinking the same about myself since I've started into, there's so much overlap between the thyroid patients and, the perimenopause. And you're right. I mean, it's just like you can't just stay doing one thing. You have to be curious about the rest of medicine. And if we're not, then the research is not gonna get done. The body of knowledge is not gonna expand and, and we will keep failing our patients as far as that goes. So that brings up another question that I had, which is something you mentioned right at the beginning, and that is how do you see this connection between Hashimoto's Disease and the elevated ANA test, anti-nuclear antibody tests?

celine-lee--md_1_05-16-2025_161001

Yeah. So ANA antibody is basically an anti-nuclear antibody, so it is an antibody that binds to the nucleus. So usually we test it by, we put the patient's plasma to this little slide that is coded with the HP two cells. So those are human epithelial cells. That is just kind of, it's actually of, you probably know it's actually stem from laryngeal carcinoma patients. And that happened to be just kind of very large and very flat cells. So it's very easy to use for that, this test. And we basically code a slide with those cells and put the patient plasma there and see the kind of culturally so that if there's any anti-nuclear antibody it'll bind to the nucleus. And then we put the secondary antibody, they have a fluorescent like little tag and to see you know, if we see those antibody, potential nucleus. So that's the antinuclear antibody and basically it means that the person's immune system produced this antibody that get that attached to human nucleus. So that's the reason why this can be a, a signal that this person could have autoimmunity. Having positive ANA does not necessarily mean that the person have autoimmune disorder because there are normal people who have positive ANA without any rheumatoid disorders. So one of the most common, consult the rheumatologists get is positive ANA consult. And people who have positive ANA have to be evaluated for potential room to disorder. But just because somebody had positive a ANA does not mean that the person have 100% rheumatoid disorder. So I always kind of tell patients, you know, don't panic about their positivity. You know, it's a blood test result. Because as long as you don't develop the disorder itself, having the antibodies you know themselves alone does not mean that you have a disorder and in fact, the possibility may increase over time. So people who are older than 65 years old, about one third of people can have positive a ANA without having any disease. Yeah, it's quite high actually. So that's the reason why it's very important to differentiate whether or not the person have room rheumatoid disorder or just have a positive ANA without any disorder, because the implication is quite significant because rheumatoid disorder usually requires treatment that suppress the immune system. Obviously we don't want to suppress the immune system for everybody who have positive ANA it'd be No, we certainly don't. Yeah. One third of the population older than 65 years old. That's the reason why the evaluation important.

dana-gibbs-md--she-_1_05-16-2025_171001

At the beginning the discussion we talked about these three diseases that are not really considered rheumatologic diseases, but they are autoimmune diseases. And we mentioned type one diabetes, which attacks the pancreas. We talked about MS, which attack the immune system, and then we mentioned Hashimoto's disease. How often if you get somebody in to do a consult for positive a NA, do you test them for all three of those disorders to see if they have those antibodies? How do you think about that person when they come to you?

celine-lee--md_1_05-16-2025_161001

So the most important thing is actually the patient's symptom because in rheumatology, rheumatology disorder is autoimmune, inflammatory disorders. So the inflammation will cause the symptoms. So whether or not the person have the rashes especially photosensitive rash that is common in lupus or dermal myositis. Or joint pain, joint swelling, morning stiffness, inflammatory back pain, you know, those kind of symptoms or whether or another person have abnormal blood tests such as increase the liver enzymes, increase creatinine which can signal the declining kidney function, protein in the urine, you know, chest pain, short or breath history of multiple miscarriages, which can be seen. Antiphospholipid syndrome.

dana-gibbs-md--she-_1_05-16-2025_171001

I'm sorry, say that one again. In what kind of syndrome?

