Sunday, October 7, 2012

On Hypothyroidism

This is the location of the thyroid gland.

  The general public, and many physicians think of hypothyroidism as a disorder simply characterized by weight gain. Although this is often a long term feature of the disorder, this is not necessarily so. In the interest of detecting and seeking proper diagnosis of this very common disorder, I have decided to post about this today. Some patients have an enlarged thyroid gland in their necks, known as a goiter, but many do not, or did not notice they had. (A goiter can occur when there is inadequate thyroid production, or sometimes when there is excessive thyroid hormone production, and rarely in the euthroid, or normal thyroid state) Some patients develop an enlarged thyroid with inadequate thyroid hormone production as the result of inadequate iodine in their salt, or in their water or soil in their region, which impacts the foods they eat. Fish can also be a good source of dietary iodine. Some hypothyroidism can be positively impacted by iodine supplementation, but not all. For some it is too late, and for others, this was not the cause of their thyroid dysfunction in the first place.
              There are a couple of basic types of Hypothyroidismm which can be best described as low thyroid hormone output. Often, this disorder afflicts women, but this also is not always the case. I have known male physicians who also developed it.  One variety of the disorder is a temporary condition where someone, perhaps just following childbirth or an illness, has a low thyroid output for a time.  In this instance, they receive thyroid supplementation of a type of thyroid hormone for a temporary period until thyroid gland recovery occurs.  Sometimes, a patient has had their thyroid removed when it became diseased,  ir when its output became excessive, and the end result becomes hypothyroidism. Since the removal is permanent, additional supplementation of hormone would be also.  Another type which should receive lifelong thyroid hormone supplementation is Hashimoto's thyroiditis.   Hashimoto's thyroiditis was thought to be rare within my own lifetime, but with the advent of very quick and effective radioimmunoassay testing, endocrinologists have discovered that the disorder is far more common than was realized.  In Hashimoto's thyroiditis, an autoimmune thyroid disorder, patients make antibodies against their own thyroid gland as if it were a  foreign organ. These attacks on the thyroid are episodic. The disorder can start in many with too much thyroid output alternating with too little. The patient may enjoy months of anxious productivity followed with a few months of a letdown and difficulty completing tasks and thinking clearly.  Some patients wonder if they have a lesser child of bipolar disorder, and this is one reason that psychiatrists diagnose a fair amount of hypothyroidism and send these patients off to endocrinologists for treatment. Often those with hypothyroidism report symptoms which are consistent with Depression.
              When thyroid hormone input is too low, the speed at which all body functions occur is decreased. What most people notice, if their diet remains stable throughout thyroid failure, is a slow and steady weight gain, as metabolism slows, but as I mentioned earlier, this does not always occur. Some patients, in the midst of hypothyroidism experience a decreased appetite and gradually adjust their food intake downward. The result is a stable weight, and a physician who might not make the diagnosis if this is all he is seeking, or if he erroneously thinks this symptom alone must be present, in all cases. The effects of hypothyroidism are much more insidious, and potentially very damaging in the long term.  Remember that in longer term hypothyroidism, that the speed at which every body function occurs is decreased.  Over time, the patient's colon does not absorb nutrients at the speed at which it should. Peristalsis of food occurs too slowly. Most patients complain of constipation which often resists conventional treatment. A few experience diarrhea, because their colon can't heal itself and becomes irritated. Some complain of alternating constipation and diarrhea or an irritable bowel.  Women usually find that their menstrual periods become farther apart and longer and heavier.  A woman who menstruated every 28 days for five days, may find she has a period every forty days for seven days, and that it's heavier. Sometimes, there is decreased libido.  Some women have difficulty becoming pregnant as a result of hypothyroidism.  Others conceive easily but miscarry on a regular basis because pregnancy quickly requires the thyroid to double its total hormone output.  A thyroid gland which fails during pregnancy can cause an early or a late miscarriage. This is one of the reasons for a pre-pregnancy check up.  Because iron may not be absorbed with a sluggish colon, and excessive loss occurs through menstruation, anemia may occur in hypothyroidism. This can be worsened as in longer term hypothyroidism, patients will not make adequate numbers of red blood cells, leading to a critical anemia.
Most patients notice dry skin, and a decrease in either the amount of hair they have, or they notice that their hair may not grow as quickly as it once did.  Since the liver is also not getting adequate thyroid, and the liver determines blood cholesterol level, a hypothyroid patient may present with a high cholesterol level when he/she never has before.  A few patients, because their pancreas and beta cells are not receiving thyroid hormone in adequate amounts may exhibit either hypoglycemia, low blood sugar, or sometimes a higher than normal fasting blood sugar.   People with hypothyroidism often experience frequent infections. They are no longer making enough white blood cells on the bone  marrow level and so, they tend to catch everything which comes down the pike and take longer to reach resolution of infections. Many times, they experience chronic sinusitis. Since the kidneys are not being told how fast to function, the patient may tend to retain fluid. Hands, feet, faces, and legs, and even our brains may carry more fluid than is optimal or desirable.  Hypothyroidism does not simply impact our metabolism and weight gain and prevention of weight loss. It adversely impacts every body system.    Almost all patients who have had hypothyroidism describe a "brain fog" or mental sluggishness or slowing.  Some complain they have difficulty with math calculations when they never did.  Others find they cannot pull the right word for something, even though it may be prominent in their work lexicon. Others are emotionally overwhelmed.  Some, as they are retaining fluid in their hands, and possibly their brains as well, complain of migraine headaches. Hypothyroid patients may also have hypertension, and a few have a bradycardic or very low heart rate, as a symptom of low metabolism. Most complain of feeling cold rather easily, but then, they don't seem to tolerate heat all that well either.
               The long term effects of hypothyrodism can be damage to the heart and cardiovascular system, or even cancer, the result of a hamstrung immune system.

