Hypothyroidism

Contents
Hypothyroidism...........................................................................................................................................2
Introduction.................................................................................................................................................2
History.........................................................................................................................................................2
Causes of hypothyroidism...........................................................................................................................2
Hashimoto’s Disease...............................................................................................................................2
Thyroiditis...............................................................................................................................................3
Subacute thyroiditis.............................................................................................................................3
Postpartum thyroiditis..........................................................................................................................3
Silent thyroiditis..................................................................................................................................3
Congenital Hypothyroidism.....................................................................................................................3
Surgical Removal of the Thyroid.............................................................................................................3
Medicines................................................................................................................................................4
Too much or too little iodine...................................................................................................................4
Damage to the pituitary gland..................................................................................................................4
Grades of hypothyroidism...........................................................................................................................4
Symptoms of hypothyroidism......................................................................................................................6
Diagnosis of hypothyroidism.......................................................................................................................6
Medical and family history......................................................................................................................6
Physical exam..........................................................................................................................................7
Blood tests...............................................................................................................................................7
TSH (thyroid-stimulating hormone) test..................................................................................................7
T4 tests....................................................................................................................................................7
Who is likely to develop hypothyroidism....................................................................................................7
pregnancy and thyroid conditions................................................................................................................8
Hypothyroidism.......................................................................................................................................8
Postpartum thyroiditis..............................................................................................................................8
Hypothyroidism and metabolic defects........................................................................................................8
Hypothyroidism treatment...........................................................................................................................9
Thyroxin(T4) replacement.......................................................................................................................9
Eating, Diet, and Nutrition.......................................................................................................................9
Dietary Supplements............................................................................................................................9
References.................................................................................................................................................11

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Hypothyroidism

Introduction.
Hypothyroidism is a disorder that occurs when the thyroid gland does not make enough thyroid
hormone to meet the body’s needs. Thyroid hormone regulates metabolism the way the body
uses energy and affects nearly every organ in the body. Without enough thyroid hormone, many
of the body’s functions slow down. It is encountered in females more than in males. The
idiopathic form of hypothyroidism occurs mainly in females older than 40 years.
Hypothyroidism is usually progressive and irreversible. Treatment, however, is nearly always
completely successful and allows a patient to live a fully normal life

History.
Hypothyroidism was first diagnosed in the late nineteenth century when doctors observed that
surgical removal of the thyroid resulted in the swelling of the hands, face, feet, and tissues
around the eyes. The term myxoedema (mucous swelling) was introduced in 1974 by Gull and in
1878 by Ord. On the autopsy of two patients, Ord discovered mucous swelling of the skin and
subcutaneous fat and linked these changes with the hypofunction or atrophy of the thyroid gland.
The disorder arising from surgical removal of the thyroid gland was described in 1882 by
Reverdin of Geneva and in 1883 by Kocher of Berne. After Gull's description, myxoedma
aroused enormous interest, and in 1883 the Clinical Society of London appointed a committee to
study the disease and report its findings. The committee's report, published in 1888, contains a
significant portion of what is known today about the clinical and pathologic aspects of
myxedema.

Causes of hypothyroidism.
Hypothyroidism has several causes, including

 Hashimoto’s disease
 thyroiditis, or inflammation of the thyroid
 congenital hypothyroidism, or hypothyroidism that is present at birth
 surgical removal of part or all of the thyroid
 radiation treatment of the thyroid
 some medications Less commonly, hypothyroidism is caused by too much or too little
iodine in the diet or by abnormalities of the pituitary gland.
Hashimoto’s Disease.
Hashimoto’s disease, also called chronic lymphocytic thyroiditis, is the most common cause of
hypothyroidism in the United States. Hashimoto’s disease is a form of chronic inflammation of
the thyroid gland. Hashimoto’s disease is also an autoimmune disorder. Normally, the immune
system protects the body against foreign invaders such as viruses and bacteria that can cause
illness. But in autoimmune diseases, the immune system attacks the body’s own cells and organs.

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With Hashimoto’s disease, the immune system attacks the thyroid, causing inflammation and
interfering with its ability to produce thyroid hormones.
Thyroiditis
Thyroiditis causes stored thyroid hormone to leak out of the thyroid gland. At first, the leakage
raises hormone levels in the blood, leading to hyperthyroidism when thyroid hormone levels are
too high that lasts for 1 to 2 months. Most people then develop hypothyroidism before the
thyroid is completely healed. Several types of thyroiditis can cause hyperthyroidism followed by
hypothyroidism:
Subacute thyroiditis.
This condition involves painful inflammation and enlargement of the thyroid. Experts are
not sure what causes subacute thyroiditis, but it may be related to a viral or bacterial
infection. The condition usually goes away on its own in a few months.
Postpartum thyroiditis.
This type of thyroiditis develops after a woman gives birth. For more information, see the
section titled “What happens with pregnancy and thyroid conditions?”
Silent thyroiditis.
This type of thyroiditis is called “silent” because it is painless, as is postpartum
thyroiditis, even though the thyroid may be enlarged. Like postpartum thyroiditis, silent
thyroiditis is probably an autoimmune condition and sometimes develops into permanent
hypothyroidism.

