Search for T3 Only Doctor

The naturopath, who diagnosed my hypothyroidism and initially prescribed a T4 drug, later added a T3 drug, because T4 only didn't eliminate my hypothyroid symptoms. After a year of intermittent success with various combinations of T4 and T3, I decided to eliminate the T4 and continue T3 only, which my naturopath approved.  She continued to prescribe whatever dose of T3 which worked best work for me, even after I began taking 75 mcg of my T3 drug (generic liothyronine) in 3 divided 2 5mcg doses.  I continued that dose for 18 months while experiencing neither hyperthyroid nor hypothyroid symptoms. I also had no cold during the 2 of the 3 years I was on higher t3 doses.
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 However, after my ND saw my DEXA scan results, she recommended bone building supplements, biodentical HRT and a much lower dose of my T3 only drug. Her last recommendation was based on research that suggested that TSH is related to bone density.  Unfortunately, taking T3 only supplements often suppresses TSH, even when the T3 dose is very low.  Nevertheless, my ND recommended that I lower my T3 dose enough to raise my TSH to a 'normal' range, even though the doctor who oversees my ND does not believe TSH is an effective measure of thyroid function.


So during a few weeks in August 2014 I reduced my total T3 dose from 75 mcg to 37.5 mcg (still 3 divided doses).  That lower dose was where I started with T3 only in January 2012 and did well for over 6 weeks before hypothyroid symptoms returned.  After a month on 37.5 mcg T3 only, I retested my thyroid hormones (free t3, free t4, tsh).  Unfortunately, my tsh was still lower than normal, although a bit higher after a month of the lower t3 dose.


Then my ND asked me to reduce my t3 dose to 25 mcg and retest after a month on that dose.  At 25 mcg daily I acquired my first cold in over 2 years. That cold turned into a severe sinus infection, from which I finally recovered over 3 weeks later. Also I experienced all my typical hypothyroid symptoms (feeling cold, tired and constipated all the time, as well as being vulnerable to respiratory infections and having fragile fingernails that tore, split and developed vertical ridges).  My next blood tests at that 25 mcg level showed that my free t4 was still very low (I stopped taking t4 in early 2012), my tsh was still below normal although slightly higher and my free t3 was now below normal range.  My ND blamed the low ft3 result on the timing of the dose preceding the test (not close enough to the blood draw) and insisted I again reduce my t3 dose to 15 mcg total daily for at least 6 weeks and retest.  She sent me home with a prescription for that amount and a lab test order.




I initially reduced my dose to 18.5 mcg total daily t3 for awhile. However, I was so hypothyroid at that dose (and had found so many articles dismissing the value of tsh testing for free t3 levels), that I talked to my primary care doctor about my hypothyroid symptoms. She encouraged me to return to my previous 25 mcg total daily and gave me a prescription for 37.5 total daily t3 (6 months worth). After she talked to my naturopath, my PCP said I needed to see an endocrinologist for further thyroid treatment.  Unfortunately all endocrinologists in my 'network' required history from my previous/prescribing doctor (my naturopath) before they would see me. Because I couldn't get an appointment until the following year, I had time to change health care plans and find an endocrinologist who actually prescribed t3 medication.


I found online a list of doctors in my area who prescribed t3 supplements. One of those doctors actually practiced at a clinic covered by my plan.  However, he would no longer see medicare patients (perhaps  because medicare plans don't pay as much as private insurance plans). So I was referred to another endocrinologist in his clinic. The first appointment with that endocrinologist seemed to go well.  He ordered many blood tests, a 24 hr urine collection,  and a one month prescription for my current level of t3 supplement.  Rather than discuss my thyroid supplements, he focussed on testing me for hypoparathyroid problems which could explain my osteoporosis.  I already told him about my years of undiagnosed celiac disease and treatments for gut symptoms which exacerbated bone loss.


When all my hypoparathyroid tests showed normal levels, that endo strongly encouraged me to begain taking Forteo for osteoporosis,  despite resasearch which showed that drug causes bone cancer. Also the benefits of Forteo on increased bone density are only temporary.  I agreed to consider Forteo until I discovered it contained mannitol, to which I react with cramps, bloating and diarrhea, as I also react to sorbitol, xylitol, etc. So I called his office and reported my discovery and declined to take Forteo.  That endocrinologist also did not like my thyroid blood test results.  However, he never tested free t3, but preferred to test total t3, which says nothing about the amount of  biologically available thyroid.  He wouldn't even listen to my experience and research about t3 medication. I never saw him again.


