Hypothyroidism Food List

The Hypothyroidism Revolution

During Phase 1 of the Hypothyroidism Revolution Program, the magic begins to happen as you begin to notice many positive changes occurring. You will begin your progressive transition towards the ideal thyroid healing diet that will give your thyroid the big boost that it needs to help your cells produce more than enough energy for you. By the end of Phase 1, your energy levels will be rapidly on the rise and you will feel amazingly satisfied with zero food cravings. You will feel in control again as your mood drastically improves and any sign of depression and anxiety begin to disappear. Your family and friends are going to notice some major positive changes in you. You will also begin to experience many of the outer changes that come with improved thyroid function. Youre skin will begin to clear up and glow while your hair and nails will begin to look healthy again. As you ease into the thyroid healing diet, you will progressively remove the foods that suppress your thyroid, disrupt your hormone pathways, cause digestive upset and irritation, and cause toxic byproducts that congest your liver. At the same time, you will be progressively adding the foods that will be supplying your cells with the right balance and combination of nutrients that they need to thrive and produce endless amounts of energy. More here...

The Hypothyroidism Revolution Summary


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Diagnosing Thyroid Disease

A normal and healthy amount of thyroid hormone is known as euthyroidism. If the thyroid hormone levels are insufficient to be euthyroid, we call this hypothyroidism (described in Chapter 3). If the thyroid hormone levels are too high, the condition is termed thyrotoxicosis (described in Chapter 4). Sometimes thyrotoxicosis is present because the thyroid is overactive, making too much thyroid hormone, a situation known as hyperthyroidism. However, thyrotoxicosis can also be present without hyper-thyroidism, such as when someone takes too high a dose of thyroid hormone tablets. In this case the thyroid itself is not overactive (thus not hyperthyroid) however, the levels of thyroid hormone in the blood are too high. Often, when I'm (Ken) lecturing to large audiences of physicians, usually late in the evening, I ask, Who is tired Who is a bit overweight Who suffers from constipation Who has dry skin Each question results in a large number of raised hands. Then I ask, Is anyone here...

Congenital and Neonatal Hypothyroidism

Roughly one out of four thousand babies is born with either neonatal or congenital hypothyroidism. With congenital hypothyroidism, the baby is born without a thyroid gland. In neonatal hypothyroidism, the baby is born with what appears to be a normal thyroid gland, but then develops symptoms of hypothyroidism after its first twenty-eight days of life. While the condition was present at birth, the symptoms may not manifest until later. Neonatal hypothyroidism is treated no differently from congenital hypothyroidism. Neonatal and congenital hypothyroidism are very serious conditions, which can lead to severe brain damage and developmental impairment. Either condition can occur from an iodine deficiency in the mother's diet. This is common in remote or mountainous areas of the world where iodine is not readily available. In fact, iodine defi ciency is the most common cause of mental retardation in underdeveloped countries. Fortunately, this is not a problem in North America, where our...

Subclinical Hypothyroidism

Now also known as mild hypothyroidism, subclinical hypothyroidism refers to hypothy-roidism that has not progressed very far, meaning that you have few or no symptoms. As you might guess, the most common cause of this is Hashimoto's thyroiditis. On a blood test, your free T4 (free thyroxine) readings would be normal or very close to normal, but your thyroid stimulating hormone (TSH) readings would be higher than normal. Right now, there is much discussion in clinical circles about doing routine TSH testing in certain groups of people for subclinical hypothyroidism. This would include anyone with a family history of thyroid disease, women over forty, women after childbirth, and anyone over age sixty. Because the TSH test is simple and can be added to any blood laboratory package, it presents an opportunity to catch hypothyroidism before serious symptoms develop, and hence prevent it and all the symptoms discussed in this chapter. The following groups of people should be screened for...

Secondary Hypothyroidism Pituitary Problems

Sometimes hypothyroidism occurs because of a pituitary gland disorder that may interfere with the production of thyroid stimulating hormone (TSH). This is fairly unusual, however. Tumors or cysts on the pituitary gland can also interfere with production of hormones from the gonads and the adrenal glands. A common type of pituitary tumor is one that makes large quantities of a hormone called prolactin, known as a prolactinoma. These can occur in both men and women, often causing milk to come from the breasts or interfering with fertility. In most cases, prolactinomas are treated with medication to shrink them rather than surgery or radiation therapy. This may result in restoration of normal pituitary function, fixing the hypothyroidism. Often, tumors can recur, requiring external beam radiation therapy to prevent further enlargement. Rarely, some pituitary tumors make a hormone known as ACTH, causing Cushing's disease in which high levels of steroids (cortisol) are made. This dangerous...

Tertiary Hypothyroidism Hypothalamus Problems

There are rare problems with the portion of the brain that is just above the pituitary, attached to the pituitary by a stalk. The most frequent is called a craniopharyngioma. This is a collection of skin cells that were left behind during fetal development and became stuck in this part of the brain. Although not cancerous, these skin cells start to grow and form cysts, which push upon the sensitive brain tissue of the hypothalamus. This portion of the brain transmits hormones down its stalk into the pituitary gland, responsible for stimulating the pituitary gland to release its own hormones. In the case of the thyroid system, this means that TRH (TSH-releasing hormone) is not sent to the pituitary gland. Consequently, the pituitary fails to make sufficient TSH to stimulate the thyroid gland, causing the thyroid to go to sleep and hypothyroidism to develop. A similar problem can happen if there is trauma (such as from an auto accident) to that portion of the brain or if a malignant...

Diagnosing Hypothyroidism

The most important clue in diagnosing hypothyroidism is looking at possible symptoms and screening people who are vulnerable to subclinical hypothyroidism. Typically, people who have four or more of the symptoms of hypothyroidism outlined earlier should be screened. On the other hand, hypothyroidism is common enough so that TSH tests performed during a regular yearly checkup may detect hypothyroidism way before there are any discernible symptoms. The next task in diagnosing hypothyroidism is to evaluate results of a TSH test properly. Abnormally high levels of TSH are a sign of hypothyroidism, while abnormally low levels of TSH are a sign of too much thyroid hormone, or thyrotoxicosis. It is important to note that the laboratory tests for people with symptoms of hypothyroidism should consist of both a free T4 level and a TSH level (see Chapter 2). This is because some people have trouble with their pituitary gland or brain that interferes with proper TSH production. In such...

Treating Hypothyroidism

Treating hypothyroidism involves taking thyroid hormone, which either replaces the thyroid hormone you're no longer making or supplements thyroid hormone to compensate for the inadequate amount your thyroid is making. What isn't so simple is finding the right dosage and restoring your thyroid levels to normal, determined by the TSH test discussed in the previous chapter. In fact, finding normal for each individual can be so tricky, it has led to a hypothy-roid patients' movement, demanding more attention be paid to adequate balancing and less rigidity in labeling certain TSH levels normal when there is a wide range. As discussed in the previous chapter in the TSH section, the normal euthyroid range used to be indicated as 0.5 to 5.0 for TSH results. However, since these were based on men instead of women (who make up the majority of hypothyroid patients), and some of the men were likely subclinically hypothyroid (appearing healthy with no reported symptoms of hypothyroidism), the...

Other Forms of Thyroiditis

This section explains other kinds of thyroid inflammation in more detail and discusses the three common forms and two uncommon forms thyroiditis can take. Sometimes inflammation can be caused by the autoimmune process, as described earlier in this chapter for Hashimoto's thyroiditis. In rare cases, bacterial infections (abscesses infectious or suppurative thyroiditis) may cause a severely painful and swollen thyroid gland, along with fever and increases in the white blood count. These situations require hospitalization and intravenous antibiotic therapy. In other rare cases, painful inflammation of the thyroid gland may be associated with inflammatory nodules (granulomas) in the gland, possibly because of viral infection and known as subacute thyroiditis.

Postpartum Thyroiditis

Women with TPO antibodies are more likely to experience postpartum thyroiditis. This is a general label referring to silent thyroiditis occurring after delivery, causing mild hyperthyroidism, and a short-lived Hashimoto's type of thyroiditis, causing mild hypothyroidism. Until quite recently, the mild hypothyroid and mild thyrotoxicosis symptoms were simply attributed to the symptoms of postpartum depression, those notorious postpartum blues, thought to be caused by the dramatic hormonal and emotional changes women experience after pregnancy. But recent studies indicate that as many as 20 percent of all pregnant women experience transient thyroid problems and subsequent mild forms of thyrotoxicosis or hypothyroidism. See Chapter 13 for more information on postpartum thyroiditis.

Acute Suppurative Thyroiditis

Also known as simply bacterial thyroiditis, acute suppurative thyroiditis is a very rare condition. The term suppurative refers to the presence of bacteria and pus. Here, the thyroid gland suffers a dramatic pus-forming bacterial infection similar to the ones that cause abscesses. The thyroid gland becomes painful and inflamed, and a high fever and chills accompany the infection. Sometimes there is an abscess within the gland containing pus. Usually, the tenderness to the thyroid gland is obvious, so it's difficult to miss the symptoms. Sometimes, a fine needle biopsy can provide abscess material to examine for bacteria. Antibiotics, incision, and drainage are the treatment, with a beneficial response to this treatment confirming the diagnosis.

