Three years ago, two women in the Richmond area struggled with weight gain and lethargy.
OK, perhaps there were a few more tired, overweight women in the population, but both of these women soon found that their complaints were symptoms of thyroid disease. I was one of them.
At age 25, I found my predicament unusual — I had no energy and described my house as "freezing" even when the thermostat was set at 70 degrees. When I talked with my doctor about my symptoms and told her that my aunt had a thyroid problem, she recommended that I get tested as well. My thyroid levels were checked, but no alarms went off. But after a year of struggling with the same symptoms, I saw an endocrinologist.
Enter Dr. Brenda Armenti-Kapros with Hanover Endocrinology Associates. She diagnosed me with hypothyroidism, an elevated level of thyroid-stimulating hormone (TSH).
Across town, Betsy Murray could barely force herself to get out of bed. The normally energetic Chesterfield County schools administrator, who was
53 years old at the time and has since retired, spent her summer exhausted and went to sleep at 6 p.m. once school started.
"I told my doctor what I was experiencing and I said, ‘I feel like I've lost my mojo — not only am I tired, I just have no motivation,' " Murray says. "The first thing that he thought was that it was depression … but I kept saying that I didn't feel sad."
Her doctor prescribed an antidepressant but also ordered a blood test. He referred Murray to an endocrinologist when the results indicated that she had hypothyroidism.
Two women, at different stages in their lives and with symptoms common to many people; our stories illustrate the potentially elusive nature of the thyroid disease diagnosis.
To test or not to test
The thyroid, a butterfly-shaped gland at the base of the throat, releases hormones that regulate the body's metabolism. There are several types of thyroid disorders, including hypothyroidism (underactive thyroid), hyperthyroidism (overactive thyroid), nodules (abnormal growths in the gland) and goiter (enlarged thyroid) — all of which are generally five to six times more common in women than in men.
Although a simple blood test makes thyroid disorders easy to diagnose, and hormone replacement makes it easy to treat, physicians don't always know when to seek a diagnosis or medicate.
Like mine, Murray's underactive thyroid wasn't secreting enough thyroid hormones, and therefore her pituitary gland, which is located in the brain, kept releasing TSH in a fruitless attempt to stimulate the thyroid's hormone production. Although there are several causes of hypothyroidism, most of the cases in the United States are the result of autoimmune thyroiditis. Also known as Hashimoto's thyroiditis, it occurs, like all autoimmune disorders, when the body produces abnormal antibodies. With thyroiditis, these antibodies essentially attack the thyroid.
Hypothyroidism is the most common thyroid disorder, affecting 1 percent of women and 0.1 percent of men overall and increasing in prevalence with age — 15 percent to 20 percent of women over the age of 60 have at least a mild form of hypothyroidism. If untreated, it may lead to progressively worsening symptoms as well as fertility problems.
Dr. David Gardner, professor of medicine in Virginia Commonwealth University's division of endocrinology and metabolism, says it's unclear why women are more likely to develop thyroid disease and autoimmune disorders in general. He also explains that the subtle symptoms of the disease make it difficult to diagnose.
"If you go into a room with 100 people and you say, ‘How many people are tired?' three-quarters raise their hands," Gardner says. "[If you ask] ‘How many people have difficulty losing weight?' they raise their hands. ‘How many people have dry skin?' they raise their hands … There are a host of symptoms of hypothyroidism that occur in the general population and occur in hypothyroid patients, so how do you know whether your patient, if you're a physician, has thyroid disease, or is just an average Joe or Jane?"
Gardner finds hyperthyroidism, which is not as common (it's found in 0.4 percent to 1 percent of patients of any age), a little easier to diagnose because the symptoms stand out: nervousness, weight loss, shaky hands, palpitations, sensitivity to heat and profuse sweating. Often the result of an autoimmune disorder called Graves Disease, which makes the thyroid gland produce more hormones than necessary, untreated hyperthyroidism may lead to heart disease, osteoporosis, weight loss and muscle weakness.
"I suspect we are missing some hyperthyroid patients, but I worry more that we are missing some hypothyroid patients," Gardner says, noting that more people are treated today because of increased diagnoses.
Which leads to a controversial question: Should physicians screen all women for thyroid disorders?
"Twenty five years ago, a thyroid test wasn't part of the routine laboratory workup when you went for a physical exam," Gardner explains, "but now the TSH test is an excellent screening test for both hyper- and hypothyroidism, and it's relatively inexpensive. It's becoming part of the routine for many physicians to order a TSH."
However, medical professionals don't agree on who to test and when to test. The American Thyroid Association recommends that everyone older than 35 get a TSH test once every five years. The U.S. Preventive Services Task Force only advocates screening for congenital hypothyroidism (when the thyroid does not function at birth) in newborns. Yet an expert panel reported in the Jan. 14, 2004, issue of the Journal of the American Medical Association that the general population should not be screened and that only those at high risk should be evaluated and then tested for thyroid disorders.