Next I saw a new PCP, whom my previous naturopath had recommended as a more naturopathic medical doctor. She was affiliated with the same clinic as the endocrinologist whom originally I wanted to see.  That PCP seem very caring and attentive to my history about celiac disease, food allergies, and prescribed meds which influenced my osteoporosis. She even physically examined me (listened to my heart, lungs, intestines, etc.), which my previous PCP had never done. However, when I returned for a followup visit to discuss my thyroid history and medication, she said that she must defer to the endocrinologists in her clinic, because she was only a 'family medicine' doctor.  I gave her a handful of studies about T3 supplement use and problems with using TSH tests.  However, she recommend I talk to another endocrinologist.  I told her that I had wanted to see an endo in her clinic who supposedly prescribed T3 but he wouldn't see medicare patients.  So she agreed to call him and talk about my history. She later called me to say that he recommended I cut my T3 and add a T4 supplement in order to raise my TSH levels.  However, I had already tried T4 plus T3 supplements for over a year.  When my T3 levels were high enough to eliminate hypothyroid symptoms, even while taking some T4, my TSH was suppressed.  Been there, done that ...


My last hope was a new naturopath, who supposedly prescibed T3 supplements.  I had tried seeing traditional docs within my health insurance 'network', but the PCPs all deferred to endocrinologists who were focussed only on TSH test results, not my hypothyroid symptoms or lack thereof.  I wanted to avoid paying out of pocket for healthcare, because I already paid for my medicare healthcare plan.  However, I previously only received accurate diagnoses and treatment from  naturopaths.  Traditional doctors had misdiagnosed or discounted my symptoms of celiac disease, food allergies, hypothyroidism and gut infections. 


The new naturopath listened to my history and current osteoporosis treatment approach (nutritional and bio HRT) as well as treatment for hypothyroidism (T3 only).  I left her office with a prescription for my current level of T3 and 3 refills (enough for a one year supply).  She encouraged me to consider taking a T4 drug to raise my TSH level.  However, after reviewing my history with T4 and T3 combinations, I noticed that my TSH level was suppressed even when taking T3 and T4 drugs.  So I called her office to remind the naturopath to review blood test results from the year I was on both T4 and T3.  Adding T4 to my current T3 dose would just further decrease my TSH.  My TSH level had only been normal when my T3 was too low to eliminate hypothyroid symptoms.  That naturopath never called me back.  Nevertheless I have enough prescriptions for about 16 months of T3 only.  I really don't know what a suppressed TSH will do to my bone density.  However, I'll get another DEXA in September or October and find out.

Biodentical HRT

I never considered HRT after menopause, because I never had hot flashes or other postmenopausal symptoms. Thanks to having undiagnosed hypothyroidism, I was cold all the time and my blood pressure and pulse were 'nice and low' (according to my traditional PCP).I also didn't want to risk getting cancers associated with HRT. However, after I fractured my hipbone and had a DEXA scan, my naturopath suggested that I consider biodentical HRT, which was less likely to cause cancers.  Also Lara Pizzorno in "Your Bones" described how estrogen and progesterone help bone growth.  So 17 years after menopause I decided to try biodentical HRT for no more than 2 years.


My insurance company agreed to cover the Estradiol patch (0.05 mg/24 hr ptwk).  However they wouldn't cover the biodentical progesterone product, Prometrium (micronized 100 mg caps), one cap daily. My ND recommended that I take both the estrogen and progesterone products together to minimize side effectt. After my ND appealed twice, my insurance company agreed to cover Prometrium. So I started taking a daily prometrium capsule and wearing the Estradiol patch.


I had read that I would experience side effects. However what I experienced during the first five days seemed more like my typical food allergy reaction, than menstrual cramping pain.  After five days of intestinal cramping I rechecked the ingredients, which I foolishly assumed my naturopath had checked before prescribing to me, and found SOY (one of my diagnosed food allergies) among the inert ingredients.  When I confronted my ND, she said 'some of my patients react to the soy'. GRRRRR!!!! I ALWAYS react to soy with gut cramps, bloating, gas, diarrhea or constipation.


