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Understand Thyroid – A Functional Myriad, and Clear Skepticism on Hypothyroidism

Dr. K. V. Narasimha Raju & Dr. B. Swapna

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Signs (Descending Order of Frequency):

  • Dry coarse skin; cool peripheral extremities
  • Puffy face, hands, and feet (myxedema)
  • Diffuse alopecia
  • Bradycardia
  • Peripheral edema
  • Delayed tendon reflex relaxation
  • Carpal tunnel syndrome
  • Serous cavity effusions
  • As the disease becomes more severe, there may be puffiness around the eyes, a slowing of the heart rate, a drop in body temperature, and heart failure. In its most profound form, severe hypothyroidism may lead to a life-threatening coma (myxedema coma). In a severely hypothyroid individual, amyxedema coma  tends to be triggered by severe illness, surgery, stress, or traumatic injury. This condition requires hospitalization and immediate treatment with thyroid hormones given by injection.
Subclinical Hypothyroidism
Subclinical hypothyroidism refers to a state in which patients do not exhibit the symptoms of hypothyroidism. These patients also have a normal amount of circulating thyroid hormone. The only abnormality is an increased TSH. This implies that the pituitary gland is working extra hard to maintain a normal circulating thyroid hormone level and that the thyroid gland requires extra stimulation by the pituitary to produce adequate hormones. The majority of these patients can be expected to progress to obvious hypothyroidism, especially if the TSH is above a certain level.

While there is some controversy, many endocrinologists will treat such patients, especially if they have a high cholesterol blood level. The abnormal cholesterol profile will likely show improvement with thyroid hormone replacement. If the cholesterol levels are normal, and the patient feels well, it is also reasonable to follow these patients without treatment and repeat the blood TSH and thyroid hormone levels in 4 to 6 months to see if more significant hypothyroidism is apparent. Both of these approaches are reasonable and patients should be encouraged to speak with their physicians about specific concerns and preferences.

Diagnosis
A diagnosis of hypothyroidism can be suspected in patients with fatigue, cold intolerance, constipation, and dry, flaky skin. A blood test is needed to confirm the diagnosis.

When hypothyroidism is present, the blood levels of thyroid hormones (T3 and T4) can be measured directly and are usually decreased. However, in early hypothyroidism, the level of thyroid hormones may be normal. Therefore, the main tool for the detection of hyperthyroidism is the measurement of the TSH. If a decrease of thyroid hormone occurs, the pituitary gland reacts by producing more TSH and the blood TSH level increases in an attempt to encourage thyroid hormone production. This increase in TSH can actually precede the fall in thyroid hormones by months or years. Thus, the measurement of TSH should be elevated in cases of hypothyroidism.

However, there is one exception. If the decrease in thyroid hormone is actually due to a defect of the pituitary or hypothalamus, then the levels of TSH are abnormally low. A special test, known as the TRH test, can help distinguish if the disease is caused by a defect in the pituitary or the hypothalamus.

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