There is good news for people with hypothyroidism, the most common thyroid disorder: While the disease often went undiagnosed in the past, delaying treatment and resulting in needless suffering, a shift in the thinking of endocrinologists and internists is changing that.
Hypothyroidism has most often been diagnosed by determining if TSH – thyroid stimulating hormone – is elevated, but doctors are now taking their cue from symptoms that occur before high TSH levels pop up.
“Old school thinking was that TSH had to be at 7 or higher to treat for low thyroid but that has changed,” says Dr. Denise Tonner, an endocrinologist with Diabetes & Endocrine Associates of the Treasure Coast. “We now know that some people have a lot of symptoms even if the TSH is a 4 or 5, and we like pregnant women to be at around a 2.”
Currently, hypothyroidism affects about 11 million Americans and as doctors attack the disease sooner and at earlier stages, more of these people are getting the help they need.
Hypo means low; hypothyroidism occurs when there is an underproduction of the T3 and T4 hormones. Very frequently, the low production is caused by Hashimoto’s Disease, an autoimmune disorder in which the body attacks and kills thyroid tissues; as a result, the thyroid stops producing hormones.
The mineral iodine plays a paradoxical role in hypothyroidism. Iodine in the bloodstream is absorbed by the thyroid and is essential to the production of the T4 hormone, and eating foods high in iodine is recommended for thyroid health. In excessive amounts, however, iodine can actually cause hypothyroidism.
Foods high in iodine include iodized salt, cod, baked potato with peel, milk, shrimp, turkey breast and navy beans. Non-food sources of iodine are some cold and sinus medicines, lithium, the heart medicine amiodarone, and contrast dyes used in the administration of X-Rays.
Symptoms of hypothyroidism can include fatigue, depression, dry skin, hair loss, constipation, feeling foggy, muscle and joint aches, weight gain and prolonged, excessive menstrual bleeding. Some of these symptoms are vague and can be attributable to other conditions or simply the aging process. Dr. Tonner says, “It’s important, especially for women, to have TSH levels checked at least once; ideally, it should be checked as part of annual blood tests, called wellness panels.”
The thyroid is a butterfly-shaped gland right above the collarbone. It’s quite powerful; the hormones it produces, T3 and T4, affect almost every cell in the body; it also affects the metabolic processes – the speed at which the body converts food into energy.
The thyroid gets its hormone-production orders from TSH, which is released by the pituitary gland; that is why abnormal levels of TSH are the marker for thyroid disease. Elevated levels of the hormone indicate the thyroid is failing to produce sufficient T3 and T4, causing the body to push harder for production by secreting more TSH.
Although the condition is seen at all ages and in both genders, it is most typically diagnosed in middle-aged and older women; approximately 10 percent of women age 60 and older have been diagnosed with hypothyroidism; fortunately the condition is easily treated by medication that contains a synthetic thyroid hormone that needs to be taken for the rest of the patient’s life.
On the other end of the spectrum, and with a much lower incidence, is hyperthyroidism – in which production of thyroid hormones is too high. A common form is Graves Disease, a malfunction of the immune system in which abnormal antibodies are released that mimic TSH, giving the thyroid an erroneous message to produce T3 and T4 hormones.
This excess of hormones can cause an array of symptoms, including tremors, nervousness, fast heart rate, fatigue, heat intolerance and unintentional weight loss. A small percentage of those with Graves Disease have the complication of inflamed and swollen eye muscles, resulting in the protrusion of the eyeballs from their sockets. It is not clear why the immune system malfunctions in Graves Disease. It is known that it too affects women more than men, and that genetics and environmental factors, including stress, play a role.
Treatment of hyperthyroidism involves decreasing the production of the T3 and T4 hormones. While the patient’s age and general health come into play, Dr. Tonner’s usual approach is to treat with medication first to “cool off” the thyroid, and then follow with a dose of radioactive iodine.
“While it sounds scary, 90 percent of the time giving a dose of radioactive iodine is a permanent cure, and there are no side effects other than the strong possibility that the patient will develop hypothyroidism,” Tonner says.
In that case, which Tonner says happens 60-70 percent of the time, patients will need to take lifelong hormone replacement medication. In effect, this is trading one condition for another, but hypothyroidism can be controlled much more reliably than hyperthyroidism, and in a safe and cost-effective way.
The good news is that both types of “thyroidism” can be well managed with medical treatment, and neither is life-threatening.
More serious is thyroid cancer, although it too has a good prognosis if detected early. There about 60,000 new cases in the United States each year; it is more common in women than men, and Asians have a higher incidence. It tends to run in families; another risk factor is prior radiation treatments.
Thyroid cancer can be hard to diagnose, as it doesn’t always have symptoms, especially early in the disease. Symptoms, when they occur, are the same as that of non-malignant throat nodules, and can include:
• A lump on the neck, which can be felt through the skin
• Changes to the voice, including hoarseness
• Difficulty swallowing
• Pain in the neck and throat
• Swollen lymph nodes in the neck
Diagnosis is usually made through a combination of physical exam, blood tests, imaging tests and biopsy.
While there are a number of treatments available for patients with thyroid cancer, Dr. Tonner’s opinion is that surgical removal of the entire thyroid followed by a “mop-up” dose of radioactive iodine is typically the best approach.
Other options include:
• Surgery to remove the cancerous nodule.
• Radiation therapy. Can be either external (e.g. X-Rays) or internal (radioactive substance is placed near the cancer in needles, seeds, wires or catheters).
• Chemotherapy. Stops the growth of cancer cells; can be taken by mouth or injected into a vein or muscle.
• Thyroid hormone therapy. This treatment removes hormones or blocks their action, to stop cancer cells from growing.
• Targeted therapy. Type of drug treatment that identifies and attacks cancer cells without harming normal cells.
Sometimes, combination treatments are used.
Dr. Tonner emphasizes that every patient is different, from the stage of their cancer to other patient-specific factors. It’s important for patients to talk through all possible treatment options with their doctor.
A quick mention of a very visible thyroid condition – a goiter. It’s an enlargement of the thyroid gland; its presence does not necessarily mean the thyroid is malfunctioning. Tests are needed to determine what treatment, if any, is called for.
Diabetes & Endocrine Associates of the Treasure Coast is located at 2835 20th Street in Vero Beach; the phone number is 772-299-3003.