So I went off both the estrogen and progesterone for a week to let side effect symptoms subside.  Meanwhile my friendly compounding pharmacist created a compounded version of prometrium without soy.  So after a week break to recover from soy symptoms, I resumed taking my 'safe' prometrium and estrogen patch.  During the next 4 weeks I experienced many of the listed side effects for estradiol patch and prometrium, including breast swelling and tenderness, weight gain, abdominal bloating and tenderness, significant white vaginal discharge with no odor, and pretty severe reflux.


I could tolerate the other side effects, but I would not tolerate severe reflux.  I do NOT have excess stomach acid.  I actually have to take betane hydrochloride capsules to digest proteins and fats.  I don't want to take acid blocker pills or even biocarbonates, because I need stomach acid to digest all the calcium I take for bone health. So I stopped the HRT for another month to recover from all those side effects.


During the first 2 weeks after I stopped taking the estrogen and progesterone, the other side effects subsided, but I increasingly felt faint when I stood up. So I wondered whether I had low blood pressure and started checking my blood pressure and pulse regularly at local drugstores.  Initially my blood pressure was 86/56.  So I continued to check that every other day and noticed my pulse and blood pressure slowly rose back to normal (for me) over the next 2 weeks. When I talked to my ND after discontinuing bio HRT, she suggested I cut my dose in half. When I reminded her that the progesterone was a capsule, not a tablet, she suggested I stop taking the progesterone.  However I had recently read that estrogen raises blood pressure and progesterone lowers blood pressure. I knew I needed both for balanced blood pressure.
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I waited a few more weeks to overcome all the side effects before I asked my compounding pharmacist to show me how to accurately split the contents of each prometrium capsule.  That was a time consuming procedure, but I learned shortcuts as I went along.  Then one month ago I resumed half dose of estradiol patch (1/2 patch or 0.025 mg/24 hr ptwk) and 1/2 dose of compounded prometrium (25 mg capsule daily).  During the past 4 weeks, I experienced some breast tenderness and swelling and slight vaginal discharge, which seem to be diminishing now.  Actually I welcomed the breast swelling, which gave cleavage without wearing a push-up bra.  I began my second month today and hope the side effects really do disappear after the first month, but neither side effect is bothersome. Nevertheless, I will reassess the benefits of bio HRT after I see my next DEXA scan results.

OSTEOPOROSIS TREATMENT

After fracturing my left femoral neck (hip bone) last June 2014, I had a DEXA scan in mid August which showed pretty significant osteoporosis. Just getting an order for the DEXA was challenging. The doc substituting for my PCP (who was on maternity leave) insisted that a hip fracture already says I have osteoporosis. He wanted me to take Fosomax (side effects: jaw necrosis, spontaneous fractures and gastrointestinal damage) ASAP.  I convinced him to order the DEXA and postpone Fosomax until I saw the results. 


The naturopathic doc, whom I'd seen regularly for 5 years, freaked when she saw my DEXA results. However, she prescribed a great nutritional supplement plan, biodentical hormones and lowering my T3 supplement. She also recommended I read "Your Bones" by Laura Pizzorno and Jonathon Wright MD, who heads the clinic where I first met my ND. 


I had taken calcium regularly when I was younger, before I had hypothyroid symptoms (esp. constipation).  Then after my celiac and dairy allergy diagnosis, I tried to get calcium fron nondairy sources.  Obviously many years of undiagnosed and misdiagnosed celiac disease prevented me from absorbing calcium and other bone strengthening nutrients. So, despite my doing regular weight bearing exercise and lifting weights for years, I have significant osteoporosis now.  I knew I was losing height (I'm 2 inches shorter than when I was in my 20s), but didn't realize the extent of bone loss before my DEXA.


