Hypothyroidism

Hypothyroidism is an underactive thyroid.

Hypothyroidism (overactive thyroid) is a condition in which the thyroid gland produces an abnormally low amount of thyroid hormone. Many disorders result in hypothyroidism, which may directly or indirectly involve the thyroid gland. Because thyroid hormone affects growth, development, and many cellular processes, inadequate thyroid hormone has widespread consequences for the body.

Subclinical hypothyroidism refers to a state in which people do not have symptoms of hypothyroidism and have a normal amount of thyroid hormone in their blood. The only abnormality is an increased thyroid-stimulating hormone (TSH) in the person’s blood work. This implies that the pituitary gland is working extra hard to maintain a normal circulating thyroid hormone level and that the thyroid gland requires extra stimulation by the pituitary to produce adequate hormones. Most people with subclinical hypothyroidism can expect the disease to progress to obvious hypothyroidism, in which symptoms and signs occur.

The thyroid gland uses iodine (mostly from foods in the diet like seafood, bread, and salt) to produce thyroid hormones.

Thyroid hormones are produced by the thyroid gland. This gland is located in the lower part of the neck, below Adam's apple. The gland wraps around the windpipe (trachea) and has a shape that is similar to a butterfly - formed by two wings (lobes) and attached by a middle part (isthmus).

The thyroid gland uses iodine (mostly from foods in the diet such as seafood, bread, and salt) to produce thyroid hormones. The two most important thyroid hormones are thyroxine (tetraiodothyronine or T4) and tri-iodothyronine (T3), which account for 99% and 1% of thyroid hormones present in the blood respectively. However, the hormone with the most biological activity is T3. Once released from the thyroid gland into the blood, a large amount of T4 is converted as needed into T3 - the active hormone that affects the metabolism of cells.

Depending upon whether the cause is in the pituitary, hypothalamus, or thyroid gland, hypothyroidism is broadly divided into two types:

1. Primary hypothyroidism: Occurs when the thyroid gland is producing lower amounts of thyroid hormones and may occur due to various reasons such as:
   • Hashimoto's disease (most common)
   • Radioiodine therapy
   • Surgical removal of the thyroid gland
   • Radiation therapy
   • Dietary iodine deficiency
   • Congenital thyroid dysplasia
2. Secondary hypothyroidism: Occurs due to conditions affecting the hypothalamus or pituitary gland. Hypothyroidism due to conditions of the hypothalamus is also called tertiary hypothyroidism.

Hypothyroidism is a very common condition. Approximately 3% to 4% of the U.S. population has some form of hypothyroidism. This type of thyroid disorder is more common in women than in men, and its incidence increases with age. Examples of common causes of hypothyroidism in adults include Hashimoto's thyroiditis, an autoimmune form of overactive thyroid, lymphocytic thyroiditis, which may occur after hyperthyroidism (underactive thyroid), thyroid destruction from radioactive iodine or surgery, pituitary or hypothalamic disease, medications, and severe iodine deficiency.

Hashimoto's thyroiditis

The most common cause of hypothyroidism in the United States is an inherited condition called Hashimoto's thyroiditis. This condition is named after Dr. Hakaru Hashimoto who first described it in 1912. In this condition, the thyroid gland is usually enlarged (goiter) and has a decreased ability to make thyroid hormones. Hashimoto's is an autoimmune disease in which the body's immune system inappropriately attacks the thyroid tissue. In part, this condition is believed to have a genetic basis. This means the tendency toward developing Hashimoto's thyroiditis can run in families. Hashimoto's is 5 to 10 times more common in women than in men.

Severe iodine deficiency

In areas of the world where there is an iodine deficiency in the diet, severe hypothyroidism occurs in about 5% to 15% of the population. Examples of these areas include Zaire, Ecuador, India, and Chile. Severe iodine deficiency occurs in remote mountain areas such as the Andes and the Himalayas. Since the addition of iodine to table salt and bread, iodine deficiency is rare in the United States.

Lymphocytic thyroiditis following hyperthyroidism

Thyroiditis refers to inflammation of the thyroid gland. Lymphocytic thyroiditis is a condition in which the inflammation is caused by a particular type of white blood cell known as a lymphocyte. Lymphocytic thyroiditis is particularly common after pregnancy and can affect up to 8% of women after they deliver their baby. In this type of thyroid disorder there usually is a hyperthyroid phase (in which excessive amounts of thyroid hormone leak out of the inflamed gland), which is followed by a hypothyroid phase that can last for up to six months. In the majority of women with lymphocytic thyroiditis, the thyroid eventually returns to its normal function, but there is a possibility that the thyroid will remain underactive.

