Mihow

Hyperthyroidism

—

by

Mihow
in

I got my blood work results back today. My thyroid levels are elevated. They are elevated enough that my doctor is concerned. I need to visit an endocrinologist as soon as possible.

This explains so much. I have almost every symptom related to hyperthyroidism except for maybe the rapid weight loss. (Although, I did lose 35 pounds in 3 months.) I am manic. I do have a ravenous appetite. I have trouble sleeping. My muscles ache or don’t feel like working at all. (I think I may be confusing joint pain with muscle pain. We’re going to find out at my next visit.) I am winded walking up stairs. I get depressed too often and easily. The checklist is full of yeses. This explains so much, so very much.

But I’m worried about my future. I have no idea what this means or what drugs I may have to take. I have no idea if I can continue supplying breast milk for Emory. Knowing helps but knowing what to do is the next step and I’m worried about that.

In other news, Emory had another vaccination today. He barely even cried. This might be getting easier. We’ll find out whenever he wakes up from his long nap.

Also! I am proud to report that starting today, I will be writing three times a week for MamaPop. (You may have noticed the banner in the sidebar.) I’m really excited about this even though I am kind of autistic when it comes to celebrities. (I’m not even sure if that means what I want it to mean.) But I think I can hang with the rest of ‘em. I know stuff about other things. Anyway, please check out my first post! It’s about McDonald’s. Y’all know how I feel about McDonald’s.

Comments

40 responses to “Hyperthyroidism”

  1. Jonathan Avatar
    Jonathan

    Not to sound callous, but don’t worry. It sucks… but my aunt has had that for a few decades. She’s 72.

    Like

    Reply
  2. jenny Avatar
    jenny

    Glad to hear they found out what the problem was – not knowing is so incredibly stressful. Both my mom and a friend of mine have the opposite problem – hypothyroidism – and both do extremely well on the medication. I know it took a bit at first to get the right dosage, and they have to get their levels checked every year, but they saw improvements really quickly once they got the right meds.

    Hope all goes well with the endocrinologist!

    Like

    Reply
  3. mihow Avatar
    mihow

    i hate to sound shallow, but I am sometimes. But does this mean I may put on weight? Doesn’t this sort of thing lead to obesity? I wouldn’t like living my life that way. I guess I have to work hard at making sure that doesn’t happen.

    Yes, it’s great knowing. But man! I so wish the physical problems would stop hitting one after another. I used to be a very healthy person and while they might be serious, it’s relative, you know what I mean?

    ugh.

    Like

    Reply
  4. Zooey Avatar
    Zooey

    I’m hypothyroid and have many strange symptoms, so I understand how stressful it can be. I see an endocrinologist every 3 months and my levels are up and down, but for the past few months, though, they have been normal. There is hope:)

    Like

    Reply
  5. schmutzie Avatar
    schmutzie

    It runs in my family, and every one of them with it lived to a ripe old age, lived well, and was healthy. My grandfather has it and just turned 90, so there you go.

    The hard part is finding the right levels for you, but as soon as you do, you’ll feel so much better. All the best.

    Like

    Reply
  6. mihow Avatar
    mihow

    Do folks with this go on anti-depressants? I didn’t have time to write the post I wanted to write because Emory had his shots today and I’m hanging with him as much as I can (napping now). But I’ve been VERY hard to live with lately. Poor TJ. I do hope this will enable me to calm the F*ck down already and maybe become my old self again. I don’t necessarily want SSRIs but I would love to regulate myself enough to be calm once again and not completely insane sometimes. (I have been very insane lately toward TJ.)

    Like

    Reply
  7. Jonathan Avatar
    Jonathan

    see! lots of people have it – they all live old and are fully ok

    the only thing you need to worry about for emory is that he has a mom that loves him and lives forever (or seemingly close to that). you’re pretty much a shoe in.

    btw, my aunt is like a stick figure. super thin. anything may lead to obesity or weight loss – but it doesn’t guarantee it.

    Like

    Reply
  8. Melanie Avatar
    Melanie

    I’m hypothyroid (I know, not the same), and it’s so true that once everything is leveled you’ll feel so much better. There are a lot of resources online, I know they helped me.

    I freaked out when I was diagnosed back in May because it meant taking a pill every day for, well, ever. But it’s easy to get into a rhythm and I do feel so much better now. Hang in there.