Congenital Hypothyroidism
Some babies are born with a thyroid that is not fully developed or does not function properly. If
untreated, congenital hypothyroidism can lead to mental retardation and growth failure. Early
treatment can prevent these complications, so most newborns in the United States are screened
for hypothyroidism.

Surgical Removal of the Thyroid

When part of the thyroid is removed, the remaining part may produce normal amounts of thyroid
hormone, but some people who have this surgery develop hypothyroidism. Removal of the entire
thyroid always results in hypothyroidism. Part or all of the thyroid may be surgically removed as
a treatment for
• hyperthyroidism
• a large goiter, which is an enlarged thyroid that may cause the neck to appear swollen and can
interfere with normal breathing and swallowing
• thyroid nodules, which are noncancerous tumors, called adenomas, or lumps in the thyroid that
can produce excess thyroid hormone
• thyroid cancer

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Medicines
Medicines such as amiodarone, lithium, interferon alpha, and interleukin-2 can prevent the
thyroid gland from being able to make hormone normally. These drugs are most likely to trigger
hypothyroidism in patients who have a genetic tendency to autoimmune thyroid disease.

Too much or too little iodine

The thyroid gland must have iodine to make thyroid hormone. Iodine comes into the body in
food and travels through the blood to the thyroid. Keeping thyroid hormone production in
balance requires the right amount of iodine. Taking in too much iodine can cause or worsen
hypothyroidism.

Damage to the pituitary gland

The pituitary, the “master gland,” tells the thyroid how much hormone to make. When the
pituitary is damaged by a tumor, radiation, or surgery, it may no longer be able to give the
thyroid instructions, and the thyroid may stop making enough hormone.

Grades of hypothyroidism
Hypothyroidism ranges from very mild states in which biochemical abnormalities are present but
the individual hardly notices symptoms and signs of thyroid hormone deficiency, to very severe
conditions in which the danger exists to slide down into a life threatening myxoedema coma. In
the development of primary hypothyroidism, the transition from the euthyroid to the hypothyroid
state is first detected by a slightly elevated serum TSH, caused by a minor decrease in thyroidal
secretion of T4 which doesn't give rise to subnormal serum T4 concentrations. The reason for
maintaining T4 values within the reference range is the exquisite sensitivity of the pituitary
thyrotroph for even very small decreases of serum T4, as exemplified by the log-linear
relationship between serum TSH and serum FT4. A further decline in T4 secretion results in
serum T4 values below the lower normal limit and even higher TSH values, but serum T3
concentrations remain within the reference range. It is only in the last stage that subnormal serum
T3 concentrations are found, when serum T4 has fallen to really very low values associated with
markedly elevated serum TSH concentrations. Hypothyroidism is thus a graded phenomenon, in
which the first stage of subclinical hypothyroidism may progress via mild hypothyroidism
towards overt hypothyroidisim.

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Fig. show Individual and median values of thyroid function tests in patients with various grades
of hypothyroidism. Discontinuous horizontal lines represent upper limit (TSH) and lower limit
(FT4, T3) of the normal reference ranges.

Symptoms of hypothyroidism
When thyroid hormone levels are too low, the body’s cells can’t get enough thyroid hormone and
the body’s processes start slowing down. As the body slows, you may notice that you feel

 colder,
 you tire more easily
 fatigue
 weight gain
 a puffy face
 cold intolerance
 joint and muscle pain
 dry, thinning hair
 decreased sweating
 heavy or irregular menstrual periods and impaired fertility
 slowed heart rate

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  your skin is getting drier
 you’re becoming forgetful and depressed
 and you’ve started getting constipated

As the symptoms are so variable and nonspecific, the only way to know for sure whether you
have hypothyroidism is with a simple blood test for TSH. Tell your family members. Because
thyroid disease runs in families, you should explain your hypothyroidism to your relatives and
encourage them to get periodic TSH tests. Tell your other doctors and your pharmacist about
your hypothyroidism and the drug and dose with which it is being treated. If you start seeing a
new doctor, tell the doctor that you have hypothyroidism and you need your TSH tested every
year. If you are seeing an endocrinologist, ask that copies of your reports be sent to your primary
care doctor.