If you notice an enlargement of your thyroid gland, you must see a physician.

               One would think a disorder with so many wide ranging symptoms would be detected by physicians very quickly, especially since their are symptoms which present themselves in every organ system. This is not always the case.  Many times, family practitioners or obstetrician gynecologists attribute a few of these symptoms to anything from "early menopause" to "anxiety" or even "psychoneurosis".  Sometimes the patient himself or herself really knows this is a problem, but the physician has obtained only one lab, and feels that the TSH is within normal limits, and does not refer to an endocrinologist to perhaps look a bit harder or follow the patient for another few months when labs might clearly indicate thyroid issues.
             We know that thyroid disorders tend to run in families. We know also that some patients with Hashimoto's, an autoimmune disorder, do go on to develop other autoimmune disorders in later life, such as Crohn's Disease, Ulcerative Colitis, Type I autoimmune diabetes, Lupus (SLE), Rheumatoid Arthritis, etc.  We could do a much better job of putting off these additional disorders if we did not pat patients on the head and tell them they are fine. Long term undiagnosed hypothyroidism can and sometimes will eventually lead to something called Myxedema Madness, where the patient develops a full blown madness with paranoia, as the disorder has impacted brain function. These patients eventually lapse into coma and die in Myxedema, the most severe form of hypothyrodism.  I often wonder how many people, particularly elderly women who die in Nursing Homes, the supposed victims of an Alzheimer's-like dementia, when a full and more careful assessment would yield the treatable condition of severe hypothyroidism, "Myxedema Madness", myxedema, or Hashimoto's encephalopathy. This diagnosis is too frequently missed or not fully considered in patients of all ages.
              If you have a thyroid disorder your management is likely best if you are followed by a board certified endocrinologist.  They tend to replace the amount of missing thyroid hormone more readily than a family practice physician who may be more uncomfortable replacing hormone at higher rates. This is a highly complex disorder and will best be managed by someone for whom this is a consuming interest and passion. They may also be more alert to subtle changes as they relate to hypothyroidism.  This is a life long disorder and will require periodic blood testing and prescription thyroid medication for a lifetime.  One followed for this disorder, most patients do very well.   Singer/Songwriter Linda Ronstadt was eventually diagnosed with Hashimoto's thyroiditis and is now treated.
             If this is a concern for you, ask for the labs necessary to rule this out.  They are a T3, a T4, a TSH and an antithyroid antibody test.   Get copies of these results and if you are not satisfied with your physician's answers as to whether you have a thyroid disorder or not, take them to a board certified endocrinologist. They will sometimes pick up cases which might take much longer by a family practce physician.
            Lately, patients early in the course of the Hashimoto's continuum have found that going on a gluten free diet has improved their symptoms.  This may be an interesting avenue for study in future.