celine-lee--md_1_05-16-2025_161001

Antiphospholipid antibody syndrome which can cause multiple miscarriages and blood clots such as DVT or pulmonary embolism. Then that is also autoimmune disorder. So I think the most important thing in evaluation of these patients who have positive ANA is actually clinical history and the clinical history we're taking should be really thorough to look for any clues that could give out that this person have rheumatoid disorder. That's the reason why the time is important to really dig into the older history, like what happened like 10 years ago. Right. Yeah. Those kind of things. All these like chronological events because sometime this symptom will, you know, wax and wane, it comes and goes, and sometime it'll build up. So sure eliciting those, history is the most important thing. And then physical exam to see if there's any rashes hiding somewhere. Or the joint swelling, synovitis, enthesitis, you know, if the person have any breathing problem, you know, crackles and things like that. And then, and then blood test. The blood test. So positive ANA does not necessarily have a positive ENA profile. So ENA is extractable nuclear antigens. So those will be you know, the Sjogren's syndrome, like A-S-S-A-S-S-P-R-N-P-J one, you know, those kind of antibodies. So if somebody have those eNA profiles are also positive, they are more likely to have actual rheumatoid disorder. So yeah, whenever I have a positive a NA patient, I usually check those antibodies to see if that person have any other more specific antibodies, the signals to a rheumatoid disorder. And history in the physical exam, very important.

dana-gibbs-md--she-_1_05-16-2025_171001

So do you test them then for the anti TPO antibody and you do as a routine now?

celine-lee--md_1_05-16-2025_161001

yeah, absolutely. Yeah. It's a routine anti-TPO and anti-TG. Yeah, I always check that because those people can have Hashimoto's disease. And it is known that the Hashimoto's diseases patient have about 35 to 45% will have ANA antibody, and about 15% of them will have a rooted disorder in the future. So it is important check those antibodies.

dana-gibbs-md--she-_1_05-16-2025_171001

You mentioned this before, you were saying about that the immune suppressant medicines are important, but when you're treating rheumatologic disease, there are other ways that we use to help people calm down. You said it's an inflammatory condition. It's like, okay, what are we gonna do to calm down this inflammation? So what kind of things do you advise your patients to do that helps them control their inflammation, besides just taking a medicine?

celine-lee--md_1_05-16-2025_161001

Yes. So I usually tell my patient: so the body is already inflamed, meaning that the body's immune system thinking there's some enemy and it is kind of dysfunctionally hyper active, you know, too much of activities to the point that it's actually attacking your own tissues. So it is not necessarily low immune problem, it's the immune dysfunction problem. So when immune system is already too sensitive and too irritable to the point that it's attacking the person's own tissue, if you give external triggers that will fuel into the inflammation, it'll just make it worse. Just so obvious. Yeah. And there's a very universal trigger for inflammation that we actually voluntarily put in our mouth. Those are inflammatory food. Yeah, sugar is universal inflammatory. Yeah, and I don't think sugar is actually a food because it's actually, yeah, it's, when you think about there's no plants that have sugar, powdery sugar as a, yeah. It's actually extracted by the king, sugar by chemical extraction. And it, it is very well known that sugar can cause like a trigger symptom of RA patient and lupus patient. In fact, that Christmas time is one of the seasons that I get a lot of phone call for the RA or lupus flare because we tend to eat a lot of cookies and cakes and they can often trigger inflammation and not sleeping well.

dana-gibbs-md--she-_1_05-16-2025_171001

That's something that never would've occurred to me. That's so interesting. But you're absolutely right. I mean, there's candy everywhere and everybody's eating cake and cookies and pie and Oh my gosh. Yeah.

celine-lee--md_1_05-16-2025_161001

I mean, it's okay to eat but you know, everything's moderation. Maybe one cookie is fine, but if half of the cookie jar is empty, by the time they, that's not okay.

dana-gibbs-md--she-_1_05-16-2025_171001

Well, I mean, you go to a Christmas party and it's like, oh, but there's 27 kinds of cookies. I gotta try'em all. Wow. What other inflammatory foods do you particularly see as problematic for people?