Diagnosis of hypothyroidism.
The correct diagnosis of hypothyroidism depends on the following:
Symptoms. Hypothyroidism doesn’t have any characteristic symptoms. There are no symptoms
that people with hypothyroidism always have and many symptoms of hypothyroidism can occur
in people with other diseases. One way to help figure out whether your symptoms are due to
hypothyroidism is to think about whether you’ve always had the symptom (hypothyroidism is
less likely) or whether the symptom is a change from the way you used to feel (hypothyroidism
is more likely).

Medical and family history. You should tell your doctor:

• about changes in your health that suggest that your body is slowing down;
• if you’ve ever had thyroid surgery;
• if you’ve ever had radiation to your neck to treat cancer;
• if you’re taking any of the medicines that can cause hypothyroidism— amiodarone, lithium,
interferon alpha, interleukin-2, and maybe thalidomide;
• whether any of your family members have thyroid disease.

Physical exam. The doctor will check your thyroid gland and look for changes such as dry skin,
swelling, slower reflexes, and a slower heart rate.

Blood tests. There are two blood tests that are used in the diagnosis of hypothyroidism.
TSH (thyroid-stimulating hormone) test. This is the most important and sensitive test for
hypothyroidism. It measures how much of the thyroid hormone thyroxine (T4) the thyroid gland
is being asked to make. An abnormally high TSH means hypothyroidism: the thyroid gland is
being asked to make more T4 because there isn’t enough T4 in the blood.

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T4 tests. Most of the T4 in the blood is attached to a protein called thyroxine-binding globulin.
The “bound” T4 can’t get into body cells. Only about 1%–2% of T4 in the blood is unattached
(“free”) and can get into cells. The free T4 and the free T4 index are both simple blood tests that
measure how much unattached T4 is in the blood and available to get into cells.

Who is likely to develop hypothyroidism

Women are much more likely than men to develop hypothyroidism. The disease is also more
common among people older than age 60.
Certain factors can increase the chances of developing thyroid disorders. People may need more
regular testing if they
• have had a thyroid problem before, such as a goiter
• have had surgery to correct a thyroid problem
• have received radiation to the thyroid, neck, or chest
• have a family history of thyroid disease
• have other autoimmune diseases, including

– Sjögren’s syndrome, characterized by dry eyes and mouth

– pernicious anemia, a vitamin B12 deficiency
– type 1 diabetes
– rheumatoid arthritis
– lupus, a chronic inflammatory condition

• have Turner syndrome, a genetic disorder that affects females

• are older than age 60
• have been pregnant or delivered a baby within the past 6 months People should get tested
regularly to help uncover thyroid problems especially subclinical problems. Subclinical means a
person has no apparent symptoms.

pregnancy and thyroid conditions

Hypothyroidism.
During pregnancy, hypothyroidism is usually caused by Hashimoto’s disease and occurs in three
to five out of every 1,000 pregnancies.
Uncontrolled hypothyroidism raises the chance of miscarriage, preterm delivery, and
preeclampsia a dangerous rise in blood pressure during late pregnancy.
Untreated hypothyroidism during pregnancy may also affect the baby’s growth and brain
development. Thyroid medications can help prevent these problems and are safe to take during

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pregnancy. Women with hypothyroidism should discuss their condition with their health care
provider before becoming pregnant

Postpartum thyroiditis.
This inflammation of the thyroid gland affects about 4 to 9 percent of women in the first year
after giving birth. Postpartum thyroiditis is believed to be an autoimmune condition and causes
hyperthyroidism that usually lasts for 1 to 2 months.
Women with postpartum thyroiditis often develop hypothyroidism before the thyroid gland is
completely healed. The condition is likely to recur with future pregnancies.
Postpartum thyroiditis sometimes goes undiagnosed because the symptoms are mistaken for
postpartum blues the exhaustion and moodiness that sometimes follow delivery. If symptoms of
fatigue and lethargy do not go away within a few months or if a woman develops postpartum
depression, she should talk with her health care provider. If the hypothyroidism symptoms are
bothersome, thyroid medication can be given.