Antithyroid Drugs Thionamides

Antithyroid drugs, a class of drugs known as thionamides, block the formation of thyroid hormone by thyroid cells. If hyperthyroidism is caused by single or multiple autonomous toxic nodules (ATNs, see Chapter 8), antithyroid drugs can be used to temporarily lower thyroid hormone levels but are not useful for long-term management since ATNs don't spontaneously get better over time. On the other hand, they're often used to treat hyperthyroidism in Graves' disease, since roughly one-quarter of people with Graves' disease will see a permanent end to Graves' thyrotoxicosis after a year of treatment with thionamides (known as a remission or resolution). Although some people take thionamides for many years, I (Ken) don't advise taking them longer than one year because of potential toxicity (explained later) and because these spontaneous remissions of Graves' disease are much less likely to occur if they do not happen within the first year of thionamide treatment.

Prevention of Hypothyroidism Because of Iodine Deficiency

Iodine deficiency, as discussed in Chapter 3, is the leading cause of hypothyroidism in the world. The daily amount of iodine that is appropriate for proper thyroid function is around 150 micrograms daily. This is the amount contained in most vitamins. Much of the population in the developing world has much lower levels of iodine in their diet. Supplementation, via iodized salt or through iodine added to the water supply, has proven effective in alleviating iodine deficiencies in specific regions. Unfortunately, a small number of older people in these regions have autonomous nodular thyroid glands (see Chapter 8). Iodine supplementation in these people permits them to show symptoms of thyrotoxicosis that were unable to develop in the absence of sufficient iodine.

Thyroid Disease in Pregnancy and After Delivery

This chapter discusses issues for distinct groups of women pregnant women with unrecognized or subclinical thyroid disease, pregnant women with preexisting thyroid disease, women who only first discover (or develop) a thyroid problem during pregnancy, and women who only first discover (or develop) a thyroid problem within the first six months of delivery. In the latter situation, this frequently takes the form of postpartum thyroiditis, classically misdiagnosed as postpartum depression. Autoimmune thyroid diseases, such as Hashimoto's disease (see Chapter 5) or Graves' disease (see Chapter 6), frequently strike during the first trimester of a pregnancy or within the first six months after delivery. That said, you should note that preexisting autoimmune thyroid disease as well as other autoimmune diseases tend to improve during a pregnancy but can worsen after delivery. Although the reasons for this are not known, these changes parallel the changes in estrogen levels in the pregnant...

Being Pregnant with Preexisting Thyroid Disease

If you are hypothyroid or are taking thyroid hormone for a thyroid condition diagnosed prior to this pregnancy, it's important to have your thyroid levels assessed monthly with a target TSH of between 0.5 and 3.0 (see Chapter 2) so that your dosages of thyroid hormone can be appropriately adjusted, which is necessary for the growing fetus. Tbtal T4 (or TT4) assessments are useless, since T4 naturally rises because of increased thyroxine binding globulin (see earlier in this chapter). Although very little thyroid hormone will cross over from you to the fetus, the little that does is very important, since normal thyroid hormone levels in you are critical for proper fetal development until the fetus develops its own thyroid gland. Sometimes a change in dosage is needed because requirements for thyroid hormone can increase during pregnancy. It's normal to require as much as a 30 to 50 percent increase in your dosage. In this case, doctors should generally monitor the TSH level monthly and...

Gestational Hypothyroidism

If hypothyroidism is suspected while you're pregnant, your doctor will give you a TSH test. Just as in nonpregnant women, your TSH levels will be increased if you're hypothyroid, and you'll be treated with thyroid hormone replacement. As discussed earlier, sometimes pregnancy itself can mask hypothyroid symptoms. For example, constipation, puffiness, and fatigue are all traits of pregnancy as well. These symptoms will likely persist after delivery if your hypothyroidism remains untreated, and they can seriously interfere with pregnancy and your postpartum health. Gestational hypertension, preeclampsia, and eclampsia are more common in women with overt or subclinical hypothyroidism. These pregnancy complications may warrant early delivery or lead to premature delivery.

Thyroid Disease in Infants and Children

Although children can have nearly all of the same thyroid problems as adults, the consequences are far more severe and the solutions more difficult. An infant's brain still has much further to grow and develop, requiring sufficient amounts of thyroid hormone for this to happen normally. Thyrotoxicosis can affect the heart, bones, behavior, and school achievement. Thyroid cancer in children has a greater chance of spreading to the lungs and bones than the same type of cancer in adults. In addition, infants and young children are unable to vocalize their symptoms, making it necessary for parents and physicians to be alert to signs of thyroid disease. In this chapter, we'll begin explaining thyroid diseases in the newborn and then deal with thyroid disease in young children. We'll discuss the remarkable benefits of newborn screening programs for hypothyroidism, which are now active in nearly all industrialized nations. Newborn infants are also susceptible to factors from their mothers...

Symptoms of Hypothyroidism in Newborns

Signs of hypothyroidism in newborn infants are unique to this age group. Classic features include a large tongue, umbilical hernia, enlarged fontanels (the soft spots on a newborn's skull), low muscular tone, goiter (unless the baby has thyroid dysgenesis), low body temperature (less than 36 C or 96.8 F), slow reflexes, and respiratory distress. Symptoms of hypothyroidism include constipation, lethargy, poor feeding, and prolonged newborn jaundice (yellowing of the skin). Newborn screening programs are effective enough so that more than a third of infants diagnosed with hypothyroidism have no abnormal signs or symptoms. Taking advantage of early laboratory testing, rather than waiting for infants to appear ill, is the best way of preventing permanent brain damage from hypothyroidism.

Permanent Hypothyroidism

The majority of hypothyroidism cases detected by newborn screening are permanent, most resulting from abnormal formation of the thyroid gland (called thyroid dysgenesis). Two-thirds of newborns with thyroid dysgenesis have thyroid glands in different body locations from the usual location, called an ectopic thyroid. Since the thyroid gland descends from the base of the tongue downward to the base of the neck during development of the embryo (see Chapter 1), the most common location for an ectopic thy roid is either at the tongue base or anywhere in the midline of the neck above the breastbone. Less commonly, thyroid glands may be found in the middle of the chest, sometimes even inside the heart or lower in the body. Ectopic thyroid glands are usually defective and unable to make much thyroid hormone, accounting for the infant's hypothyroidism however, sometimes they work well enough, making the discovery of a thyroid gland, appearing as a strawberry-like lump at the base of the...

Transient Hypothyroidism

A variety of iodine-containing cleansing agents or contrast dyes used in x-ray imaging tests can be given to the mother during pregnancy or to the baby after birth. Excess iodine can inhibit the production of thyroid hormone by the baby's thyroid. This is more likely to happen in small or premature babies. Likewise, medications given to the mother for Graves' disease, such as methimazole or PTU (see Chapters 11 and 13), can block the baby's thyroid from making thyroid hormone. Since the effects of excess iodine and antithyroid drugs disappear when they're no longer around, they cause only transient hypothyroidism. Antibodies from the mother that block the effects of TSH on its receptor (see Chapter 1) can cause a very rare case of hypothyroidism in her baby. These antibodies are similar to the antibodies that cause Graves' disease by stimulating the TSH receptor,

Thyroid Disease ana Obesity

The most important fact we wish to emphasize when it comes to thyroid disease and obesity is that it is extremely common for all obese persons to wonder whether their thyroid is making them fat. This chapter will help you sort out whether your obesity predates your thyroid problem, is aggravated by a thyroid problem, or is the result of one. Obesity refers to a body size that is too overweight for good health. Obese people have greater incidences of type 2 diabetes, heart attacks, strokes, peripheral vascular disease (circulation problems, leading to many other health problems), and certain types of cancers. Hypothyroidism can aggravate obesity and complications from obesity. Hyperthyroidism or thyrotoxicosis, however, may cause an unhealthy type of weight loss, aggravating other conditions that may be linked to obesity, such as heart disease (see Chapter 25) or type 2 diabetes. It is not known how many people with thyroid disease are obese but it is clear that the majority of obese...

How Thyroid Disease Impacts Obesity

The typical obese person with thyroid disease frequently has multiple problems going on at once, which are usually complications of obesity that can become magnified with thyroid disease. For example, the majority of obese people with thyroid disease are also managing high cholesterol, hypertension, and, frequently, type 2 diabetes. Worse, many people who are obese also smoke, which aggravates preexisting obesity complications. It's a complex health-care puzzle for most thyroid specialists. The key to managing thyroid disease in obese people is to treat all problems at once treat the thyroid problem as well as obesity and other health complications. In this way, many thyroid specialists see themselves as a primary care doctor. It's not unusual for the thyroid doctor to initiate prescriptions for thyroid hormone, cholesterol and blood pressure-lowering medications, as well as the most important prescription going to the type of program that emphasizes calorie-counting (such as Weight...

The Hypothyroid Obese Individual

Hypothyroidism can cause or aggravate hypertension and high cholesterol, which are risk factors for cardiovascular disease and can also lead to atherosclerosis (clogged arteries) and congestive heart failure, discussed in Chapter 25. When type 2 diabetes is in the picture, some individuals may need to be on more intensive diabetes control and may even require insulin, since hypothyroidism can affect blood sugar control, which in turn increases the risk of heart attack and stroke. Hypothyroidism can also worsen weight gain, because of decreased activity, bloating, and decreased gastrointestinal motility. In a few cases, unrecognized hypothy-roidism contributes to obesity, but many more people who wonder whether my In people who are made permanently hypothyroid because of thyroid ablation or thyroidectomy, obesity is usually not caused by hypothyroidism if they are on sufficient doses of thyroid hormone (see Chapter 10). Again, Graves' disease and many types of thyroid cancers first...