celine-lee--md_1_05-16-2025_161001

Well, the processed food. So processed food that anything that it's pre-made and you just heat it up in the microwave, majority of those food have preservatives and those are chemicals. And when it goes to our body, our immune system, you know, evolutionally, our immune system are not supposed to see those chemical preservative because it doesn't exist in nature. So when you think about the really popular diet, like paleo diet, and we just go back to time, we just eat whatever there was available in nature. Whole grain, not processed. Fish or some games those kind of things. And none of them had chemical preservative in it. But right now in our era and if you put some like the junk food or fast food and j ust kind of let it sit in the room temperature and see how long they last. They last quite long time. And when you put like,

dana-gibbs-md--she-_1_05-16-2025_171001

I am thinking about Twinkies, but

celine-lee--md_1_05-16-2025_161001

Yes. And Twinkies. Yeah. They have a lot of sugar in it and they just like last forever. So it's not natural.

dana-gibbs-md--she-_1_05-16-2025_171001

it's completely unnatural.

celine-lee--md_1_05-16-2025_161001

Exactly. That's unnatural. So they might be good for emergency situations, if we have disaster happen and we have to just sleep on something, maybe that's helpful for that. Just give us a calorie. But they are really non-natural food and the non-natural things in those food, when it comes to our body, it really confuse our immune system because it's not something that our DNA is trained to recognize, as beneficial for our body because it didn't exist just about, just like a few, just like 100 years ago, you know? It didn't exist. Right?

dana-gibbs-md--she-_1_05-16-2025_171001

It didn't exist.

celine-lee--md_1_05-16-2025_161001

Yeah. Uhhuh Right. Exactly. So our body does not know what to do with it. And whatever things that our immune system doesn't recognize becomes the target of attack. So any food that have a, a chemical preservative. Can cause inflammation in our body. So I usually tell my patients, try to avoid sugary food and processed food. And even those two things can cause a huge impact because a lot of food that we can just buy from grocery to store if we are not careful about those ingredient, we'll buy a lot of sugary processed food, like Twinkies.

dana-gibbs-md--she-_1_05-16-2025_171001

yes. I mean, fresh vegetables, fresh fruits, beans that you cook yourself. Even if they're dried, they're still pretty good'cause there's not a lot of preservative there. I think you're right, absolutely about that. Anything else? I mean, food obviously is super, super important, but what about other techniques? Do you encourage people to do yoga or acupuncture or any other modalities that you find to be really helpful for rheumatologic disease?

celine-lee--md_1_05-16-2025_161001

Yes, actually. The thing that I've stressed after the diet is sleep. So sleep is so important that there, there's like bad names about sleep saying that, oh, sleeping is just, you're not doing anything. You're not productive. Sleep is actually probably the most productive time for our body system. Our conscious mind is resting, but our physiology is probably the most active during our sleep. So if we are accumulating this stress and inflammation in our bodies and the tissues get this inflammatory molecules, if we can get enough sleep and enough nutrition, our body can heal a lot of things without taking any medication. So for adult, about seven to eight hours of sleep. And that is really essential. It's so essential to the point that, you know, in, in the war they use sleep deprivation as a tool of torture

dana-gibbs-md--she-_1_05-16-2025_171001

Yeah, you're absolutely right. They do in medical school too.

celine-lee--md_1_05-16-2025_161001

Yes, that's right, that's right. Yeah, we're kind of partially tortured in medical school and residency. Yeah. And these soldiers, you know, strong mind, strong body soldiers, they break, you know, with just deprivation without any pain method. And because our body cannot survive without getting enough sleep, and unfortunately, these days because of too much screen time. There are so many interesting, the social media, all the reels and shorts and tv shows. And a lot of people lose sleep and it's kind of they're torturing themselves. So anybody who's getting less than seven hours of sleep you know, we can almost guarantee that there will be some unresolved inflammation in the body. They'll be just carry on to the next day.

dana-gibbs-md--she-_1_05-16-2025_171001

it's funny. We call that a doom loop in my house. It's like when you get sucked in and you can't get away because they keep showing you more and more and more things that you wanna watch. It's like you can't get away. You're in a doom loop. Yeah. All right. So we've got watch your inflammatory foods, we've got sleep as a key. Anything else that you particularly encourage folks to do that's that's not a medication?