    Like

    Reply
  9. mihow Avatar
    mihow

    P.S. To all the judgmental and mean breastfeeding mothers: THIS DOES decrease milk supply. I just read it on the LL Web site.

    Do you have any idea how happy it makes me to know that this could be directly related to WHY I don’t make nearly enough milk to support my own son?

    Like

    Reply
  10. jenblossom Avatar
    jenblossom

    You now have a diagnosis – this is a good thing. It took two years of doctors and tests and specialists and more tests before I finally got my fibro diagnosis but let me tell you, THE RELIEF I felt at finally knowing my enemy, finally being able to give it a name and feeling validated that I wasn’t just some loony hypochondriac – man, it was incredible. And it sucks to have a chronic health condition, to know that you’re going to be living with this for the rest of your life, but you will LIVE with it. It will color every aspect of your life but you know what you’re dealing with now, and you can take positive steps to treat it and get back to feeling like yourself again. :)

    Like

    Reply
  11. stfarmer Avatar
    stfarmer

    Michele,

    My ex-wife was hyperthyroid. Her treatment consisted of irradiation of her thyroid to destroy it. Normally, a person is then given a thyroid hormone replacement which helps regulate their metabolism. In my ex’s case, the radiation didn’t distroy her thyroid totally and she ended up with normal thyroid hormone levels and didn’t have hormone replacement therapy. Unfortunately, she later developed thyroid cancer and they surgically removed her thyroid and she was placed on Thyroxin.

    She is very involved in her own medical care and demands that her physician keep her thyroid hormone level in the upper range because she is concerned about weight issues related to low thyroid levels.

    Like

    Reply
  12. mihow Avatar
    mihow

    Thanks for that, StFarmer. Going to read up on stuff. I don’t want to put on a bunch of weight. I can’t think of anything that could make me more depressed. That’s something I will make sure that my doctor knows.

    Like

    Reply
  13. stfarmer Avatar
    stfarmer

    FYI – The ex is 5’6” and I’d say around 125 or so. Then again, she works out and eats a healthy diet too. The point is, destroying your thyroid turns you from being hyper to be hypothyroid but it doesn’t mean that you will automatically gain weight.

    Like

    Reply
  14. hobbs Avatar
    hobbs

    Don’t worry! I’ve been going to an endocrinologist for decades (for my diabetes), but also for my thyroid which went to shit a few years ago. One little pill a day now and all is well :-) Seriously, the thyroid is a very common thing to go out of whack and pretty easy to resolve! I’m happy to answer any questions – though I’m definitely not a doctor. Peer support is more like it!

    Like

    Reply
  15. Heather Avatar
    Heather

    I say be shallow! Who cares, this is you talking about your worries about yourself and your family. I can say that I would be very worried about gaining weight as that has always seemed to effect my happiness or lack there of and if I’m not happy then my body suffers and so does my health. It’s all linked somehow!

    I too wish that these things would stop happening to you, it just doesn’t seem to end but like everyone has said so far at least you know a possible link to why everything else is happening to you.

    Like

    Reply
  16. Gillian Avatar
    Gillian

    Yup, my mom’s had a thyroid problem since forever, and it’s never caused her much trouble (beyond remembering to take that pill). You Will Be OK! And your symptoms will go away – which will surely be a relief.

    Concern about weight isn’t shallow – it has to do with health, energy levels, and lots of other things in addition to self-perception. I’d worry about it, too, if I was in your boat! Luckily you have all these educated people and great websites to help you navigate this stuff.

    Like

    Reply
  17. mihow Avatar
    mihow

    Sometimes, I come off as being more freaked out then I really am. DRAMATIC! WOO!

    But in all honesty as long as I can maintain a healthy weight, I’m OK with this. Now that I know what was wrong, I can address the issue.

    I have a call into my OBGYN about finding out if there’s something I can take to fix this whole 4-month long breast feeding saga (not enough milk). She is chatting with my primary care doctor. Hope to have that resolved soon, too.

    Turns out, I am one of the rarities who actually DOES NOT produce enough breast milk.

    Like

    Reply
  18. Zooey Avatar
    Zooey

    I truly don’t think you will gain weight due to treatment. The main reason people with hypothyroidism gain weight is due to lack of energy and so on as a result of the impaired thyroid function… not so much because of the hypothyroidism in general.