Thyroid destruction secondary to radioactive iodine or surgery

People who have been treated for hyperthyroidism (underactive thyroid) like Graves' disease, and received radioactive iodine may be left with little or no functioning thyroid tissue after treatment. The likelihood of this depends on several factors including the dose of iodine given, along with the size and the activity of the thyroid gland. If there is no significant activity of the thyroid gland six months after the radioactive iodine treatment it usually means that the thyroid gland is no longer functioning adequately. The result is hypothyroidism. Similarly, removal of the thyroid gland during surgery causes hypothyroidism.

Pituitary gland or hypothalamic disease

If for some reason the pituitary gland or the hypothalamus is unable to signal the thyroid and instruct it to produce thyroid hormones, it may cause decreased T4 and T3 blood levels, even if the thyroid gland itself is normal. If pituitary disease causes this defect, the condition is called "secondary hypothyroidism." If the defect is due to hypothalamic disease, it is called "tertiary hypothyroidism."

Pituitary gland injury

A pituitary injury may result after brain surgery or the blood supply to the brain has decreased. When the pituitary gland is injured, hypothyroidism results in low thyroid-stimulating hormone (TSH) blood levels because the thyroid gland is no longer stimulated by the pituitary TSH. Usually, hypothyroidism from pituitary gland injury occurs together with other hormone deficiencies, since the pituitary regulates other processes such as growth, reproduction, and adrenal function.

Pituitary gland injury from medications

Medications used to treat an overactive thyroid (hyperthyroidism) may cause hypothyroidism. These drugs include methimazole (Tapazole) and propylthiouracil (PTU). The psychiatric medication, lithium (Eskalith, Lithobid), is also known to alter thyroid function and cause hypothyroidism. Drugs containing a large amount of iodine such as amiodarone (Cordarone), potassium iodide (SSKI, Pima), and Lugol's solution can cause changes in thyroid function, which may result in low blood levels of thyroid hormone.

Anyone can develop hypothyroidism, but the risk is high in those:

• Who are female.
• Aged above 60 years.
• With a positive family history of thyroid disease.
• Having other autoimmune diseases such as type 1 diabetes or celiac disease.
• With a treatment history of radioactive iodine or anti-thyroid medications.
• With a history of radiation therapy to the head, neck, or upper chest.
• With a previous thyroid surgery (partial thyroidectomy).
• Who are pregnant or recently delivered a baby.

Does menopause put you at risk of hypothyroidism?

Women are more likely to get hypothyroidism after menopause than earlier in life. Hypothyroidism is a common condition affecting around 4.6% of the US population aged 12 years and older. It is particularly common in women aged above 60 years. Hypothyroidism, however, can affect people of all genders, ages, and ethnic backgrounds.

The symptoms of hypothyroidism are often subtle. They are not specific (which means they can mimic the symptoms of many other conditions) and are often attributed to aging. People with mild hypothyroidism may have no signs or symptoms. The symptoms generally become more obvious as the condition worsens and the majority of these complaints are related to a metabolic slowing of the body.

Common symptoms and signs of hypothyroidism include:

• Fatigue
• Depression
• Modest weight gain
• Cold intolerance
• Excessive sleepiness
• Dry, coarse hair
• Hair loss
• Menstrual disturbances
• Mood changes
• Decreased perspiration
• Constipation
• Dry skin
• Muscle cramps
• Increased cholesterol levels
• Decreased concentration
• Vague aches and pains
• Leg swelling

As hypothyroidism becomes more severe, signs and symptoms may include puffiness around the eyes, a heart rate slowing, body temperature dropping, and heart failure.

• Severe hypothyroidism may lead to a life-threatening coma (myxedema coma).
• In a person with severe hypothyroidism, a myxedema coma tends to be triggered by severe illness, surgery, stress, or traumatic injury.
• Myxedema coma requires hospitalization and immediate treatment with thyroid hormones given by injection.

If you have signs or symptoms the same or similar to hypothyroidism (for example, weight gain, constipation, or fatigue) discuss them with your doctor or other healthcare professional. A simple blood test is the first step in the diagnosis. If you need treatment for hypothyroidism, let your doctor know of any concerns or questions you have about the available treatment, including home or natural remedies.

People with symptoms of fatigue, cold intolerance, constipation, and dry, flaky skin may have hypothyroidism. A blood test can confirm the diagnosis.