celine-lee--md_1_05-16-2025_161001

Yes. So in rheumatology, as you know, that joints are one of the most common target of autoimmunity. So rheumatology is actually not a joint disease. So immune disease and joints are to be the kind of everybody's doormat. That's kind of easy target that any autoimmune disorder actually can cause inflammatory arthritis is because they're right there to attack. So whenever this autoimmune inflammatory cells see the synovium or 10 synovium, you know, they just like to attack them. So inevitably, a lot of patient will have joint pain, joint stiffness, and you know, associated muscle pain. And sometimes people just don't want to move because of this, which is very very understandable. So when the joint is inflamed, it's painful to even just move. So patient tend to not move which can cause other problems too. So yeah, when the patient starts the treatment the inflammation will go down and as soon as the inflammation's going down and the joint is now safe to move, I usually ask the patient to start some light exercise. It is important to note that when the joint is severely inflamed, they actually should not exercise because severely inflamed joint, if they are getting additional physical strain, it can actually get worse. And worst case scenario, for example, if somebody had psoriatic arthritis and have Achilles tendonitis. And if somebody tried to exercise and strain that inflammed achilles tendon, it can rupture. So this actively inflamed joints and tendon need to be rested. However, once that inflammation goes down, then the patient should start some light exercise to preserve the range of motion of the joint and just to prevent contractors of the joint. And this is very important. And if the patient fears that, oh, my joints are inflamed, I should not move and just are stuck in the stage too long, then the person can be deconditioned and their joints can lose range of motion. The muscle can atrophy and the person's physical health can decline overall and they can develop physical deconditioning. So I usually tell my patient once the active inflammation goes down, make sure that they do some exercise.

dana-gibbs-md--she-_1_05-16-2025_171001

that's super interesting. So if I see a patient with Hashimoto's Disease and because that's mostly what I see and they have joint discomfort, how do I advise them on whether they should have an ANA test or a rheumatologic workup. What history elements am I looking for?

celine-lee--md_1_05-16-2025_161001

Yes. So as you know the thyroid disease and her and the menopause and those menopause, yeah.

dana-gibbs-md--she-_1_05-16-2025_171001

Perimenopause and menopause. They all cause joint pain.

celine-lee--md_1_05-16-2025_161001

Exactly. They all cause joint pain and joint stiffness and you all feel achy in the morning when you wake up. So it's very similar and that's one of the reasons why it's so confusing. And we have a lot of overlap because the Hashimoto disease, hypothyroidism, menopause, rheumatoid disorder, they all cause joint pain. But there's some key differential that kind of give you some signal that this could be more than thyroid or estrogen deficiency. When we see the morning stiffness that's for too long, so it is normal, after we get older, and I'm feeling it these days too because I am perimenopausal myself. Oh no, you, we feel a little bit of stiffness. I'm in my forties, so I'm, I'm getting there. Yeah. So usually you feel about, you know, 10 to 15 minutes, feel achy and back pain. Joint pain joint feet and t he hand feel a little bit swollen and usually after like 15 minutes it gets better. 30 minutes, it's gone. So those kind of joint stiffness, you know may not always be a rheumatoid disorder, but rheumatoid disorder the morning stiffness usually lasts much longer. So the diagnosis criteria, it says more than one hour. So if you one hour the morning stiffness, just persist, then it is something that we need to think about. And some patients who have rheumatoid arthritis or lupus arthritis, they just say, oh, 30 minutes. So it's not like a written the stone. So some people can have a little bit less morning stiffness, and sometimes it's the patient's perception. Some patients are just so used to feeling stiff. If they feel just a little less stiff, they think, oh, that's normal for them it feels great. Yeah. Even though it's actually stiff. And they after they, they get treatment, they say, oh my God, I did not know that what I was feeling was not normal. I thought that was normal. So sometime is the bias by patient's perception and their pain tolerance and their stiffness tolerance. Yeah, there's some caveats there, but usually rheumatoid disorder patient will say that the stiffness lasts for longer and usually more than one hour. And also it'll come with some swelling issues, not always. Rheumatoid arthritis not always can show the joint swelling that the patient can perceive themselves, but they can say something like: I cannot grab object firmly in the morning because I just feel my hand grip is weaker. And when their joints are swollen, they cannot make a full hand grip, the normal hand grip, and they can feel, oh, I cannot open a jar. I cannot do certain things that require the full joint function. So that's another one. You can kind of, or maybe this is something more than hormone and they maybe could be actual autoimmune disorder. And also if they have some other symptoms such as have a rash that is also sensitive. So every time they go out, they get rash on their cheeks. The lupus rash characteristically spare the nasal labial fold. So the line that connects the, the side of the nose to the side of the lips. If the rash really spares that the line and comes on with the sun exposure that can be suspicious for lupus or the patient can have some scaly rashes on their scalp or some abnormal nails. Nails look very there's a lot of pitting in the nails. The nails just break down so easily. There could be so psoriasis. Or they could have some GI symptoms such as they have diarrhea all the time. They cannot gain weight because they just cannot absorb the nutrient they see sometimes the floaters blood in the stool. So they have some other symptom of autoimmunity. So that's the Crohn's disease or ulcer colitis. So if they have those symptoms, those patient need to get evaluation to look for underlying rheumatology or other autoimmune disorder. So that could be the giveaway sign for something else is going on.