At the very least, Gardner supports testing women at high risk, meaning any woman with a family history of thyroid disease, a family or personal history of autoimmune disorders (including Type I diabetes — 15 percent to 20 percent of these patients have thyroid disease), suspicious symptoms, previous surgery on the thyroid, high cholesterol, a thyroid that feels enlarged or a history of psychiatric disease (particularly depression because the symptoms overlap).
He says those over the age of 60 and those who are pregnant should also get their blood tested, as well as patients taking certain medications associated with the development of hypothyroidism or those who have had head or neck irradiation as a cancer treatment.
To treat or not to treat
The next question up for debate: Once an abnormality is discovered, should it be treated?
Gardner says it's hard to find good evidence to support treatment of very mild hypothyroidism, especially if there are few to no symptoms, but the more abnormal the test, the more likely physicians are to treat the disease.
He commented on several studies that suggest mild hypothyroidism is associated with heart disease. "Let's say that's true," he says. "Does treating mild hypothyroidism prevent the development of heart disease? Not necessarily. But there are data that suggest that mild hypothyroidism may have other consequences; it may increase the risk of coronary disease in particular, and might tend to raise your cholesterol, so those might be other reasons to treat it even if the patient doesn't feel bad."
Murray's TSH level was approximately 9.9 when she was diagnosed with hypothyroidism. According to the American Thyroid Association, a TSH of 4 to 10 constitutes subclinical or "mild" hypothyroidism, and although treating it does no harm, more research is needed to determine whether or not treatment is beneficial.
"I have energy now because I take the pills — I have the energy, I can get out of bed," Murray says, although she has found that, even with regular exercise and a strict diet, she still can't lose the weight she gained. Like most hypothyroid patients, Murray and I will take a synthetic thyroxine pills (also called L-thyroxine or levothyroxine) every day for the rest of our lives to replace the thyroid hormones our bodies fail to produce.
Murray doesn't know if she has a family history of thyroid disease but suspects her grandmother had hypothyroidism. It's an inherent problem when it comes to determining risk — relatives with the disease may have never been tested.
Unlike Murray, I knew about a family history — my aunt was diagnosed with hypothyroidism in her late 30s, and it was she who referred me to Armenti-Kapros. "It was the symptoms and the numbers; [the disease] wasn't that overt," Armenti-Kapros says of my condition when I first visited her office. "The question is to treat or not to treat. It becomes both a clinical and a metabolic issue. What does the number look like? How does the patient really feel? Is [treatment] beneficial? Does the good outweigh the bad? Those are the questions you ask yourself when someone is mildly hypothyroid."
Armenti-Kapros put me on a low dose of synthetic thyroid hormone, but the numbers continued to rise every few months. "If the person has mild thyroid disease, it could be transient," she says. "Sometimes you treat it for a short time and you can back off and see if it resolves. Some people, you start them on medication in the early stages when the TSH is 6 or 8, not 50 or 60, and you've caught it as the thyroid gland is dying. The residual function sort of peters out and then you do need to adjust the medication."
I felt better almost immediately after the treatment began, and then I learned I was pregnant late last year. After my first prenatal visit at eight weeks, my obstetrician consulted with Armenti-Kapros, and they immediately increased my dosage. They have raised it again since then.
Had I not started treatment, my condition would have been much worse during the critical stages of the baby's development. The baby depends on the mother for thyroid hormone in the first trimester, and untreated maternal hypothyroidism may lower the child's IQ or lead to miscarriage or impaired fetal brain development, according to the ATA.
Armenti-Kapros says it's becoming routine for obstetricians to test women who are pregnant. Gardner also tests those struggling with infertility. "My understanding is that hypothyroidism leads to anovulatory cycles — cycles in which there is no ovulation," he says. Therefore, thyroid testing is recommended for females struggling with fertility.
"If a woman goes to the doctor and says, ‘I've been trying to get pregnant for the last six months and haven't been able to conceive' … one of the tests every gynecologist and every internist would do is a thyroid test to make sure the thyroid is functioning properly," Gardner says. "It's usually normal, but it's the easiest thing to fix [if it's not]."
----------------------------
More on the Thyroid
• Iodine deficiency is a major cause of hypothyroidism because iodine is essential for thyroid hormone production. This is rare in the United States, though, because iodine is in processed foods and an additive to table salt. However, there is some evidence based on animal research that ingesting soy may increase the risk of hypothyroidism if iodine intake is low.
• According to the American Thyroid Association, soy does not cause hypothyroidism, but if a patient is being treated with thyroid supplements it may interfere with the ability to absorb those hormones — drinking a glass of soy milk when taking thyroid medication could diminish the drug's effectiveness.
• By law, all babies born in the United States are tested for congenital hypothyroidism — their thyroids simply do not function from the start. This form of thyroid disease affects one in every 3,000 to 4,000 newborns. If detected, doctors administer treatment quickly to prevent irreversible brain damage.
• Hyperthyroid patients may be treated with anti-thyroid drugs or radioactive iodine, which damages or destroys overactive thyroid cells. Most patients treated with radioactive iodine become hypothyroid over time and are then treated with thyroid hormone supplements.