So after my DEXA and visit to my ND I started taking the following supplements: 

AlgaeCal 5 caps daily for 1250 mg total calcium (Per cap 250mg Ca, 22 Mg, 333 D3);

Magnesium 3-3/4 caps daily (Per cap 300mg Mg, 200mg K) plus AlgaeCal Mg;

Strontium 2 caps daily (680 mg for 2 cap) 3-4 hours after calcium;

Vitamin D3 (1000 IU per tab) 1-1/2 tabs daily (plus Algae Cal which also contains D3);

Vitamin K2 (100 mcg per cap) 1 cap daily;

Vitamin B Complex (includes 80mg Niacinamide, 400mcg Folate, 600mg B12) 1 cap daily;

Vitamin B (balanced B 100) 1 cap daily;

Niacinamide (500mg per cap) 1-2 caps daily for thumb joint and elbow arthritis;

Vitamin C (500 mg per cap) 2 caps daily;

Vitamin E (400 IU) 1 cap daily;

Zinc (30 mg tab) 1 tab daily 

Custom Probiotics Adult CP-1 Formula (50 billion live cells per cap); 1 cap daily;
IAG (arabinogalactans) 1 tsp dissolved in 6 oz water daily (2 g arabinogalactans) for immunity;
Betaine Hydrochloride (650 mg per cap) 2-4 caps per meal w/ fats and protein for hypochloridia

I also do weight bearing exercise (walking, jumping and lifting weights, as well as pt exercises to strengthen my hips and back) daily.

I'm still taking all those supplements and doing well.  However, I had to battle my insurance company to get biodentical hormones.  I also had to find a doc who would give me an effective level of my thyroid supplement.  Neither too little or too much thyroid hormone is good for bone health.  However, I'll describe those battles in another post.

I suspect this post will make me  vulnerable to loads of comments, criticizm and suggestions by posting my osteoporosis treatent supplements. However, I'll try to respond to every comment, unless it's really an advertisement for drugs for osteoporosis, which I will immediately delete and/or block. Nevertheless I'll reply to questions about treatment and my experience with supplements.

 

Update: June thru November

I haven't posted for several months, because I've been busy with health issues. Before 2014 ends I wanted to describe what happened after my second toenail surgery:

By late May both of my big toes had bulky bandages. So I could only wear sandals with velcro straps around the ball of my foot and over the toes.  That didn't provide much support while walking. So I was unbalanced and slipped several times while walking on concrete sidewalks with rocks or sticks.  I only sustained a few scrapes and bruises from those falls until June 28, when I was walking downhill on a sidewalk with scattered landscaping rocks. I slipped on the rocks, slid downhill and fell on my left hip.  When I tried to stand I felt excruciating pain down my leg.  So my husband ran home to get the car and we drove to 'Urgent Care' where I received x-rays which weren't definitive.  So then we drove to a nearby hospital to get a cat scan, which showed a non-displaced fracture of the femoral neck (large leg bone which fits into the 'ball and socket' joint at the hip).  Based on that x-ray I was admitted to the hospital immediately, had nothing to eat until late the next day, and nothing to drink after midnight.

The next morning I had surgery to stabilize the femoral neck fracture with 3 pins and 3 screws.  In recovery my surgeon told me I could walk on that leg now.  Despite problems with medication (the anesthetic made me nauseas and Demerol for pain made me throw up my first post surgery meal), I finally got some IV Tylenol and did well after that. That afternoon I was given a walker and was walking well the next day.  I was released the next day with a walker, which I used for 2 weeks before getting a cane and leaving the walker for my cockatiel who liked to perch on it.  After a week on the cane I started physical therapy and abandoned the cane to walk unassisted.

 After 10 sessions of physical therapy I noticed that I had developed new muscles in my thighs and hips.  So I decided to try on my heavier clothes (fall/winter pants, jeans, skirts) to see what still fit. After a day of trying on pants, I was a little stiff. After the second day of standing in a small closet in a cramped position trying on clothes I could barely move without excruciating pain in my back. I could no longer do most of my pt exercises without pain. Around that time I was scheduled for another x-ray of my surgery site (left thigh) and visit with my surgeon.  He said my femoral neck fracture was healing well, but suggested I get an MRI and get more pt for my back.  I decided to wait until after the MRI before starting pt so the therapists wouldn't have to guess what my back problem involved.

The MRI showed that I had a bulging disc at L5/S1 in my lower back as well as several (old) vertebral fractures.  I had recently gotten a DEXA bone scan which showed significant osteoporosis in my back and right (nonfractured) thigh bone. So the vertebral fractures and osteoporosis were consistent with loss of height (about 1-1/2 inches) over a 30 year period.  So I went for more physcial therapy, which focused on strengthening my back this time.  After 12 pt sessions I'm doing well, but I continue at home physical therapy exercises daily to prevent more back problems. I still have occasional pain and stiffness, but I can easily walk 3-4 miles or about an hour without stopping and do almost everything I previously did,except lift heavy objects without pain. 