    Like

    Reply
  19. daisyduck Avatar
    daisyduck

    To treat hyperthyroid they irradiate your thyroid and make it non-functional. Then you are given Thyroxine/Synthroid because you are without a functioning thyroid. This does not mean you will gain weight…the people with hypothyroid gain weight before they are diagnosed and then they should eventually level out once they are treated adequately. In other words, once you have been treated and are on the medication, it will be like you are normal. And the anxiety/depression should normalize too, once your T3/T4 levels are in range. Worry not (and don’t worry about shallowness, it’s your health and that includes all aspects of your health

    Like

    Reply
  20. We Avatar
    We

    My boss was diagnosed with hyperthyroidism quite a few years ago. His doctors wanted to give him radioactive iodine to burn out his thyroid, then medicate him with thyroxin, but he refused. He has gone on a very strict diet, no alcohol, no cigarettes, and less processed foods etc. And it seems to work for him. His thyroid being out of whack was also making his heart go out of whack, and this diet helped both. He can’t fall off the wagon though, or his heart beats irregularly, with just one or two glasses of wine. Research the different levels of treatment to find one you are comfortable with!

    Like

    Reply
  21. Meredith Avatar
    Meredith

    I am hypo thyroid too. It’s fine. You take a pill and you feel SO much better. :)

    Like

    Reply
  22. erin Avatar
    erin

    you will feel soooooo much better when you start taking the meds for the hyperthyroid. omg. my husband had troubles with his thyroid, he finally figured out it was messed up, started taking the meds that level everything out, and our life was changed forever! yay! good luck.

    Like

    Reply
  23. Pascha Avatar
    Pascha

    Michelle,

    I’m not a doctor (just going to nursing school) but I unfortunately am very knowledgeable about thyroid issues. Why? Because I had hyperthyroidism, then thyroid cancer, and my husband had hypothyroidism, then thyroid cancer. We are both fine now.

    If you have questions about what kinds of things the doctors will do, and things you may experience, feel free to email me. I’ll give you some highlights:

    I was diagnosed with hyperthyroidism about 5 years ago. I had toxic nodules. The thyroid is made up of nodules, and a few of them had become so large and overactive that they shut down the rest of my thyroid. And my levels were still off the charts. Normal TSH levels (this varies from doctor to doctor) are usually around 0.5-5.0. My level was less than 0.01, pretty extreme. We tried a new procedure, which was to inject alcohol directly into the toxic nodules (they give good drugs for this!) in the hopes of shrinking them. I did that, my levels returned to normal, then went haywire again. I did the injections 3 times before they did a biopsy and found I had thyroid cancer. I had been dating my boyfriend, Andy, for a month when I was diagnosed. (He’s now my husband.)

    Usually with cancer, they remove the entire thyroid and then do a radioactive iodine therapy, a pill you swallow, that gets rid of the bits of thyroid left behind, the parathyroid. Those are 4 small areas that connect the thyroid to the larynx, which is why a doctor usually won’t remove those—you run the risk of losing your voice temporarily or permanently. The radioactive iodine usually kills those off. The interesting thing about this, is that thyroid cells can travel throughout your body. So they do a full body scan after the iodine to see if there is thyroid left in the body. It’s possible you can have those thyroid cancer cells in your foot, for example.

    We decided we would only remove the left half of my thyroid. My doctor did not like this, but I refused to have the entire thing removed. (I did not want iodine therapy or to have to take synthroid). They removed half of it, and the rest of my thyroid has made up for the missing half. And now I am becoming hyperthyroid again, so we may have to do those things afterall. I have never been on medication for my thyroid. My doctor said all my thyroid issues are from Grave’s disease. Luckily, I don’t have bulging eyes.

    Two weeks before I got married (almost 3 years ago now), I noticed a large bulge on my husband’s neck and instantly felt sick. I made him go to the doctor that day, and they did a biopsy. It came back inconclusive, so they had to do ANOTHER one (they don’t give good drugs for that) and we found out the day we got back from our honeymoon that he had thyroid cancer. He had surgery, did the radioactive iodine therapy, (luckily he only had to do it one time) and now takes synthroid everyday.

    Since I still have half my thyroid, and it is becoming hyper again, there is a SMALL chance that I could get cancer again. But that is unlikely.