• "Secondary" or "tertiary" hypothyroidism occurs when the decrease in thyroid hormone is due to a defect of the pituitary gland or hypothalamus.
• A special test, known as the TRH test, can help distinguish if the disease is caused by a defect in the pituitary or the hypothalamus.
• This test requires an injection of the TRH hormone and is performed by a doctor who treats thyroid conditions (endocrinologist or hormone specialist).

Blood work confirms the diagnosis of hypothyroidism but does not identify the cause. A combination of the patient's clinical history, antibody screening, and a thyroid scan can help diagnose the underlying thyroid problem more clearly.

An MRI of the brain and other tests may be ordered if the cause is thought to be from the pituitary gland or hypothalamic problems.

Hypothyroidism can be easily treated with thyroid hormone replacement. The preferred treatment for most people with an underactive thyroid is levothyroxine sodium (Levoxyl, Synthroid). This is a more stable form of thyroid hormone and requires once-a-day dosing. Liothyronine sodium (Cytomel) also may be prescribed to treat hypothyroidism under certain conditions.

Except for certain conditions, the treatment of hypothyroidism requires life-long therapy. However, overtreating hypothyroidism with excessive thyroid medication is potentially harmful and can cause problems with heart palpitations and blood pressure control, and contribute to osteoporosis.

There is no special diet required for people with hypothyroidism. In the U.S., routine supplementation of salt, flour, and other foods with iodine has decreased the rates of hypothyroidism caused by an iodine deficiency.

Can you lose weight if you have hypothyroidism?

Yes, weight loss is possible even with a thyroid disease, but it does take the right approach. This approach includes the evaluation of your hormones, including those beyond your thyroid, and consistently making the right diet choices. By evaluating, diagnosing, and treating any imbalances, you will be able to lose weight and keep it off.

Untreated hypothyroidism can cause complications, for example, an enlarged heart (cardiomyopathy), worsening congestive heart failure, and an accumulation of fluid around the lungs (pleural effusion).

If hypothyroidism is not treated, it can lead to various complications, such as:

• Goiter: The lack of thyroid hormone causes constant stimulation of the thyroid gland that eventually leads to its enlargement. This is called a goiter. Goiter can cause cosmetic concerns and affect breathing and swallowing.
• Cardiac (heart) problems: Hypothyroidism increases the risk of heart disease, and causes irregular heart rate and heart failure. Hypothyroidism increases the levels of low-density lipoprotein (LDL) cholesterol, known as the "bad" cholesterol, leading to cardiovascular complications.
• Mental health issues: Depression, slow mental function, lethargy, and poor memory can occur and may worsen over time.
• Peripheral neuropathy: Long-term untreated hypothyroidism can damage peripheral nerves (in the arms and legs) causing pain, numbness, and tingling in the affected areas.
• Myxedema: This is a rare, life-threatening complication of long-term, untreated hypothyroidism. Its signs and symptoms include swelling of the face and facial parts like lips, eyelids, and tongue, as well as swelling and thickening of the skin and underlying tissues. Patients also have intense cold intolerance and drowsiness followed by profound lethargy and unconsciousness.
• Infertility: Low levels of thyroid hormone can interfere with ovulation presenting with irregular periods.
• Birth defects: Babies born to women with untreated thyroid disease may have a higher risk of being born with birth defects. The children also have a risk of serious developmental problems. Hypothyroidism in the mother may lead to mental retardation in the child.
• Infants: Infants with untreated hypothyroidism present at birth are at risk of serious problems regarding physical and mental development.
• Pregnant women: Untreated hypothyroidism during pregnancy increases the risk of miscarriage, premature delivery, and preeclampsia (high blood pressure in the last trimester).

Women with untreated or under-treated hypothyroidism may find it difficult to conceive. Hypothyroidism may retard or prevent the release of the egg from the ovary. Ovulation is the process occurring in menstruating women in which the ovary releases an egg each month. In women with hypothyroidism, however, the process of ovulation may occur less frequently or not at all. Hypothyroidism may cause longer or heavier periods leading to anemia. The periods may also stop completely.

If fertilization occurs, hypothyroidism can interfere with the development of the fertilized egg or embryo. It can further increase the risk of miscarriage. In pregnant women with untreated hypothyroidism, the baby may be born prematurely (delivery before the 37 weeks of pregnancy). The baby may have other complications such as low birth weight or a lowered mental capacity.

If you have hypothyroidism and are planning to get pregnant, consult your doctor to get your thyroid hormones checked and receive appropriate treatment for the condition.