dana-gibbs-md--she-_1_05-16-2025_171001

Sure. So another thing that I have heard is that rheumatoid arthritis, for example, affects joints in your hand, but if you have osteoarthritis, generally it's a certain, it's like these knuckles versus the the metacarpals. So, which joints are more specific for the rheumatologic diseases versus osteoarthritis.

celine-lee--md_1_05-16-2025_161001

Yes. So rheumatoid arthritis usually involve these joints. So these joints call PIP joints, second joint of the joint. And these knuckles which is MCP joints. So those are the rheumatoid arthritis. Preferred joints to involve psoriatic arthritis can actually involve all of those. So psoriatic arthritis can involve this. The top joints, the DIP joints, the middle joints, PIP joints and the knuckles, the MCP joints. So, so we are arthritis can involve all of those. Osteoarthritis tend to more involve the top joints and the middle joints, but not the MCP joints, but not the knuckles. And osteoarthritis usually, almost always at some point will involve the this thumb base here, because the, this joint, the thumb base joint is the one that is most used in our hand because without this joint moving, we cannot actually do this opposition movement. So this joint is the reason why human can use tools.

dana-gibbs-md--she-_1_05-16-2025_171001

You can't grip anything.

celine-lee--md_1_05-16-2025_161001

Exactly. Yeah. And because this is the one that used the most, most people will have arthritis here which will cause pain in the thumb base. Sometime this base can be protruded and we call that thumb squaring. When they square when this one protruded, this one will just go in. So you may see some older patients, they have really put it here and then look like this, almost like this. And that's one of the common sign. And a bony prominence in the middle joints which is called Bouchard nodes. The bony prominence of the top joint, which cause Heberden's nodes. So those are sign of osteoarthritis. So one of the tip to differentiate is osteoarthritis and rheumatoid is when you just look at the patient hand, you could just look all swollen or when you actually feel the joint. If it's mostly bony and just hard bone it's most likely osteoarthritis. But in rheumatoid it'll be softer and feels like, almost like you're pushing a little mushroom. So you feel some like soft tissue swelling or even some like fluid inside. And they will be more likely rheumatoid. Yeah. Osteoarthritis can also cause fluid as well, but it'll be less common than rheumatoid arthritis and also x-ray will look very different because osteoarthritis will cause more bone spurs when rheumatoid arthritis will cause more bone erosions. So that's another thing that they can be differentiated.