Hypothyroidism in Older Persons

In older people, the signs of hypothyroidism are not obvious, and often few symptoms point to hypothyroidism, particularly when so many of the symptoms can be attributed to aging. For these reasons, it is recommended that anyone older than sixty be screened for hypothyroidism annually with a TSH test. Older thyroid patients report that they feel better once treated with thyroid hormone, and a lot of vague health problems will get better or even disappear. Most causes of primary hypothyroidism in older people are the result of Hashimoto's disease (see Chapter 5). Hashimoto's disease in younger people frequently causes an enlarged thyroid or goiter (see Chapter 7). In older people, Hashimoto's disease tends to be more insidious and quietly damages the thyroid gland until it shrivels up (or atrophies). Older people could walk around for years with unrecognized Hashimoto's disease unless a thyroid function test was done. Unlike younger people with Hashimoto's disease, thyroid antibody...

Treating Hypothyroidism in Older Persons

In people with a TSH of greater than 10, there is a clear benefit to treatment with thyroid hormone. In people with a TSH of 5 to 10, treatment is also likely to be helpful, although the benefits in symptoms are much less obvious. Normal ranges for TSH values in older people are generally set higher. It is not completely clear whether this is a normal and expected aspect of aging or, rather, an improper resetting of the normal range. The difference may be because some normal older people, whose blood tests were included as part of the normal samples to determine the normal range, were actually hypothyroid with elevated TSH levels, making the normal range higher than it should be.

Thyroid Disease in a Person with Alzheimers Disease

First, thyroid disease is not more or less common in those with Alzheimer's disease. But there are special considerations for longtime thyroid patients who develop Alzheimer's or people who are first diagnosed with thyroid disease while in obvious phases of Alzheimer's disease. Alzheimer's disease affects certain areas of the brain that control memory and basic functions or abilities. This results in specific symptoms or changes in behavior, and unlike a stroke, once an ability or function is lost, it can rarely be relearned. With respect to thyroid disease, it is the loss of mental abilities that can dramatically interfere with managing both hypothyroidism and thyrotoxicosis. Behavior may also be radically affected by Alzheimer's disease, and can include repeating the same action or words, hiding possessions, and having physical outbursts. All of this may be badly aggravated by hypothyroidism or thyrotoxicosis. If you suspect a loved one with thyroid disease has Alzheimer's, it's...

My Obesity Is Caused by Hypothyroidism Even Though My TSH Levels Are Normal

How many euthyroid people are obese Millions Why is that Because they eat more food than they burn off in activity. We are a sedentary society that is aging and out of shape. If your TSH levels are normal, and you are clinically euthyroid, then your obesity is just as manageable as for those obese individuals with no thyroid problem. Coming from both a hypothyroid patient (Sara) and a thyroid specialist (Ken) who sees nothing but hypothyroid people all day long, we bemoan the unfortunate and inappropriate assumption made by patients that all their problems with obesity are consequent to hypothyroidism. If this were the case, all obese patients would be cured with thyroid hormone and no one with normal thyroid function would ever be overweight. Sadly, being a patient who is being treated for hypothyroidism with thyroid hormone therapy does not automatically disqualify one from the weight-control issues that plague all the other people with normal thyroid glands. During bouts of...

RAI Therapy for Graves Disease Is Bad Because It Causes Permanent Hypothyroidism

It's amazing how many times you see statements like this on the Internet by outraged patients surprised to find out that they are hypothyroid after RAI therapy for Graves' disease when, in fact, it is the end goal and raison d' tre of RAI therapy for Graves' disease in the first place. RAI therapy treats hyperthyroidism caused by Graves' disease by destroying or ablating the thyroid gland, which causes it to stop producing thyroid hormone. No one should be advised that the thyroid gland will be normal after RAI therapy, although in rare cases hypothyroidism does not immediately occur, and normal thyroid function may resume without thyroid hormone replacement therapy at first. But in those cases, the thyroid gland will likely fail on its own without a repeat RAI dose. In short, people with Graves' disease who are surprised to learn that they are hypothyroid did not have full information about RAI treatment for Graves' disease from their doctors prior to consenting to this therapy. If...

Assessment of Iodine Deficiency in a Population

Iodine deficiency of a population, iodine concentration in casual urine samples from about 40 people is usually adequate.59 The most important information comes from measurement of the urinary iodide and blood TSH concentrations in neonates and pregnant women. The results of these two measures indicate the severity of the problem, and can also be used to assess the effectiveness of remedial measures.60

What to Eat After Treatment for Thyroid Disease

People who have had thyroid disease make the mistake of thinking they have to be on a special diet to maintain a healthy weight. Unless you're actively hypothyroid, thyrotoxic, or are preparing for a whole body scan (see Chapter 2), you are in the same boat as the rest of the population your metabolism will slow down with age, which will likely cause weight gain as you approach your forties and fifties, unless you compensate with more activity. Basically, eating healthy means you must distinguish between good fat and bad fat as well as good carbs and bad carbs.

Treating Heart Failure in Hypothyroidism

The first step in treating heart failure is to take the appropriate medications prescribed by your physician that decrease the workload of the heart and make it perform more efficiently. This includes reducing the peripheral vascular resistance (seen as high blood pressure or hypertension), decreasing the volume of blood backing up (by using diuretics), and taking medication that enhances the strength of the heart muscle. When hypothyroidism is present and contributing to the heart failure, treatment with thyroid hormone should be started as soon as possible however, it takes several weeks to fully take effect, and it is important to make sure that you are taking the proper heart medication in the meantime. It is very unusual for hypothyroidism, on its own, to be able to weaken the heart sufficiently to cause heart failure. This makes it very important to continue looking for primary heart problems and treat them in addition to treating the hypothyroidism. If you have underlying heart...

Causes of Hypothyroidism in Children and Teens

Just as in adults, Hashimoto's thyroiditis is the most common cause of hypothyroidism in industrialized countries. Antithyroid antibodies in the blood, particularly antithy-roid peroxidase and antithyroglobulin antibodies, are present in more than 95 percent of children with Hashimoto's thyroiditis (also known as chronic lymphocytic thyroiditis). Although occasional children with mild Hashimoto's thyroiditis might regain full normal thyroid function, most become more severely hypothyroid over time unless given appropriate thyroid hormone treatment with levothyroxine. Additional causes of hypothyroidism are less common. Unusual partial defects in forming thyroid hormone (dyshormonogenesis), mild enough to evade detection as a newborn, rarely reveal themselves as they worsen in childhood. Pituitary tumors or unusual tumors in the part of the brain controlling the pituitary, the hypothalamus, may result in hypothyroidism because it interferes with TSH production. The most common type of...

HRT Menopause and Thyroid Disease

The average woman will live until age seventy-eight, meaning that she will live one-third of her life after her menopause. Since thyroid disorders affect women so much more frequently, particularly as they age, balancing thyroid hormone replacement with the confusion surrounding traditional estrogen and progesterone hormone replacement is challenging. Since heart disease can be a major complication of hypothy-roidism or thyrotoxicosis, in the 1980s and 1990s, women with thyroid disease were encouraged to seriously consider hormone replacement therapy after menopause, For women in good health without thyroid disease, taking HRT in the short term to relieve menopausal symptoms is still considered a good option, as there is no evidence to suggest that short-term use (one to five years) of HRT is harmful. The study has implications only for women on oral HRT for long-term use (versus the patch) some-thing that was recommended to millions of women over the past twenty years because of...

Driving While Hypothyroid

People who are moderately to severely hypothyroid, with TSH levels higher than 10, should not be driving a vehicle of any kind, flying a plane, or operating heavy machinery. These rules do not apply to the vast majority of those who are mildly hypothyroid (usually with levels 5 to 10). Thyroid cancer patients preparing for withdrawal scans (see Chapters 2 and 9), whose TSH levels will typically go above 30 while in preparation, should most definitely not be driving while hypothyroid. Clearly, this is more of a problem for people who do not have access to public transit or taxis, and in some cases, doctor's notes may be necessary. Indeed, there have been several cases of hypothyroid patients being seriously injured or killed in car acci The Hypo Reflection A View of Blatant Hypothyroidism If you look in the mirror, you may notice the following changes in your appearance when you are hypothyroid, compared to a photo taken in the past when your thyroid was functioning normally dents....

Thyroid Hormone and Antithyroid Drugs

Diseases associated with thyroid glands are the result of either excess production of thyroid hormone (hyperthyroidism), or its insufficiency (hypothyroidism). Both cases can result in a goiter. Thyroid hormones are used clinically primarily to treat hypothyroidism. This disease is characterized by a decrease or lack of endogenic thyroid hormone secretion. When originating in childhood, it can be clinically described as cretinism (infantile hypothyroidism), and in adults as myxedema (adult hypothyroidism), which is expressed in a loss of mental or physical ability to work, suppression of metabolic processes in the body, and edema. Since thyroid function cannot be restored, the clinical effect is only visible when using thyroid hormones. Using thyroid hormones in hypothyroidism is a replacement therapy that does not correct the disease itself. Currently, a very small number of various drugs such as drugs of animal thyroid glands and synthetic drugs are used to treat hypothyroidism....