However, when my naturopath saw my DEXA scan results, she freaked out and wanted me to start a complicated program for bone health, which included talking many supplements, adding biodentical HRT and cutting my thyroid supplement dose drastically.  I'm doing most of that now, but I'll describe that process and problems in another post.

Toenail Treatment Finale Part 2

Yesterday I had my second total matrixectomy (removal of toenail and matrix 'envelope' at the base). After enduring the same procedure on my left big toenail one month ago, I had the same procedure done on my right big toenail. (For anyone who hasn't read my previous 'toenail treatment' posts: longterm untreated toenail fungus caused bone spurs on the ends of my big toes, which prevents normal nail grow out, even after I finally treated and eliminated the fungus. Rather than endure bone spur grinding and skin tuck in hopes of normal nail grow out, I opted to just remove the toenails, which had been problematic for about 35 years.) The second matrixectomy went as smoothly as the first. My doctor wisely distracts me by asking about my cockatiel.  However, he tried a new bandaging technique, after I told him how much the first toe surgery bled. He wrapped the first dressing with a small ace bandage hopefully to reduce swelling and bleeding. Unfortunately the second sugery site bled much more than the first. Oh well, the idea sounded good at the time.


For 48 hours after total matrixectomies I need to keep my foot elevated, which also reduces swelling and bleeding, but mostly reduces pain.  I can't take narcotic drugs (which make me vomit) or NSAIDs like Alleve which causes stomach pain and inflammation. So I rely on Tylenol for pain. However, I can't take more than 4-5 capsules daily without getting sick from overdose symptoms. My low weight and my nonuse of drugs make me vulnerable to overdose symptoms from painkillers.  Nevertheless, I can take a tylenol capsule about every 5 hours and endure the worst of my post surgery pain.  I suspect I also have a high pain tolerance level after enduring 30+ years of undiagnosed gut pain, which I later learned was celiac disease, food allergies and gut bug infections. I never took anything for celiac or allergy pain. I wanted to discern the cause, rather than mask the symptoms. So I also learned to keep myself distracted.  I can sense the pain, but I don't obsess about it as long as I know the cause and treatment.


Next week I return to my podiatrist for a dressing change and another dressing change (to just a bandaid) after another week. As I learned from my first total matrixectomy 4 weeks of healing removes most of the pain and allows the skin to grow over the surgery site.  On my left toe (first surgery), I just replace the dressing daily with a large cloth bandaid (after applying antibacterial ointment).  I can wear most of my sandals on that foot now.  However, in order to accomodate my swollen toe from my second surgery, I wear old sandals which allow for adjustment at the toe and ankle straps.


So for the next week I'll be sitting more often with my foot propped up and blogging more often, IF my cockatiel will stay away from my laptop.  Usually he wants to watch singing cockatiel videos and/or peck the keys (with disastrous results) anytime he sees me with my open laptop.  Fortunately he got bored with the video thing after an hour. Now he's on top of his cage foraging for sprays of oats which I hung around his cage to keep him entertained ... at least for a few minutes.

Dress Like Your Bird Day

4 days ago (before toenail surgery) we had very warm weather. So I wanted to take my cockatiel Kiwi for a walk outside in the sunshine.  I would never consider letting him outside without a flight prevention harness.  Fortunately we ordered from Avian Fashions a 'flight suit' (harness attached to a birdy diaper garment) even before we brought Kiwi to live with us. After less than a week of getting Kiwi accustomed to seeing the flight suit, he began playing with it (chewing on and dragging it around his play table).  So we thought he would be ready to wear the flight suit.  He resisted every attempt to put him into the suit.  At one point he even stopped playing with the suit. However some touch training and millet rewards got him more comfortable with the garment.  However, with my hand recovering from injuries from the cast for my fractured elbow, I needed an extra pair of hands to get Kiwi into the flight suit. With my husband's help we got Kiwi ready to see the world outside our house. in his flight suit.


Because the weather was so sunny, I dressed in yellow jeans, tee, sweater and a straw hat with an orange band.  I wore Kiwi's colors!  After we got him into his orange flight suit, we took him outside immediately so that he would associate the flight suit with a good experience.  After a little pruning (a blueberry bush) in the front yard with him attached to my shoulder with harness, we decided to walk around the block twice to let Kiwi see new things and hear new sounds.   