    Ok, I know this is getting long, but I have to add: I think I’ve had hyperthyroidism since I was a child. In third grade, my resting heartrate was 115. My gym teacher told me to tell my parents to have my thyroid checked, but I was a painfully shy child and never told them. I have also always been very thin. I did not even hit 100 pounds until the summer after I graduated high school. (I’m 5’4”)

    I am also having problems producing milk for Adeline (almost 5 months old). It’s getting so bad that I pump about 6 times a day, and I’m lucky if I get a few ounces TOTAL. This makes me very sad. I also weigh 19 pounds less now than before I got pregnant—and I have not dieted or exercised. I’m not bragging here, just saying that this is one of the main reasons I think it is becoming hyper again. My heartrate is around 100, and just walking up a flight of stairs makes it go up to 120-130.

    Sorry this became so long. If you have any other questions, feel free to email me.

    Like

    Reply
  24. mihow Avatar
    mihow

    Don’t apologize. I am going to email you. One thing I wonder about, however, is if my levels have ever been tested. My primary care doc kicked himself today for not checking them back in 2005 when I went in to find out why my heart rate was so insane. (Same as you. Went from an awesome resting rate to something extremely high whenever I worked out.)

    I wonder if this was something my OBGYN would have checked.

    I may have to find out even though I still haven’t heard back from her for an earlier phone call.

    The whole breast milk thing makes me happy and really sad at the same time. If I had known this, Emory would have been breast fed. I may throw in the towel entirely. He visited the pediatrician today and she said he was doing well on the supplemented formula and not to worry if my milk dropped so much. Since he’s doing so well, maybe I will start fixing myself up a bit. :]

    Like

    Reply
  25. Sharon Avatar
    Sharon

    I too know a lot about hyperthyroidism, unfortunately. My thyroid went bananas after the birth of my first daughter five years ago, I took anti-thyroid drugs for a while until it went into remission. I did gain weight but this is due mostly to the fact that your diet goes a bit crazy too when your thyroid is overactive, we crave high energy foods and eat a lot so develop bad eating habits.
    Just before my second pregnancy my thyroid starting acting up again, I took propylthiouracil during my pregnancy, this drug has been called the breastfeeding friendly drug but there is very little research to confirm that entirely and I was stongly advised not to breastfeed my baby. She is now 13 months and I’m weaning her so that I can take my medication as the symptoms are becoming overwhelming again, I have taken small doses of the above mentioned drug to get me here today, I don’t have milk supply problems, or maybe I do, but in the other sense, I over produce.
    I have been diagnosed with graves disease which is an auto immune disease, I feel very similar to you and question when I will feel healthy again. There is loads more to say regarding drugs etc so if you want to talk about it more please feel free to mail me. You can pretty much rest assured that you won’t need to take anti-depressants, about a week into taking your thyroid drugs you’ll start to feel human again…
    good luck.

    Like

    Reply
  26. rachel b Avatar
    rachel b

    Hey Michele,

    Get a good Endo and they will just adjust your metabolism so it is normal. It will make you feel human again AND it is usually the imbalance that leads to needing anti-depressants. My sister has hypo. This is pretty common with women who have babies. I think there is something related to the physical trauma of child birth. Anyway she is on Cynthroid which I think is the med of choice for under active.

    It may be scary but I hope you are relieved to know what is going on and the chance to map out a plan of action with a specialist.

    All my love coming your way.

    Like

    Reply
  27. stfarmer Avatar
    stfarmer

    Michele,

    You should definitely discuss with your physician the recommendations for isolating yourself while any radioactive iodine you might have during the course of your treatment, dissipates from your body. This could involve minimizing contact with Emory and I suspect giving him your breastmilk during that time would be a no-no.

    Disclaimer: I’m not a medical professional and I don’t play one on TV.

    Like

    Reply
  28. mihow Avatar
    mihow

    Well, my thyroid levels haven’t been checked before, so I have no idea when this actually began I wish I had known what the symptoms where. I felt arm pain at about 38 weeks. I have read that the symptoms that I’m now feeling are later ones and that this could have happened a while ago. Anyway, I wish I had known. The whole breast feeding thing would have been so much easier to deal with since this could be directly responsible for my low supply. My OBGYN said they normally don’t check thyroid levels unless there’s a problem. Thing is, problems don’t often show up until advanced stages.