Subacute Thyroiditis A Pain in the Neck

Subacute thyroiditis is also known as painful thyroiditis and de Quervain's thyroiditis, after the Swiss physician who first described it. This form of thyroiditis seems to be particularly prevalent in North America although still quite uncommon. It's suspected that subacute thyroiditis has a viral cause, but there is not yet sufficient real proof that this condition is viral in origin. The condition ranges from extremely mild to severe and runs its own course the way a normal flu virus would. Usually, most people with a very mild case of subacute thyroiditis would not bother to see a doctor, because they wouldn't notice any unusual symptoms other than a sore throat perhaps. But in more severe cases, you can be extremely uncomfortable. The illness usually imitates the flu. This means you'll be tired and have muscular aches and pains, a headache, and fever. As the illness progresses, your thyroid gland will swell or enlarge from the infection and become very tender. It will hurt to...

Gestational Thyroid Disease Thyroid Disease During Pregnancy

With two rare exceptions, discussed further on, the causes of thyroid disease during pregnancy are the same as in the general population. The most common thyroid diseases in pregnancy mirror the most common thyroid diseases in the general population. As in the general population, Hashimoto's disease (see Chapter 5) is the most common thyroid disease in pregnancy, followed by Graves' disease (see Chapter 6). In both cases, the risk spikes during the first three months of pregnancy, and then spikes again in the first six months after delivery. Many women will first develop Hashimoto's or Graves' disease within a year of their pregnancies. After delivery, up to 20 percent of all women (particularly those with thyroid antibodies or insulin-dependent diabetes) will develop postpartum thyroiditis, which usually resolves on its own but 25 percent of the time can leave women permanently hypothyroid. Just as in the general population, pregnant women can develop hypothyroidism or thyrotoxicosis...

High Cholesterol Hypercholesterolemia and Hypothyroidism

Hypothyroidism can increase cholesterol in people whose cholesterol levels would ordinarily be normal while euthyroid. But if you have high cholesterol that predates your hypothyroidism, your already high cholesterol level can jump off the charts. High cholesterol is dangerous because the excess cholesterol in your blood can lead to narrowed arteries (ASCVD), which in turn can lead to a heart attack or stroke. In the absence of hypothyroidism, saturated fat (see Chapters 16 and 20) is often a culprit when it comes to high cholesterol, but the highest levels of cholesterol are the result of genetic features affecting the creation or disposal of cholesterol in the liver. Familial hypercholesterolemia refers to a genetic cause for high cholesterol that does not respond adequately to diet modification. The major effect of hypothyroidism is to increase the levels of LDL cholesterol in the blood. Much of this is caused by increasing the absorption of cholesterol from bile (a...

Why Do I Still Feel Hypothyroid

If you have normal TSH levels but still have symptoms of hypothyroidism, then you will be relieved to know that the symptoms that persist are not likely to be related to your hypothyroidism and you can, at last, investigate other causes and remedies. The goal of treating hypothyroidism is to restore your thyroid levels to normal (indicated by normal TSH). The hypothyroid state in your body may exist along with other problems. Ask people who are not hypothyroid if they're tired, depressed, constipated, or have muscular aches and pains, and a huge majority will say yes to at least one of those complaints in spite of normal thyroid levels and no history of thyroid disease. It's been suggested in some thyroid patient literature that some people fail to properly convert T4 into T3, which is why you may still feel hypothyroid. Again, this is completely erroneous (see Chapter 19). We've seen numerous false and bizarre theories put forth about why hidden hypothyroidism persists in spite of...

Hashimotos Thyroiditis

Hashimoto's disease is caused by abnormal autoantibodies and white blood cells attacking and damaging thyroid cells. Eventually, this constant attack destroys many of the thyroid cells the absence of sufficient functional thyroid cells causes hypothyroidism. In most cases a goiter develops because of the inflammation and overstimulation of the residual thyroid cells by TSH from the pituitary gland, though sometimes the thyroid gland can actually shrink. Classically, the diagnosis of Hashimoto's thy- roiditis was limited to people who had enlarged thyroid gland (goiters) that contained invading white blood cells (specifically lymphocytes) and some scar tissue. In common practice, most situations of thyroid inflammation (thyroiditis) caused by autoimmune invasion of lymphocytes are called Hashimoto's thyroiditis, even if the thyroid is not enlarged. Some of the differences between these different forms of thyroiditis will be discussed later in this chapter. Also, in keeping with common...

Heart Complications from Hypothyroidism

As we explained in Chapter 3, hypothyroidism slows down the heart, causing a slow pulse (known as bradycardia). This might cause decreased exercise tolerance, shortness of breath, or a feeling of being winded when you try to exert yourself. Prolonged hypothyroidism will also lead to the accumulation of fluids, called lymphedema, which can swell your hands and feet and mimic the type of edema seen with congestive heart failure. Because your arteries require thyroid hormone to relax, hypothyroidism causes them to tense up, resulting in high blood pressure. People with chronically weakened hearts from underlying ASCVD may not be able to pump blood very easily through these constricted blood vessels, worsening congestive heart failure with fluid accumulating in the lower limbs or in the lungs. Hypothyroid-induced edema can aggravate any existing congestive heart failure or might even be mistaken for congestive heart failure. Heart Failure or Hypothyroidism Some people with hypothyroidism...

Why Am I Hypothyroid

There are two categories of people who become hypothyroid. The first category is called primary hypothyroidism. By this, we refer to people who develop hypothyroidism as a condition because of the primary failure of the thyroid gland itself in essence, a broken thyroid is primary hypothyroidism. This group includes people who develop Hypothyroidism at a Glance thyroiditis (inflammation of the thyroid gland) from Hashimoto's disease or other causes babies born without a thyroid gland or people who stop making as much thyroid hormone as they used to because of aging. People who develop iatrogenic hypothyroidism (meaning doctor-caused) as a result of having their thyroid glands surgically removed or receiving radioactive iodine therapy for the purpose of ablating the thyroid gland also have primary hypothyroidism because their thyroid glands no longer work. Also, roughly 25 to 50 percent of all people who have received external radiation therapy to the head and neck area for cancers such...

Iodine Deficiency

The introduction of iodized salt in our diet has virtually eliminated goiters resulting from iodine deficiencies in North America. But the problem of iodine deficiency is far from solved in other parts of the world. In fact, more than one billion people are at risk for iodine deficiency-related hypothyroidism, which is reversible with either sufficient quantities of iodine, or iodine and thyroid hormone. Three hundred million people in Asia alone suffer from goiters, while twenty million people suffer from brain damage because of iodine deficiency in pregnancy and infancy. Goiters from iodine deficiency are regularly found in Asia, Africa, South America, parts of Holland, and especially in mountainous regions such as the Himalayas and the Andes, the Alps, portions of mainland China, central Mexico, and much of Greece. This phenomenon is very disturbing because these problems could be completely prevented by the simple addition of iodized salt or iodized oil (proposed in some regions)...


Again, thyroiditis means inflammation of the thyroid gland, and some types of thyroiditis can cause thyrotoxicosis. In Hashimoto's disease, the most common cause of autoimmune thyroiditis, the thyroid gland can leak out too much thyroid hormone, creating thyrotoxic symptoms. Then the gland usually is unable to make any more thyroid hormone, causing hypothyroidism. This is known as Hashitoxicosis or silent thyroiditis. Hashimoto's disease is discussed in Chapter 5, as are other types of thyroiditis, such as subacute (De Quervain's) thyroiditis. Thyroiditis from drugs (particularly amiodarone) can also cause thyrotoxicosis, and this is discussed in Chapter 11.


The standard treatment for TSH deficiency or primary hypothyroidism is levothyroxine replacement therapy (Fig. 5.1 2 d). Thyroid hormone replacement can precipitate clinical decompensation in patients with unrecognized adrenal insufficiency, because levothyroxine treatment may improve the metabolic clearance of cortisol. Thus, it is necessary to evaluate patients for adrenal insufficiency and, if this condition is present, treat it with hydrocortisone before initiating thyroid hormone therapy. In patients who also have ACTH deficiency, we usually initiate cortisol replacement three days before beginning thyroid hormone therapy. Unlike primary hypothyroidism, it is not useful to monitor TSH in patients with central hypothyroidism. In a prospective study of 37 patients with central hypothyroidism, free T4 and free T3 were monitored during therapy and adjusted to achieve free T4 in the midnormal range without free T3 elevation and without symptoms of hypothyroidism or hyperthyroidism 14...

Silent Thyroiditis

This silent form of thyroiditis is so named because it's tricky to diagnose and often avoids detection until symptoms become sufficiently severe. It is debatable whether this is a unique type of thyroiditis or merely a type of Hashimoto's thyroiditis that is not associated with a goiter. Since it is common to call most forms of autoimmune thy-roiditis that have lymphocytes invading the thyroid gland (lymphocytic thyroiditis) Hashimoto's thyroiditis, the differences between these two labels might be insignificant. Silent thyroiditis runs a painless course and is essentially the same as Hashitoxicosis. With this version, there are no symptoms or outward signs of inflammation, but thyrotoxicosis is present because of the same stored hormone leakage reasons. Usually silent thyroiditis sufferers are women, and it's common in the postpartum period. Actually, postpartum thyroiditis, discussed in Chapter 13, is silent thyroiditis after delivery. This kind of thyroiditis was not discussed...