Although Kiwi ate lots of millet (his favorite seed treat) as reward for getting into the flight suit, we needed lunch. So we went home, had lunch and set out for another walk this time around Greenlake.  We had just walked to the business area (restaurants) near the lake, when someone wanted to take a picture of me in my sunny yellow outfit. I told her today was 'dress like your bird day'.  Then she saw Kiwi and wanted to take several pictures.  So after we returned home I asked my husband to take more pics on my camera.  You can barely see Kiwi's flight suit, because it closes in back and attaches to the lanierd leash in back, but you can see the orange leash (which attaches to his flight suit) around my neck.  That should really be called an 'antiflight suit', beause he tried to fly off me, but only got as far as my wrist.


He wore the flight suit for almost 3 hours. The inserted diaper (cotton wafer) absorbed guano very well.  I feared we'd need to wash the flight suit, but the diaper protected it well and slipped out easily.  I hope Kiwi asociates the flight suit with good experiences.  He was 'cruising' on my shoulder as I walked the lake. Most of the time he was cuddling next to my cheek.  Sometimes he closed his eyes, but I suspect the wind bothered his eyes.  Nevertheless he was glad to get out of the flight suit.  I just hope he will tolerate it the next time we have a sunny day (and my toe surgery has healed enough for me to walk).

Toenail Treatment Finale Part 1

After years of unsuccessful treatments for toenail fungus, including grinding, removing the toenails (which grew back with fungus), and soaking daily in Listerine, I finally successfully treated the fungus on my 2 big toenails with daily applications of oil of geranium mixed with DMSO.  A year of that treatment eliminated the fungus so that the toenails would regrow normally. Unfortunately during all the years when I had thick, fungus laden toenails, I developed bone spurs on the ends of my toes from pressure from toenails.  So the 'healthy' toenails could only grow into the fleshy, bone spurred ends of my toes and become 'ingrown'.


One podiatrist suggested I could either (1) keep trimming the nails as best I could or (2) have the toenail and matrix (envelope holding the nail) completely removed so that the nail would not grow back or (3) get the bone spur removed and flesh tucked to allow room for the nail to regrow naturally.  Option 3 sounded most promising for healthy looking nails.  However, that meant major inflammation and recovery after surgery.  Nevertheless, I planned to pursue that option with that doctor UNTIL I discovered he wasn't covered under my medicare plan.  I didn't want to pay for surgery outa pocket.  So I got a referral for a doc who was in network. 


The new doc saw the x-rays taken by the previous podiatrist, when I saw him 4 months later. However, he said the toenails were already looking ingrown and removing the bone spur may not cause normal regrowth.  The toenails had been damaged in the original accident and then later removed by an inept podiatrist who didn't remove the matrix, but only removed the toenail which grew back with fungus.  With that much injury and that much passage of time the new doc thought regrowing normal toenails was not possible.  He suggested option 2 (complete matricectomy), which would prevent toenail growout.  That would still require surgery, but not as complicated. 


So after enduring 2 more months of ingrown toenails (and daily application of analgesic ointment), yesterday I had a total matricectomy on my left big toenail.  The anesthetic prevented me from feeling anything beyond pressure.  However, I was advised to elevate my foot as often as possible for the next few days above my heart level to prevent swelling and more bleeding. Unfortunately I had to walk a long ways to my husband's car in the clinic lot. Then I had to walk up 2 flights of  stairs into our house.  By that time my toe was throbbing. So I took another tylenol (my 3rd for the day with my upper limit of 5 daily) and propped up my foot.  However, getting to sleep with my left foot propped up and my left arm propped on pillows and ice bags was almost impossible.  I finally gave up about 4am and read for another hour before rearranging the pillows and blankets and finally drifting off to sleep for a few hours before I had to get up and take care of my bird. Hopefully I can sleep better tonight.  At least I had my foot elevated for about 8 hours last night. 


The good news is that I may be able to walk around after a few more days. I will return to the clinic to have the dressing changed next week. The dressing look pretty bad now, but my sandle hides the worst blood stains.  The bad news is that I have to endure the same surgery on my other toe (right foot) next month.  Hopefully the first toe and my fractured elbow will have healed enough to make the second matricectomy process go more smoothly.