    So, this is my question. If doctors, medical books, other women, lactation consultants, midwives, and our very own government wish to push breast feeding to the point where women question whether or not they’re good mother, before women blame themselves, shouldn’t there be tests done after birth to make sure every woman is capable? They say that most all women have enough milk but how do they know that if they aren’t checking thyroid levels especially if thyroid problems lead to supply issues and therefore cause problems for breast feeding.

    I’m so relieved to know that this may not have been my fault after all. But I’m also very annoyed that I wasn’t aware of this possibility especially since it’s SO VERY common for women after childbirth.

    There should be tests run. Lactation consultants should know this, doctors should make sure women are OK in the thyroid department, if not for breast feeding, then to help with postpartum depression.

    I feel a rant coming on.

    Like

    Reply
  29. sharon Avatar
    sharon

    I totally agree with you but low milk supply can be blamed on any number of things, as far as I understand you pump only and that could also be a contributing factor, the breast pump doesn’t stimulate the breast in the same way a baby does, babies feed differently all day long depending on their needs and the breast adapts to this demand. Like I said earlier I had problems with too much milk and strong ejection but for the life of me I have never gotten more than 60ml pumping…go figure.
    As for the thyroid question, I do feel strongly that a blood test should be standard procedure for all women after giving birth, since I’ve been ill I have come across so many people like me who only found out once the symptoms started ruining their lives.
    Please note that radioactive iodine is only given when they want to destroy part of the thyroid, most cases of hyperthyroidism following childbirth can be treated with a course of anti-thyroid drugs and if you do want to continue breastfeeding look into the drug I mentioned earlier, I would be curious to hear what they say in your neck of the woods (I was treated in France)
    bisous

    Like

    Reply
  30. mihow Avatar
    mihow

    I know all of that. But I also know that my milk never “came in” as I was told it would even even when Emory was sort of breast feeding. I thought I was doing something wrong. Maybe I was. Maybe I should have NOT pumped and just kept him at it all the time. But I began pumping and trying to get him to eat from my breast as well. I tried both from the beginning and nothing made my milk come in. I kept him near me, skin on skin. I got him close to me. My boobs never became full. Ever. Not even a couple of days after he was born even as I tried to get him to latch.

    We’ll never know. But I’ll tell you one thing, maybe my depressed state of mind was due to high thyroid levels and that too could have helped me out with the whole breastfeeding fiasco.

    I’d also love it if the nurses didn’t suggest I wasn’t trying hard enough. Maybe, just maybe things would have worked out differently for me if I had known. That’s all I’m saying. And I think women should not be scolded for not trying if there could possibly be something wrong with them physically.

    Like

    Reply
  31. daisyduck Avatar
    daisyduck

    There is not enough evidence to recommend testing seemingly normal women for thyroid hormones routinely. However, any problems that present should be investigated for thyroid. Also, they do test all newborns for thyroid levels, and a problem in a newborn can point to a problem in a mother.

    I would not beat yourself up over this, just be glad that it was found and now you can treat it and enjoy your baby!

    Like

    Reply
  32. mihow Avatar
    mihow

    Since this seems to be pretty common among women after they give birth (judging by the number of email i have received, i am assuming it’s a lot more common than I originally thought) why not make it part of the 6 months postpartum check up? Is it pricey? If bad levels can lead to depression (and other problems) why not check for it? 

    I really do enjoy my baby. It's that I haven't been easy to live with and the anxiety I feel is, in fact, at times overwhelming, sometimes crippling. I only wish I had known sooner. That's all I'm saying. :]

    Like

    Reply
  33. daisyduck Avatar
    daisyduck

    Without getting too nerdy, yes, it is common (as all autoimmune problems are more common in women) but it doesn’t mean a lot of people have it, which means it isn’t cost effective to routinely screen. The problem you run into when you routinely screen for things is that an abnormal result can actually be normal for you, and cause more expensive testing and distress mentally for something that is not consequential. The position statement for thryoid screening is that there are too many subclinical presentations (meaning the levels are off but causing no problems) to be of any benefit.