Riedels Thyroiditis

Riedel's thyroiditis is the rarest form of thyroiditis. Here, the thyroid gland is invaded by scar tissue, infiltrating throughout the gland and binding it to surrounding portions of the neck. The thyroid will feel very hard like wood. Hence, the term ligneous (meaning woody) or fibrous (meaning scar tissue) thyroiditis is used to describe this peculiar condition. Because the gland attaches itself here to overlying skin and deeper structures in the neck, your windpipe might feel constricted, and your vocal cords could be

Thyroid Disease

Hypothyroidism frequently manifests with psychiatric symptoms. Cognitive disturbances and mood disorders are most commonly present. However, in some cases, psychotic symptoms occur comor-bidly with mood instability and cognitive symptoms. In unselected hypothyroid populations, only about 5 of patients presenting with psychiatric symptoms have psychosis (24). Several case reports, however, suggest that psychosis may be more common in hypothy-roidism (25,26).

In Thyroid Disease

In addition to thyroid hormone, discussed in Chapter 10, and radioactive iodine, discussed in Chapter 12, several medications are used to treat thyroid disease. Other medications used to treat hyperthyroidism include propylthiouracil (PTU), methi-mazole (Tapazole), beta-blockers, and stable (nonradioactive) iodine. Stable iodine is also valuable as a protection against thyroid radiation from radioactive fallout. Potassium perchlorate is sometimes used to diagnose thyroid gland enzyme deficiency recent reports of groundwater contamination with perchlorate in the western United States have renewed interest in it (see Chapter 3). Lastly, lithium carbonate, normally used to treat manic-depressive illness (bipolar affective disorder) can also be used in thyroid treatment I (Ken) have found it to be useful in enhancing the treatment of thyroid carcinomas with radioactive iodine under certain circumstances.

The Hypothyroid Diet

Because everything slows down when you're hypothyroid, you need to know how to eat and what to eat to compensate for your body's slowness during this time, as well as to avoid complications of hypothyroidism. A high-fiber diet low in saturated fat and rich in unsaturated fat (described later in this chapter) can help improve constipation and bloating, fatigue, and weight gain. In essence, this diet will help you feel better while combating periods of hypothyroidism when you're not properly balanced on thyroid hormone, while helping to prevent cardiovascular problems and colon health problems. It will also complement your thyroid medication if you are balanced right now. And finally, it will help you combat a preexisting weight problem, which may be aggravated by your hypothyroidism.

Our Goals for Our Readers

We've been told that we are a unique pairing in the thyroid world. Together, we bring you a wealth of information from quite opposite perspectives. We share a common goal to bring our readers much fuller information about the biology and biochemistry of the thyroid gland, thyroid hormone, diagnostic tests, and treatments. We have observed that most thyroid patients are forced to self-educate about thyroid disease, without the benefit of a medical education or even sufficient health literacy. Added to this problem, many primary care doctors and even endocrinologists are not as immersed in thyroid disease as dedicated thyroidologists. They may not order the appropriate tests or understand how to interpret certain test results, and they may misconstrue facts and confuse patients further. Some may even have their own nonstandard thyroid health miracle treatments, which they advocate in their own books for their own financial gain. There is also the continuing problem of how to identify...

Diencephalic Dysfunction

Disorders of the diencephalon may affect consciousness either directly, by interfering with reticular system function, or indirectly, by producing endocrine disorders. These conditions may develop slowly, as with anterior pituitary syndromes resulting in hypothyroidism or cortisol deficiency, or rapidly, as with osmoregulatory disorders. The lesions producing these problems may also affect the cerebral cortex, as in the case of neoplasms, and produce seizures or other focal neurological disorders. Patients with structural diencephalic lesions may have toxic downward eye deviation, small pupils, decorticate posturing, and Cheyne-Stokes respirations as an archetype, although varying combinations of signs may appear.

TSH The Most Sensitive Test to Assess Thyroid Hormone Status

One problem with trying to use the free T4 level to diagnose hyperthyroidism or hypothyroidism is that it is not very sensitive for an individual. This is because the normal range of the free T4 is normal in respect to large groups of people, but not to individual persons. For example, the normal range of the free T4, in some labs, is 0.8 to 2.1 ng dL. However, for one particular person, the normal level for free T4 could be 1.2 precisely. If that person is given extra thyroid hormone pills to raise the free T4 to 2.0 (still within the normal range), he or she will have symptoms of thyrotoxicosis. Another person whose individual normal free T4 is 1.7, after receiving sufficient antithyroid medication (see Chapters 6 and 11) to lower the free T4 to 0.9, would become truly hypothyroid, even though the free T4 is still in the normal range. The most sensitive way to see how the body feels euthyroid, hypothyroid, or thy-rotoxic is to look at the body's own natural thermostat for thyroid...

Thyroglobulin The Specific Thyroid Protein

The measurement of thyroglobulin can be very useful in diagnosing thyroid conditions. In general, the level of thyroglobulin in the blood reflects the amount of thyroid tissue in the body. When the TSH level is very high, as when a person is hypothyroid, each thyroid cell makes more thyroglobulin. On the other hand, when levothyroxine tablets are given in high enough dosages to keep the TSH level very low, each thyroid cell makes much less thyroglobulin. Measuring the thyroglobulin level in the blood has several uses. In thyrotoxic people, it can discriminate between people taking too many thyroid hormone pills, in which case the thyroglobulin level would be very low, and those who are hyperthyroid with overactivity of the thyroid gland, in which the thyroglobulin level would be high. In situations when the thyroid gland is inflamed (thyroiditis), release of thyroglobulin that had been stored in the gland accounts for high thyroglobulin levels during blood tests.

Pathology Do You Need Surgery What Did the Surgeon Find

Laboratory blood tests are useful to determine thyroid diseases that result in too much thyroid hormone or too little thyroid hormone. On the other hand, the only way to It is very important to know that cytologists are not all the same. Some have more or less expertise in thyroid disease than others. The interpretation of FNA biopsy slides by a cytologist may not be definitive, and second opinions from other experienced cytologists may be both cost-effective and wise. It may seem strange to you, but the most important diagnostic test you will ever have in your entire life, with regard to your thyroid, is the evaluation of the body parts removed during your thyroid surgery (surgical specimen). The pathologist's decision on the name of the thyroid disease revealed by your surgical specimen will determine the course of your medical care for the rest of your life. The decision may result in the use of treatments and diagnostic tests that entail significant time, commitment, and expense....

Affective Disorder Syndromes

The differential diagnosis of depression includes primary psychiatric syndromes other than major depression such as behaviors associated with schizophrenia, generalized anxiety disorder, and obsessive-compulsive neuroses. Medical and neurological disorders either associated with or mimicking depression include malignancy, infections, medications (steroids, reserpine, levodopa, benzodiazepines, propranolol, anticholinesterases), endocrinological dysfunction (Cushing's disease, hypothyroidism, apathetic hyperthyroidism, diabetes), pernicious anemia, and electrolyte and nutritional disorders (inappropriate secretion of antidiuretic hormone, hyponatremia, hypokalemia, hypercalcemia). Depression is also associated with multiple sclerosis, Parkinson's disease, head trauma, stroke (particularly of the left frontal lobe), and Huntington's disease. Interictal changes in temporal lobe epilepsy may mimic depression, particularly with right-sided epileptic foci. Patients with diencephalic and...

Cardiovascular Changes

Hypothyroid people will have an unusually slow pulse rate (between forty-five and sixty beats per minute) and blood pressure that may be too high. More severe or prolonged hypothyroidism could raise your cholesterol levels as well, and this can aggravate blockage of coronary arteries. In severe hypothyroidism, the heart muscle fibers may weaken, which can lead to heart failure. This scenario is rare, however, and one would have to suffer from severe and obvious hypothyroid symptoms long before the heart would be at risk. But even mild hypothyroidism may aggravate your risk for heart disease if you have other risk cofactors. For example, if you are hypothyroid, it's not unusual to notice chest pain (which may be confused with angina), shortness of breath when you exert yourself, or calf pain (which is caused by dysfunction of the muscles in the leg). Fluid may also collect, causing swollen legs and feet. For more on cardiovascular disease see Chapter 25.

Depression and Psychiatric Misdiagnosis

Hypothyroidism is linked to psychiatric depression more frequently than hyperthy-roidism. The physical symptoms associated with unipolar depression (discussed more in Chapter 24) overlap with hypothyroidism and can cause the psychiatric misdiag-nosis. Sometimes, psychiatrists find that hypothyroid patients can even exhibit certain behaviors linked to psychosis, such as paranoia or aural and visual hallucinations (hearing voices, seeing things that are not there). This used to be called myxedema madness. Interestingly, roughly 15 percent of all patients suffering from depression are found to be hypothyroid. Chapter 24 discusses depression and unmasked hypothyroidism, as well as simultaneous depression and hypothyroidism. Bipolar disorder and lithium are also discussed in detail.

Fatigue and Sleepiness

The most classic symptom is a distinct, lethargic tiredness or sluggishness, causing you to feel unnaturally sleepy, even though you slept well more than twelve hours the night before. Your doctor may also notice that you exhibit very slow reflexes. Researchers now know that when you are hypothyroid, you are unable to reach the deepest stage 4 level of sleep. This is the most restful kind of sleep. Lack of it will explain why you will remain tired, sleepy, and unrefreshed. See Chapter 26 for more on coping with fatigue.