dana-gibbs-md--she-_1_05-16-2025_171001

Okay, so if somebody comes to you with joint pain, and they are in that age, they're in their late forties, and they say, oh yeah, this joint pain started two years ago, and it gets better, it gets worse, gets better, it gets worse. How would you go about verifying that that person is actually having perimenopause related musculoskeletal pain versus a more serious condition.

celine-lee--md_1_05-16-2025_161001

That's very good question. So that's the question that I wish there's a blood test to take. Tell me the just gimme the answer. Because it's very difficult to differentiate sometimes. And the first thing is a rheumatologist, what I would do is what I would do anyway to rule out rheumatoid arthritis or other autoimmune disorders, the history, you know, also symptoms, physical exam, blood test, x-rays and those things and that will gimme about 80% of the answers, 80 to 90% of the answers. This is likely rheumatologic or not. And if there's not enough clinical suspicion, rheumatoid disorder, I usually don't push medication because it could be something else. And a lot of time it could be perimenopausal symptoms or some patient it could be Hashimoto's Disease. And when I check those TPO antibodies, the thyroid panels, or the patient, other symptoms such as the person have hot flashes or not. So there will be some other symptoms that could signal that, oh, this person could have actually perimenopausal symptoms too.

dana-gibbs-md--she-_1_05-16-2025_171001

So it's right back to the history again. It's right back to the history.

celine-lee--md_1_05-16-2025_161001

Yes. Yeah. Right. Back to the history. History is the most important. So if I have you know, kind of balancing, oh, is it rheumatology problem or more perimenopausal or thyroid problem? If I have really little clinical evidence of rheumatoid disorder and no blood tests or x-ray findings you know, this score will just go down. If there's a more of symptom of perimenopausal and you know, there's no antibodies that signal autoimmune disorder, then, it score will go up. I think it's almost impossible to have zero and 100 scores to usually somewhere in the middle. One of the reason is rheumatoid disorder actually does not have any single blood test to confirm even like a rheumatoid arthritis, 40% of RA patient actually don't have positive rheumatoid factor.

dana-gibbs-md--she-_1_05-16-2025_171001

Oh my goodness. That makes it even harder.

celine-lee--md_1_05-16-2025_161001

a lot of RA patient will not have increased inflammatory markers in the blood such asrate or CRP. And people can have severe synovitis in their joints. Completely normal ES RCRP and no rheumatoid factor or anti P antibody. So that's the reason why there's a no 100 percent score and zero score because there's no single diagnostic test like that. So it's more like really clinical acuity about what kind of symptoms the patient is going through. With some help of blood tests, but not completely learn the blood test or the imaging. And then try the most likely treatment, they will help the patient and we evaluate. But if the symptom and other evidence are less for wounds disorder using I immuno provision for those patient will cause more harm than benefit. So obviously we don't want to suppress somebody's immune system just because somebody have joint problem from menopause problem. Right?

dana-gibbs-md--she-_1_05-16-2025_171001

that's absolutely right. So I have a patient that I wanted to share with you.'cause it's, it's kind of just the opposite of what you just said. So, the patient says to me, you know what, I think I might have thyroid problems. I'm tired and my joints hurt when I wake up in the morning and I just feel terrible. And I asked her, I said, okay, when did you last have your period? And she says, oh, about 10 months ago. And the reason she was seeing me is because her primary care doctor had said that she needed to go see a rheumatologist. He said, I think you have lupus. And I'm like, well, do you have a rash? And she's like, no. And I did my very basic panel on her. She did not have thyroid disease. And I put her on menopausal hormones and within two months, she was sleeping better. And her joint pain was 90% gone. And it was just like, I don't think you need to see a rheumatologist at this point. So, so yeah, it's so common. And it's funny to me that there are primary doctors, primary care doctors out there who jump immediately from joint pain to, oh, you have lupus when somebody is 49 years old. It's, it's just a wild thing.