    Here’s a good layperson link:

    http://www.ahrq.gov/clinic/3rduspstf/thyroid/thyrrs.htm

    And I’m sure you enjoy your baby (who couldn’t, he’s adorable!) and didn’t mean to imply that you didn’t, just that now you can enjoy him without guilt because you weren’t doing anything wrong as far as breastfeeding goes. Hopefully the treatment will get the anxiety/depression under control, as well as your metabolic problems.

    :-)

    Like

    Reply
  34. mihow Avatar
    mihow

    That makes sense, Diasyduck. Sorry if I came off as bitchy. I didn’t mean to. You are right, I can’t wait to feel “normal” again.

    checking link…

    Like

    Reply
  35. Pascha Avatar
    Pascha

    Regarding the radioactive iodine, yes, you do have to stay away from people. This was part of the reason I did not want to do it. When my husband did it, he was told to stay at least three feet away from people for a few days. He also had to use different plates, utensils, and glasses than I did and we had to store and wash them separately. After using the bathroom, he was told to flush three times (the radioactive iodine exits your body through urine). He was told that if he went to the airport, he would need a letter from his doctor because he would have set off their detectors.

    So if you did that treatment, you most likely would not be able to be around Emory for a few days. And no, he would not be able to have your pumped breastmilk during that time, either. They also say if you’re a woman, you should wait at least six months after this type of therapy before trying to conceive. Our doctor told my husband that men typically only have to wait about 1-2 months.

    Like

    Reply
  36. mihow Avatar
    mihow

    The things you learn.

    The endocrinologist my doctor recommended had a cancellation for tomorrow! (I was told I would have to wait a while to see him.) So, I’m hoping to have an answer soon.

    Thanks, everyone for all the help. Pascha, you have been really informative, hell, everyone has.

    Also, go figure, after writing about not wanting to be away from Emory again, I may have to. :[ Perhaps I’ll plan it with a trip somewhere, just me and some radioactive iodine. Sounds like a blast. The vacation I never had.

    Like

    Reply
  37. sharon Avatar
    sharon

    I don’t want to hog your message box but I just wanted to say to you that I totally sympathise for what you are feeling right now.

    Not only do I suffer from this thyroid problem but my mother did too, she went untreated for years and I remember her most shouting and hitting us, today I question what kind of a mother she would have been had she not had this illness. I’ve caught myself screaming at my daughter or resisted the awful urge to hit her and then cried myself to sleep wondering what kind of person I was turning into.

    I’m happy for you that you’ve found out so soon and I hope you can make peace with your breastfeeding experience and put all guilt to rest.

    Like

    Reply
  38. Sarah Avatar
    Sarah

    Taking fenugreek (you can buy it in capsules- probably even at Target in the vitamin isle) will help increase your milk supply. It also makes you smell like maple syrup. Also try drinking a half a beer a day…that helps. I had low supply when nursing both of my boys (now 1 and 3) and that gave my supply a noticeable boost.
    Re: taking meds and nursing. Having a healthy happy mother is the best thing for a baby so if you have to give up nursing he really will be just fine—in spite of what the crazy breastfeeding meanies will have you believe.

    Like

    Reply
  39. mihow Avatar
    mihow

    Yeah, I tried fenugreek for a while, actually. Oatmeal, too. It didn’t much other than give me a bad tummy ache. (It gave Emory really stinky gas, too. heh)

    I think it may be time to give up entirely and focus on getting healthy again. :[ as hard as this is for me to decide, it’s time. I lasted almost five months. Time to throw in the towel. I think. (I was only producing 10 oz a day anyway. we supplement with organic formula.)

    Thanks everyone. And, Sharon, don’t apologize, you all helped me a lot.

    Like

    Reply
  40. Allison Avatar
    Allison

    Your thyroid is involved with a lot of your hormones, like insulin, etc. So once it’s under control, you will feel human again and likely regain the milk supply your body originally intended.

    My hubby had the thyroid cancer, totally removed it, radioactive iodine treatment, lived in the basement for 4 days. Easy. (well the surgery sucked, but doesn’t it always?) In fact, just today he had to take a mini-radioactive pill for his yearly scan and had to steer clear of our 18-month old, which didn’t really work out well at her daycare’s scary santa visit party.

    So yeah, if you have any of the irradiation treatments, Toby will have to take over handling Emory at least for a couple of days.

    But you may just start out on synthetic hormones and see what happens. It may take 6 months to a year to get the precise dosage.

    Good luck!!

    Like

    Reply

Leave a Reply