Poor Memory and Concentration

Hypothyroidism causes a spacey feeling, where you may find it difficult to remember things or to concentrate at work. This is especially scary for seniors, who may feel as though dementia is settling in. In fact, one of the most common causes of so-called senility has been undiagnosed hypothyroidism. If it seems a loved one is experiencing dementia, consider setting up a thyroid function test before declaring it's Alzheimer's. See Chapter 17 for more details about thyroid disease and aging.

Thyroid Stimulating Hormone

Thyrotropin, also known as thyroid-stimulating hormone (TSH), is a glycoprotein synthesized in the anterior pituitary. The secretion of TSH is stimulated by thyrotropin (or TSH)-releasing hormone (TRH) and inhibited by somatostatin and dopamine, secreted from the hypothalamus. In persons older than 12 months of age, the TSH concentration is low in the afternoon, rises dramatically (surges) after 1900 hours, and reaches its highest concentrations between 2200 and 0400 hours (Fig. 5.2a) 51 . Thus, at least one third of the trophic influence of TSH on the thyroid gland occurs at night. TRH is necessary for TSH synthesis, post-translational glycosylation, and secretion of a fully bioactive TSH molecule from the pituitary 48 . Altered TSH glycosylation, resulting in altered bioactivity, is seen in mixed hypothyroidism (central hypothyroidism with mild TSH elevation 5-15 mU l ) 23,49 .

When Thyroid Hormone Doesnt Work

Thyroid hormone resistance is a rare genetic disorder in which the receptors that stick to T3 (then stick to specific parts of the chromosomes of each body cell) are mutated so that they don't stick to T3 very well. Because of this, much, much more T4 is needed to enter each cell and change to T3 to make up for this abnormal T3 receptor. In this case, you would have either high TSH levels, despite normal or high levels of free T4 or free T3 (making you hypothyroid), or normal TSH levels and very high levels of T4 and T3 (making you euthyroid because the high levels compensate for the resistance). In either case, just as in normal individuals, a high TSH reflects too little thyroid hormone and a normal TSH reflects sufficient thyroid hormone. We devote a separate chapter to thyroid hormone resistance (Chapter 18). If you have thyroid hormone

Injury of the Hypothalamic Pituitary Axis in Patients with Cancer

In addition to these dysfunctions, patients who receive chemotherapy alone (with no history of RT or CNS tumor) may be at risk for neu-roendocrinopathy. Of the 31 patients evaluated in one study for altered growth and development, 48 had GH deficiency, 52 had central hypothyroidism, and 32 had pubertal abnormalities 57 . GH deficiency is commonly believed to be the first hypothalamic-pituitary deficiency to emerge after injury to the HPA, followed by deficiencies of gonadotropin, ACTH and TSH 60,65 however, these deficiencies can occur in any order 11,21,35,54,67 . Although the most common neuroendocrinologic abnormality in survivors of childhood cancer is GH deficiency, hypothyroidism is at least as prevalent when sensitive testing methods are used 54 . The next most common alteration is in pubertal timing (precocious, rapid, delayed, or absent). ACTH deficiency, although less common than the other disorders, has more serious consequences if it is not detected....

Clinical Manifestations 521 GH Deficiency

The growth rate is typically slow in children who are undergoing treatment for cancer and usually improves (or catches up) after completion of cancer therapy (Fig. 5.8). Children whose growth rate does not improve or whose growth rate is less than the mean for age and sex should be evaluated for growth failure (Fig. 5.9). Causes of slow growth other than GH deficiency include hypothyroidism, radiation damage in growth centers of the long bones or the spine, chronic unresolved illness, poor nutrition, and depression. In individuals who have attained adult height, GH deficiency is usually asymptomatic 71 , but may be associated with easy fatigability, decreased muscle with increased fat mass, and increased risk for cardiovascular disease 12,16 .

Testing for Antibodies

If you are not hypothyroid, and medication balancing is not an issue, then it's important to find out whether you have autoimmune thyroid disease, the most common cause of hyperthyroidism, which causes thyrotoxicosis. You may have the beginnings of Hashimoto's disease (and Hashitoxicosis as discussed earlier), or you may have Graves' disease. Although there are blood tests for detecting the antibodies associated with these thyroid diseases, sometimes the physician, if experienced, is able to make the correct diagnosis and treatment without measuring them in the blood. In other situations, these antithyroid antibodies may prove useful to aid in the diagnosis and management of your thyroid disorder. These tests are discussed in detail in Chapter 2.

Associated Medical Findings

Because one of the most common causes of orbital infiltration is thyroid disease, patients with orbital signs such as proptosis, chemosis and conjunctival injection together with abnormal ocular motility should be examined for goiter, pretibial myxedema, smooth moist skin, and loss of lateral eyebrows. y In thyroid disease, the extraocular muscles can develop edema, lymphocytic infiltration, and fibrosis, resulting in loss of elasticity more than loss of contractile strength. The diplopia that results from this restrictive feature is due to the tethering of the eye in an abnormal position by one or more shortened inelastic extraocular muscles.

Pregnancy and Autoimmune Disease

Autoimmune thyroid disorders such as Graves' disease or Hashimoto's thyroiditis are most likely to strike during the first trimester of a pregnancy and within the first six months after delivery, or in the postpartum (right after childbirth) phase. It's normal for the thyroid gland to enlarge slightly during pregnancy because the placenta makes a hormone, human chorionic gonadotropin (HCG), that stimulates the mother's thyroid gland. Researchers have found that HCG has portions that share a very similar molecular structure to TSH (thyroid stimulating hormone). Situations that increase TSH levels often stimulate the enlargement of the thyroid gland (goiter). Likewise, the great increase in HCG seen in pregnancy affects the thyroid gland in a similar fashion, working like TSH to cause some enlargement of the thyroid gland. It is possible that this is part of the complex assortment of factors that help induce autoimmune thyroid problems. During pregnancy, the immune system is naturally...

Inflammatory Bowel Disease IBD

This is an umbrella term that comprises Crohn's disease as well as ulcerative colitis. IBD is a miserable condition where the lower intestine becomes inflamed, causing abdominal cramping, pain, fever, and mucus-laden, bloody diarrhea. IBD is not known to occur more often in thyroid disease patients, although the effects of too much or too little thyroid hormone may worsen its symptoms. If you have IBD, it's best to ask to be referred to a gastroenterologist (also know as a GI specialist), who is the specialist to manage it. This is not to be confused with irritable bowel syndrome (IBS), a stress-related disorder that often masks hyperthyroid symptoms. Hypothyroidism slows down the rate at which food travels through the stomach and intestines. This can result in gastroesophageal reflux disease (heartburn) and constipation. On the other hand, thyrotoxicosis from untreated Graves' disease causes more frequent bowel movements consequent to an increased rate of movement of food through the...

Antithyroid Medication

Sometimes, doctors (or patients) prefer to treat Graves' disease with antithyroid drugs. These drugs prevent the thyroid from manufacturing thyroid hormone and are usually a way of managing Graves' disease in the short term. Propylthiouracil (PTU) and methimazole (Tapazole) are the most commonly used drugs, and they are very useful under specific circumstances, such as As the production of thyroid hormone decreases, the symptoms of thyrotoxicosis will disappear. The practice is to take you off the drugs after several months of treatment, if the TSH has been normal or elevated, to see if Graves' disease relapses, which occurs about 80 percent of the time, or goes into remission. Some people like to take their chances at remission, which is certainly reasonable, unless Graves' disease is severe. Usually, antithyroid drugs are used if patients are pregnant or refuse to consent to RAI, but some doctors prefer to use them as a first option.

Remission and Antithyroid Medication

The main benefit to going on antithyroid medication is to try your luck at achieving full remission without the need for RAI or surgery. This usually results in either an indefinite period of normal thyroid activity or lifelong hypothyroidism. In general, antithyroid drugs are effective in achieving remission about 20 to 30 percent of the time, but some doctors report even lower success rates. The main effect of antithyroid drugs is to buy time until either a spontaneous remission occurs, in which the immune system stops producing thyroid stimulating antibodies (TSA), or the autoimmune effects destroy enough of the thyroid gland to ablate the gland despite persistent TSA production. This spontaneous remission is most likely to be seen in people with very mild thyrotoxicosis and small goiters. The process can take from six months to a year, if it is going to happen at all. Such a percentage begs the question, why even bother with antithyroid medication Many patients and doctors feel...

Thyroidectomy or Partial Thyroidectomy

A thyroidectomy is also major surgery that involves a general anesthetic, carries other risks, and requires a postsurgical stay in the hospital of at least one to two days. Some surgeons attempt this surgery with same-day discharges, but thyroid experts consider this to be too risky. Sometimes, even in total thyroidectomy, small pieces of thyroid tissue are left behind that could potentially continue the thyrotoxicosis of Graves' disease. Radioactive iodine is used to kill off the remaining bits of tissue. These small pieces can also leave you euthyroid, without having to be on thyroid hormone. In most people, surgery will leave them hypothyroid, and thyroid hormone will be prescribed.

Allowing Graves to Run Its Natural Course

Many with Graves' disease have mild symptoms and wonder whether they should refuse active therapy and allow Graves' disease to run its natural course, which might normally result in the thyroid gland burning out and failing on its own, leaving you hypothyroid anyway. This approach is commonly recommended for the small group of people who have such low degrees of thyrotoxicosis that ablative therapy with RAI, surgery, or risks of drug effects of antithyroid medications seem unnecessary. These people often do well with beta-blockers however, they must be carefully monitored since thyrotoxicosis may worsen without warning. Also, the risks of worsening of osteoporosis and chronic effects of excess thyroid hormone on the heart should be considered. For these reasons, post-menopausal women with brittle bones (see Chapter 14) and people with irregular heart rhythms (see Chapter 25) are appropriately directed toward RAI treatment.