Hypothyroidism and metabolic defects

The thyroid hormones act directly on mitochondria, and thereby control the transformation of the
energy derived from oxidations into a form utilizable by the cell. Through their direct actions on
mitochondria, the hormones also control indirectly the rate of protein synthesis and thereby the
amount of oxidative apparatus in the cell. A rationale for the effects of thyroid hormone excess
or deficiency is based upon studies of the mechanism of thyroid hormone action. In
hypothyroidism, slow fuel consumption leads to a low output of utilizable energy. Many of the
chemical and physical features of these diseases can be reduced to changes in available energy.
Thyroid dysfunction is characterized by alterations in carbohydrate, lipid and lipoprotein
metabolism, consequently changing the concentration and composition of plasma lipoproteins. In
hyperthyroid patients, the turnover of low-density-lipoprotein apoprotein is increased, and the
plasma cholesterol concentration is decreased. Hypothyroidism in man is associated with an
increase in plasma cholesterol, particularly in low-density lipoproteins and often with elevated
plasma VLD lipoprotein, and there is a positive correlation with premature atherosclerosis.
Although it is known that myxoedemic patients have decreased rates of low-density lipoprotein
clearance from the circulation, it is not known with certainty if the elevated concentration of
VLD lipoprotein is due to increased secretion by the liver or to decreased clearance by the
tissues.

Hypothyroidism treatment.
Thyroxin(T4) replacement.
Hypothyroidism can’t be cured. But in almost every patient, hypothyroidism can be completely
controlled. It is treated by replacing the amount of hormone that your own thyroid can no longer
make, to bring your T4 and TSH levels back to normal levels. So even if your thyroid gland can’t
work right, T4 replacement can restore your body’s thyroid hormone levels and your body’s

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function. Synthetic thyroxine pills contain hormone exactly like the T4 that the thyroid gland
itself makes. All hypothyroid patients except those with severe myxedema (life-threatening
hypothyroidism) can be treated as outpatients, not having to be admitted to the hospital. For the
few patients who do not feel completely normal taking a synthetic preparation of T4 alone, the
addition of T3 (Cytomel) may be of benefit.
Health care providers treat hypothyroidism with synthetic thyroxine, a medication that is
identical to the hormone T4. The exact dose will depend on the patient’s age and weight, the
severity of the hypothyroidism, the presence of other health problems, and whether the person is
taking other drugs that might interfere with how well the body uses thyroid hormone. Health care
providers test TSH levels about 6 to 8 weeks after a patient begins taking thyroid hormone and
make any necessary adjustments to the dose. Each time the dose is adjusted, the blood is tested
again. Once a stable dose is reached, blood tests are normally repeated in 6 months and then once
a year. Hypothyroidism can almost always be completely controlled with synthetic thyroxine, as
long as the recommended dose is taken every day as instructed.

Eating, Diet, and Nutrition

Experts recommend that people eat a balanced diet to obtain most nutrients
Dietary Supplements Iodine is an essential mineral for the thyroid. However, people with
autoimmune thyroid disease may be sensitive to harmful side effects from iodine. Taking iodine
drops or eating foods containing large amounts of iodine such as seaweed, dulse, or kelp may
cause or worsen hypothyroidism or hyperthyroidism. Women need more iodine when they are
pregnant about 250 micrograms a day because the baby gets iodine from the mother’s diet. In the
United States, about 7 percent of pregnant women may not get enough iodine in their diet or
through prenatal vitamins. Choosing iodized salt supplemented with iodine over plain salt and
prenatal vitamins containing iodine will ensure this need is met.
To help ensure coordinated and safe care, people should discuss their use of dietary supplements,
such as iodine, with their health care provider.

Follow up.
You’ll need to have your TSH checked 6 to 10 weeks after a thyroxine dose change. You may
need tests more often if you’re pregnant or you’re taking a medicine that interferes with your
body’s ability to use thyroxine. The goal of treatment is to get and keep your TSH in the normal
range. Babies with hypothyroidism must get all their daily treatments and have their TSH levels
checked as they grow, to prevent mental retardation and stunted growth. Once you’ve settled into
a thyroxine dose, you can return for TSH tests about once a year.

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References
1. https://www.researchgate.net/publication/231814713
2. Ahmed OM, El-Gareib, AW, El-bakry, AM, Abd El-Tawab, S.M, Ahmed, RG. Thyroid
hormones states and brain development interactions. Int J Devl Neurosc 2008; 26: 147–209.
3. Golden SH, Robinson KA, Saldanha I, Anton B, Ladenson PW. Prevalence and incidence of
endocrine and metabolic disorders in the United States: a comprehensive review. Journal of
Clinical Endocrinology & Metabolism. 2009;94(6):1853–1878.
4. Ogunyemi DA. Autoimmune thyroid disease and pregnancy. emedicine website.
http://emedicine. medscape.com/article/261913-overview. Updated March 8, 2012. Accessed
February 11, 2013.
5. Zimmerman MB. Iodine deficiency in pregnancy and the effects of maternal iodine
supplementation on the offspring: a review. American Journal of Clinical Nutrition.
2009;89(2):668S–672S.

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