celine-lee--md_1_05-16-2025_161001

lupus tend to be more active in the premenopausal women. So a patient who have lupus I mean, can, it can go it can occur to any patients, but lupus patient that tend to have most aggressive symptoms are usually in the premenopausal age. You know, the childbearing age women especially, Hispanic Americans and African Americans, they can have severe nephritis problems. But it can come to any age. But there's something to think about. Because every women will become postmenopausal at some point, and a lot of them will develop joint pain, but it does not mean that it's a worrisome for lupus. Yeah, there's some other things and osteoarthritis is a common thing, and that's what I have problem right now. Mm-hmm. Developing a ARD note in my right hand. So it's achy when I wake up. Yeah. It's normal. I'm getting older.

dana-gibbs-md--she-_1_05-16-2025_171001

Yeah. Well, we're kind of coming to the end of our session and there was one more question that I wanted to ask you, which was how has the COVID ERA changed your practice, specifically the practice of rheumatology in general? Have you noticed some changes there?

celine-lee--md_1_05-16-2025_161001

Yes. The COVID pandemic definitely 100% increased autoimmune disorders. It's somewhere about like about 30% increase. The, I think the hinge ratio is about 1.3, according to the research. So definitely more patients develop autoimmune disorders after having COVID infection. Thankfully not everybody who have COVID will develop autoimmune disorder, but it is clear that you know, a lot of them can, and the positive ANA can be seen about in about 30% of patients who have COVID infections. So if we test 10 patient who just had COVID. Three of them will have positive ANA. Thankfully, not all of them develop disorder. I think about like according to the one, the research, about 12% of those people can actually develop autoimmune disorder most commonly rheumatoid arthritis or lupus or one syndrome.

dana-gibbs-md--she-_1_05-16-2025_171001

Yeah, that's, that's a really high percentage. That's really scary to me. Wow.

celine-lee--md_1_05-16-2025_161001

Yeah, and the researchers think that it could be because the COVID virus really disrupt the immune system and just cause systemic autoimmunity in the immune system. And this is not entirely new because we already know that EB virus infection can also increase autoimmune disorders.

dana-gibbs-md--she-_1_05-16-2025_171001

Oh, Epstein Barr virus. Yeah.

celine-lee--md_1_05-16-2025_161001

Yes. So there's this viral infections that really provoked the immune system and the EB virus is actually the virus that infected the B cells. So that kind of makes sense. COVID also tends to be really disruptive to the immune system and can cause autoimmune disorders. So definitely after COVID, I see a lot of patient who develop positive ANA and some of them do develop rheumatoid disorders. I had patient very clear, clearly have time correlation with just two or three weeks after going from COVID. They just develop synovitis in the hands and that that she never used to have before. So yeah, there's a definitely correlation between COVID infection and autoimmune disorders.

dana-gibbs-md--she-_1_05-16-2025_171001

All right, so we are at the end of our time, so go ahead and tell the audience how we can find you, where to find you on the socials and where's your office and how can they work with you if they have an issue that they need help with.

celine-lee--md_1_05-16-2025_161001

So I practice in Maori, Utah. So it's just from Salt Lake City, Utah. And my website is lotusrheumatology.com and is like a flower Lotus, L-O-T-U-S. I picked the name because Lotus represent resilient beauty to me and because Lotus can thrive in the really murky order because it can purify itself. So when I think about patients who able do immune disorder, they're going through a lot of symptoms, joint pain, swelling, stiffness, fatigue different rashes and a lot of difficult symptoms. But with the right treatment and right lifestyle modification, they can still thrive in their life and that's why I got inspiration from Lotus Flower because they bloom the magnificent flowers, even though they are stemmed from not the ideal environment. And that's the reason why I like the flower. Yeah, so it's a Lotus Room two.com and I have YouTube channel and Facebook and Instagram which can be found on the website.

dana-gibbs-md--she-_1_05-16-2025_171001

Excellent. Well, thank you very much for coming on. This has been really fun and super informative though. I learned a lot of things. And thank you for coming on the Beyond the Thyroid podcast. This has been really great. Yeah, I enjoyed it. All right. Bye-bye everybody.

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