Functional Assessment

The TSH is most sensitive, provided that your pituitary gland is normal. That's why a normal TSH is confirmed by the free T4. If the free T4 is low, despite a normal or low TSH, this could be a sign of a dysfunctional pituitary gland, often from a benign pituitary tumor. On the other hand, if the free T4 is very high, yet the TSH is inappropriately normal or elevated, there are two possible explanations. If you have thy-rotoxic symptoms (see Chapter 4), you may have a rare pituitary tumor that makes TSH. If you are clinically euthyroid, with no symptoms of hypothyroidism (see Chapter 3) or thyrotoxicosis, then you may have thyroid hormone resistance (discussed in Chapter 18). If the TSH is elevated then you're hypothyroid, and it's likely that the elevated TSH itself has contributed to the growth of the goiter. Of course, the TSH is most often elevated because of Hashimoto's thyroiditis (in industrialized countries), discussed in Chapter 5, or iodine deficiency (in much of the...

The Pembertons Maneuver

It's a good idea to have a thyroid surgeon remove obstructive goiters, particularly if very large. Exceptions include moderately obstructive goiters associated with elevated TSH levels (hypothyroid goiters), which may shrink with thyroid hormone treatment goiters with Graves' disease, which may shrink with radioactive iodine treatment and very rare thyroid lymphomas, which usually shrink very rapidly with external beam radiation therapy.

Preventing Thyroid Exposure from Radioactive Fallout

Difficult to do unless an accident or incident is predicted in advance, or the air path of a specific accident is tracked and therefore anticipated. And potassium iodide is not designed as a long-term therapy because of side effects that occur with prolonged use. Complications include serious allergic reactions, skin rashes, and thyroid disorders (aggravating Hashimoto's thyroiditis or worsening hyperthyroidism). In pregnant women, long-term use of potassium iodide can also cause the fetus to develop a goiter however, the short-term use would protect the fetus against radioactive iodine isotopes.

Tithi Biswas Louis SConstine Cindy LSchwartz

Thyroid dysfunction or deregulation is a clinically significant sequelae of cancer therapy due to the spectrum of physiologic consequences. Primary hypo-or hyperthyroidism may result from direct irradiation of the thyroid gland incidental to the treatment of malignancies such as Hodgkin's disease and head and neck rhabdomyosarcoma. Primary hypo- or hy-perthyroidism may also result from central nervous system (CNS) tumors that require spinal axis irradiation 7,11,32 . Central hypothyroidism may develop in children with brain tumors treated with cranial irradiation or chemotherapy that includes the hypothalamic-pituitary axis 25 . The development of benign thyroid nodules and malignancy after thyroid radiation therapy (RT) is also a sequela with potential adverse consequences 12,13,16,18,23,44 .

Thyroid Hormone Suppression Therapy

Thyroid hormone treatment in the form of levothyroxine is absolutely necessary after the thyroid is removed. In people who have never had thyroid cancer but are merely hypothyroid, sufficient levothyroxine is given to make the TSH normal (0.5 to 3.0 see Chapter 2). People with thyroid cancer should keep their TSH levels less than 0.1. This is because TSH stimulates the growth of thyroid cancer cells. When you are preparing for radioactive iodine scans or therapies, or when you need to assess the level of thy-roglobulin, you want to stop your levothyroxine to make the TSH greater than 30, stimulating thyroid cancer cells to suck up iodine and make thyroglobulin. On the other hand, it's necessary to keep the TSH suppressed (less than 0.1) at all other times, so that any thyroid cancer cells still in your body are not stimulated to grow and reproduce. Chapter 10 gives all of the details on thyroid hormone medication.

Monitoring Thyroglobulin Levels

Whenever you are made hypothyroid to prepare you for a radioactive iodine scan, besides stimulating any residual thyroid cancer cells to take up radioactive iodine, the cells are stimulated to make more thyroglobulin also. For this reason, the thyroglobu-lin blood test is most sensitive during this hypothyroid preparation. Thyrogen will do much the same, stimulating the release of thyroglobulin from any thyroid cancer cells.

Problems in Taking T4 Compliance

Remembering to take a pill every day, and or taking it correctly, is known as compliance in pharmacy-speak. Some people take their daily T4 medication like clockwork but most people (including Sara) are a bit forgetful. A useful device is a day-of-week pill container. These can be filled up once a week and used to remind you to take your pill. Forgetfulness in regularly taking T4 seems to be the most common reason for people to become hypothyroid while taking the same T4 dosages that were previously sufficient to make their TSH levels normal.

Drugs Used to Treat Hyperthyroidism

Alternatively, antithyroid drugs (thionamides) can be used to block your thyroid from making more thyroid hormone, allowing thyroid hormone levels to diminish over the course of a couple of weeks. This is useful if your thyrotoxicosis is causing severe symptoms or if there is some reason beta-blockers can't be used. Thionamides can be used as the only treatment or they can be used to quiet things down prior to radioactive iodine treatment.

Control by extracellular signals

The timer is also regulated by thyroid hormone (TH), which has been known for many years to influence oligodendrocyte development. In developing animals that are hypothyroid, for example, myelination is greatly delayed (Dussault & Ruel 1987, Rodriguez-Pena et al 1993), whereas in developing animals that are hyperthyroid, myelination is accelerated (Walters & Morell 1981). The evidence that TH influences the intrinsic timer in OPCs comes from experiments that compare the behaviour of purified OPCs cultured in PDGF in the presence or absence of TH (Barres et al 1994). When OPCs purified from the optic nerve of postnatal day 8 (P8) rats are grown at clonal density in PDGF and TH, the cells divide a maximum of eight times before they stop and differentiate in the absence of TH, by contrast, most of the cells tend to keep dividing and do not differentiate. If the OPCs are cultured at clonal density in PDGF in the absence of TH for 8 days, and then TH is added, most of the cells stop...

Other Valuable Uses for Beta Blockers

Besides managing obvious thyrotoxicosis, beta-blockers have additional benefits in people with thyroid cancer. Unlike people with hypothyroidism, taking sufficient thyroid hormone to provide normal TSH levels (see Chapter 2), those with thyroid cancer take a slightly higher daily levothyroxine dosage, sufficient to suppress the TSH to levels less than 0.1 (see Chapter 9). In most, this doesn't cause any thyrotoxic symptoms, but in around one-third of such people (including Sara), this causes a rapid resting pulse rate (greater than 80 beats per minute), a sensation of palpitations, or some difficulty getting to sleep. If this happens, a once daily beta-blocker (particularly one that is beta-1-selective) makes these symptoms disappear. It also prevents any potential effects of this dosage of thyroid hormone on thickening the left ventricle heart muscle. (See Chapter 25.)

Structural Abnormalities

Lesion deficit correlation studies demonstrate that certain disorders are more likely to be associated with a major depression than others (a) discrete brain lesions, as seen with trauma, surgery, stroke, tumors, and certain types of epilepsy (b) neurodegenerative diseases with regionally confined pathologies such as Parkinson's, Huntington's, and Alzheimer's diseases (c) disorders affecting diffuse or multiple random locations such as multiple sclerosis and (d) system illness with known central nervous system effects such as thyroid disease, cancer, and acquired immunodeficiency syndrome (AIDS) (Table 7.1). Hypothyroidism,

Radioactive Iodine Therapy

The thyroid gland is unique because it's the only part of the body that makes special use of iodine to do its job, namely, the production of thyroid hormone. Most of the iodine in the body is stored in the thyroid gland, except for the iodine contained in the thyroid hormones T4 and T3 (thyroxine and triiodothyronine) and the thyroglobulin released into the bloodstream. A healthy thyroid gland can take up around a quarter of the total iodine taken into your body each day from food and beverages. This is possible because each thyroid follicular cell makes special proteins that are found in its membrane (see Chapter 1) that pump iodine from the blood into the cell. These iodine pumps (officially known as the sodium-iodide symporters) are found in much smaller amounts in salivary glands, female breasts, and the lining of the stomach. The dawn of the atomic age fostered great interest among physicians who treated thyroid disease. Since thyroid glands took up iodine, it seemed reasonable...

Patchy Nonscarring Alopecia

It is a nonscarring, usually patchy but sometimes diffuse, hair loss of unclear cause. Many cases are familial, and it is believed that there may well be an autoimmune etiology. It is seen more commonly in patients with atopic dermatitis, thyroid disease, vitiligo, and Down syndrome.

Radioactive Iodine for Graves Disease

There are two ways that someone with Graves' disease can be prepared for RAI treatment. If you are young or in a reasonably healthy state, aside from your hyperthy-roidism, it is often easiest to treat you immediately with radioactive iodine, avoiding using antithyroid drugs (see Chapter 11). Beta-blockers (see Chapters 11 and 25) can be used as needed. Alternatively, if you have heart disease (see Chapter 25) or are sufficiently ill or unstable from your thyrotoxicosis (see Chapter 4), it's often a good idea to lower your thyroid hormone levels with antithyroid drugs before giving you RAI. The antithyroid drug (methimazole or propylthiouracil) should be stopped three or four days before giving the I-131 dose so that it doesn't interfere with the treatment. RAI is an excellent treatment for Graves' disease and physicians in North America most frequently use it. In Europe and Japan, antithyroid drugs are used more often than RAI. It seems that this reflects regional differences in how...