Linda said...

I have hypothyroidism from having half my thyroid removed. It is a trial. However, I do take 75 mg levothyroxin. I was going to go to an endocrinologist that specialized in thyroid diseases. But, there are only two in the state and both are difficult to deal with. I apprecial this post.

JaneofVirginia said...

Linda, Yes, there are too few endocrinologists in many states, leaving many patients waiting months for a proper initial consultation. In order to become board certified, physicians must complete four years of medical school, a year of internship, a three year internal medicine residency and then a two year fellowship in endocrinology. It's a complex and heady specialty, but following completion of fellowship, many of them go to upscale urban centers to practice and not to America's heartland. I tried to convince one to stay locally following completion of fellowship, just this week, but I think she already has plans. Sometimes, a Nurse Practitioner with specialized training in internal medicine and a particular interest in endocrinology can help to bridge the gap between stop gap care, and state-of-the-art care. Many patients require different doses of thyroid replacement in winter than they do in the summer months, yet this adjustment is made for only a very few patients. Thanks for your post.

Mystic Mud said...

I'm new to hypothyroidism, having only found the problem and started treatment in the last year. I'd heard of thyroid problems before, but never knew anything about them. I wish I did, because I spent years not feeling well thinking I was just getting old when it actually turned out to be my thyroid issue. Once on meds I felt 20-something again, but in trying to find the right balance my dose is now too high and I'm back to feeling bad - almost worse than when I was untreated, if you can imagine. It seems to be a long process to get it all figured out, but I'm hopeful that once my dose is right again I will feel great again. Thanks for a post that brings more light to thyroid issues - hopefully it will help a few people from suffering for very long.

JaneofVirginia said...

Mystic, I am sorry you are feeling poorly. Yes, having too much thyroid hormone can absolutely feel worse than too little, many times ! Perhaps you can call the ordering physician and get a dosage adjustment between physician visits. It really is my hope that through reading this post, more people mention concern for their thyroid and are tested, sparing them the more uncomfortable and more dangerous ends of the untreated spectrum. Thanks for posting. Please feel better soon.

Kathy Felsted Usher said...

Hi, I'm your newest follower. I have thyroid issues and they have me on 137 mg levoxyl which seems high to me since I know people without thyroid glands at all taking less. I just don't think everything is normal but without it, I was foggy. I need to seek out an endocrinologist.

JaneofVirginia said...

Welcome Kathy !
Regarding your dose, there is great variation in the amount required for supplementation person to person. Some patients have a complete thyroid failure and others are simply left in a deficit situation, the result of being unable to produce optimal amounts. Physicians use a formula by weight in order to gauge the eventual dose, but often the patient over time winds up on a higher or lower one. Some patients also absorb thyroid hormones through their gastrointestinal tract more readily than others. Food eaten at the same time can impede some absorption and so will calcium supplements and iron supplements. Most physicians urge patients to take their Levothyroxine supplement in the morning, however a few endocrinologists are having some patients take it at bedtime when the slower peristalsis and emptier stomach may improve gastrointestinal absorption. Welcome and best wishes !