How Much RAI Is Used for Graves Disease

Different methods are used to decide upon the dosage of RAI. Some physicians give arbitrary doses of I-131, knowing that most people will have some good results as long as the dose is reasonable (often around 10 millicuries). I (Ken) prefer to make measurements that permit the dose to be individually adjusted. It is nearly impossible to reliably give such a precise dose of RAI that a person ends up with normal thyroid gland function and, ultimately, the ongoing autoimmune processes of Graves' disease usually cause the thyroid gland to eventually fail anyway, resulting in hypothyroidism. For this reason, I feel that it's better to aim to give enough RAI to make a person hypothyroid reasonably soon, so that thyroid hormone replacement therapy can be started, which will allow that person to resume his or her usual quality of life faster. First, I estimate the size of a person's thyroid in grams, knowing that a normal-sized thyroid weighs around eighteen to twenty grams. Then I obtain the...

Criteria for animal models

The simplistic approaches of studying a single gene mutation on one inbred genetic background are being circumvented by very complicated and sophisticated manipulations when multiple mutations are combined on the same inbred background to do standardized studies in which factors or cells are added or subtracted to answer very specific mechanistic questions. For example, historically, to investigate the role of hormones on hair growth one would study hair follicles in patients with various endocrine diseases. Today it is possible to graft human skin with hair follicles onto the back of various immunodeficient mice that will accept such xenografts. Such mice can be created to carry mutant genes that create deficiencies in various hormones, such as mutant mice that lack thyroid hormones (hypothyroid, thyroid-stimulating hormone receptor gene, gene symbol Tshrhyt), androgens and

Morning Sickness and Sufficient Iodine

Morning sickness refers to the infamous nausea and vomiting women tend to experience during early pregnancy. Between 60 and 80 percent of all women suffer from morning sickness in their first trimester, and a significant number have severe morning sickness that can last the duration of pregnancy, also known as hyperemesis gravidarum Morning sickness may interfere with sufficient iodine intake during pregnancy. It's critical that adequate amounts of iodine are in the maternal diet for normal fetal development in fact, maternal iodine deficiency is one of the leading causes of mental impairment and cretinism in underdeveloped countries. If you live in the United States or Canada, or other developed countries, this is usually not a problem. But if you can't keep anything down, you may be nutrient-deprived. The recommended total daily iodine intake for pregnant women should be 220 micrograms per day and 290 micro-grams per day for lactating women. If you are suffering from severe morning...

Pregnancy and Graves Disease

If you're pregnant with active Graves' disease that was newly discovered, you must start antithyroid drugs as soon as possible, and you should remain slightly hyperthy-roid so the baby can be properly suppressed. This is discussed more in the section on gestational thyrotoxicosis.

Morning Sickness and Thyroid Hormone Replacement

The problem with nonstop nausea and vomiting is that your thyroid hormone pill could be poorly absorbed, leaving you hypothyroid, which is dangerous to fetal health. If you think your thyroid hormone pill came out with your breakfast, with your doctor's permission, it's probably all right to take an additional tablet as long as this isn't a frequent event. In extreme situations, your physician could give you thyroid hormone medication as an intramuscular (IM) or subcutaneous (SC) injection, but this is rarely necessary.

Clubbed Nails Hippocratic Nails

Clubbing of the nails may be acquired, idiopathic, or hereditary-congenital. About 80 of acquired bilateral clubbing is associated with respiratory ailments including pulmonary carcinoma and 10 to 15 is associated with cardiovascular and extrathoracic diseases. Multiple, diverse systemic diseases have been associated with clubbing including hepatic disease, thyroid disease, toxin exposure, and POEMS syndrome. Clubbing may be inherited as an autosomal dominant and not associated with other diseases.

After the Baby Is Born

If you first develop an autoimmune thyroid disease such as Graves' disease or Hashimoto's disease after you deliver, you would undergo normal treatment for either disease, as outlined in Chapters 5 and 6. If you developed Graves' disease after delivery and are breast-feeding, you may continue breast-feeding while on antithyroid medication but must not breast-feed if you're having radioactive iodine therapy or scans. If you develop Graves' disease during pregnancy, the condition can get worse after delivery unless antithyroid drugs are continued.

Splenectomy For Hematologic Disorders

Because thrombocytopenia has many causes, ITP is a diagnosis of exclusion. Bearing in mind that spleens of normal size may be palpable occasionally, the physical finding of an enlarged spleen can almost always be attributed to a diagnosis other than ITP. An initial evaluation with ancillary laboratory studies aids in eliminating many of the other specific immune and nonimmune causes of thrombocytopenia. Examination of the bone marrow is essential for demonstration of an adequate number of megakaryocytes, a finding that eliminates many conditions that produce a hypoplastic bone marrow. In addition to the many causes of secondary hypersplenism, which are discussed subsequently, other conditions that should be considered as possible etiologic factors include the following effects of drugs or toxins various infections, including infectious mononucleosis and other viral diseases autoimmune thyroid disease thrombotic thrombocytopenic purpura giant cavernous hemangioma and familial...

Compliance Issues When They Wont Take Their Medicine

Roxine pill every morning, yet the child remains hypothyroid. Sometimes a month's supply of pills is found hidden under the refrigerator where they've been spit out. This is not unusual with other pills, such as vitamin pills or antibiotics, but in those cases, they're not as critical. It's a good idea to watch your child swallow the pill, then have the child open his or her mouth to demonstrate that it was actually swallowed. These problems become worse during adolescence, sometimes as an expression of rebellion. I've found compliance issues equally difficult in boys and girls.

Treating Graves Disease in Children

Treating Graves' disease in children remains an area of controversy. Most often, thion-amides (antithyroid drugs) are the first line of therapy (see Chapter 11), while beta-blockers (see Chapter 11) are used to control thyrotoxic symptoms. Compliance with these medications is also a special problem in children. Although methimazole is preferred, because it can be effective given only once or twice a day, around 10 percent of these children develop some significant reactions to thionamides, forcing them to go off of this drug. The rate of remission (disappearance of thyrotoxicosis after stopping six to twelve months of thionamides therapy) is a bit higher than in adults however, most children eventually need definitive treatment, either surgery or radioactive iodine. American physicians have been more likely to use radioactive iodine for children than physicians in Europe or Japan. Although there is reasonable concern that children may be susceptible to developing thyroid cancers from...

Treating Hyperthyroidism in Older Persons

Most people over sixty with Graves' disease (see Chapter 6) or toxic nodules (see Chapter 8) will be offered the same options for treatment as a younger person. The one exception is surgery, which is sometimes too risky for people in this age group who have other health problems or who may be frail. Radioactive iodine is not dangerous to older persons, although many older people fear it more than younger people do and may be more inclined to refuse it. Generally, radioactive iodine therapy (see Chapter 12) is preferable in this age group because it is reliable, effective, and (aside from hypothyroidism) free of side effects.

Hypothalamic Pituitary Dysgenesis

Hypothalamic-pituitary dysgenesis is a form of congenital (from birth) hypothyroidism caused by a failure in the normal formation or function of the pituitary gland and or hypothalamus. A number of genetic mutations cause such failures. Mutations in one particular gene, LHX3, cause a loss of the thyroid and gonadal (sex organs) function of the pituitary gland. Mutations in another gene, HESX1, cause something known as septo-optic dysplasia. This is characterized by poor growth of the optic nerve, defects of parts of the brain, and deficiencies of pituitary hormones. Mutations in other genes cause failure of growth of specific pituitary cells responsible for making TSH and other pituitary hormones. One case of hypothyroidism has been described in which the pituitary cell TRH receptors fail to work because the gene is mutated.

Defects in the Production of Thyroid Hormone

Multinodular goiters that are unable to concentrate radioactive iodine and are thus hypothyroid with high TSH levels. There are also people with mutations in the gene for thyroid peroxidase (TPO), the enzyme that is partly responsible for permitting iodide to be combined with portions of the thyroglobulin molecule, a process called organification. There are additional steps in organification that are susceptible to flaws or dysfunction from mutations as well (see Chapter 15 for the incidence of organifica-tion defects).

The Falsely Suppressed TSH Theory

Some materials claim that excess T3 generated at the pituitary level can falsely suppress TSH, which is why TSH tests are not reliable in testing for hypothyroidism. This idea is completely false. T4 is converted into T3 by an enzyme called 5 deiodinase. This enzyme can be found in both the pituitary gland and the body cells. There has never yet been any research showing that the enzyme works differently in the pituitary than in the body cells. The enzyme is what makes T3 out of T4, and the TSH level therefore accurately reflects the effect of T4 on the entire body.

The Reverse T3 Theory

Some materials claim that trauma and stress can create a fake normal T3 level, known as reverse T3. The claim is that many people with so-called normal TSH levels really have reverse T3 and are actually hypothyroid but can't seem to prove it to anyone. This theory takes some fact and creates fiction. T4 is converted to T3 by removing a particular specific iodine from the four iodines on each of the T4 molecules. If a different iodine is removed, reverse T3 is formed. Reverse T3 is inactive it cannot do the job of T3, and therefore will not suppress TSH. It will not affect TSH levels at all. If T4 is converted to reverse T3 without making enough regular T3, the TSH levels will be high and you will be hypothyroid. If the TSH levels are normal, so are the levels of regular T3 inside of your cells.

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