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Jump to: navigation, search Hypothyroidism Classification and external resources Thyroxine (T4) normally produced in 20:1 ratio

to triiodothyronine (T3) ICD-10 E03.9 ICD-9 244.9 DiseasesDB 6558 MedlinePlus 000353 eMedicine med/1145 MeSH D007037

Hypothyroidism / hapardzm/ is a state in which the thyroid gland does not ma e enou d hormone. Iodine deficiency is often cited as the most common cause of hypothyroidism worl dwide but it can be caused by many other factors. It can result from the lac of a thyroid gland or from iodine-131 treatment, and can also be associated with i ncreased stress. Severe hypothyroidism in infants can result in cretinism. A 2011 study concluded that about 8% of women over 50 and men over 65 in the UK suffer from an under-active thyroid and that as many as 100,000 of these people could benefit from treatment they are currently not receiving.[1] Contents 1 Classification 2 Signs and symptoms 2.1 Early 2.2 Late 2.3 Uncommon 2.4 Subclinical hypothyroidism 3 Pregnancy and fertility 4 Epidemiology 5 Causes 5.1 Stress and hypothyroidism 6 Diagnosis 7 Treatment 7.1 Treatment controversy 7.2 Subclinical hypothyroidism 7.3 Alternative treatments 7.4 Non-human presentation 8 See also 9 References 10 Further reading 11 External lin s Classification Hypothyroidism is often classified by association with the indicated organ dysfu nction (see below):[2][3] Type Origin Primary Thyroid gland The most common forms include Hashimoto's thyroi ditis (an autoimmune disease) and radioiodine therapy for hyperthyroidism. Secondary Pituitary gland Occurs if the pituitary gland does not c reate enough thyroid-stimulating hormone (TSH) to induce the thyroid gland to pr oduce enough thyroxine and triiodothyronine. Although not every case of secondar y hypothyroidism has a clear-cut cause, it is usually caused by damage to the pi tuitary gland, as by a tumor, radiation, or surgery.[4] Secondary hypothyroidism

accounts for less than 5%[5] or 10%[6] of hypothyroidism cases. Tertiary Hypothalamus Results when the hypothalamus fails to produce s ufficient thyrotropin-releasing hormone (TRH). TRH prompts the pituitary gland t o produce thyroid-stimulating hormone (TSH). Hence may also be termed hypothalam ic-pituitary-axis hypothyroidism. It accounts for less than 5% of hypothyroidism cases.[5] Signs and symptoms Early hypothyroidism is often asymptomatic and can have very mild symptoms. Subc linical hypothyroidism is a state of normal thyroid hormone levels, thyroxine (T 4) and triiodothyronine (T3), with mild elevation of thyrotropin, thyroid-stimul ating hormone (TSH). With higher TSH levels and low free T4 levels, symptoms bec ome more readily apparent in clinical (or overt) hypothyroidism. Author Hilary Mantel wrote a memoir, Giving up the Ghost, which describes amongs t other things the effects on her of thyroid failure, which was treated by perma nent medication once belatedly diagnosed.[7][8] Hypothyroidism can be associated with the following symptoms:[9][10][11] Early Cold intolerance, increased sensitivity to cold Constipation Weight gain and water retention[12][13][14] Bradycardia (low heart rate fewer than sixty beats per minute) Fatigue[15] Decreased sweating Muscle cramps and joint pain Dry, itchy s in Thin, brittle fingernails Rapid thoughts Depression Poor muscle tone (muscle hypotonia) Female infertility; any ind of problems with menstrual cycles Hyperprolactinemia and galactorrhea Elevated serum cholesterol Late Goiter Slow speech and a hoarse, brea ing voice deepening of the voice can also be noticed, caused by Rein e's Edema. Dry puffy s in, especially on the face Thinning of the outer third of the eyebrows (sign of Hertoghe) Abnormal menstrual cycles Low basal body temperature Thyroid-related depression Infertility in both men and women Mood swings Acute fatigue syndrome Stress Decreased libido in men hypertension; Hypothyroidism increased peripheral vascular resistance, incre ase diastolic pressure, increased mean arterial pressure carpal tunnel syndrome and bilateral parethesias Uncommon Impaired memory[16] Impaired cognitive function (brain fog) and inattentiveness.[17]

A slow heart rate with ECG changes including low voltage signals. Diminished cardiac output and decreased contractility Reactive (or post-prandial) hypoglycemia[18] Sluggish reflexes Hair loss Anemia caused by impaired haemoglobin synthesis (decreased erythropoietin le vels), impaired intestinal iron and folate absorption or B12 deficiency[19] from pernicious anemia Difficulty swallowing Shortness of breath with a shallow and slow respiratory pattern Increased need for sleep Irritability and mood instability Yellowing of the s in due to impaired conversion of beta-carotene[20] to vit amin A (carotoderma) Impaired renal function with decreased glomerular filtration rate Acute psychosis (myxedema madness) (a rare presentation of hypothyroidism) Decreased libido in men[21] due to impairment of testicular testosterone syn thesis Decreased sense of taste and smell (anosmia) Puffy face, hands and feet (late, less common symptoms) Gynecomastia Deafness[22] Enlarged tongue[23] Subclinical hypothyroidism Subclinical hypothyroidism occurs when thyrotropin (TSH) levels are elevated but thyroxine (T4) and triiodothyronine (T3) levels are normal.[24] In primary hypo thyroidism, TSH levels are high and T4 and T3 levels are low. TSH usually increa ses when T4 and T3 levels drop. TSH prompts the thyroid gland to ma e more hormo ne. In subclinical hypothyroidism, TSH is elevated but below the limit represent ing overt hypothyroidism. The levels of the active hormones will be within the l aboratory reference ranges. Pregnancy and fertility Main article: Thyroid disease in pregnancy During pregnancy there is a substantially increased need of thyroid hormones and substantial ris that a previously unnoticed, subclinical or latent hypothyroid ism will turn into overt hypothyroidism. Subclinical hypothyroidism in early pregnancy, compared with normal thyroid func tion, has been estimated to increase the ris of pre-eclampsia with an odds rati o (OR) of 1.7 and the ris of perinatal mortality with an OR of 2.7.[25]

0.3% of the general American population have overt hypothyroidism, and 4.3% have subclinical hypothyroidism.[26] A 1995 survey in the UK found the mean incidenc e (with 95% confidence intervals) of spontaneous hypothyroidism in women was 3.5 /1000 survivors/year (2.84.5) rising to 4.1/1000 survivors/year (3.35.0) for all c auses of hypothyroidism and in men was 0.6/1000 survivors/year (0.31.2).[27] Data from the CDC spanning the years 1999 to 2010 yield similar numbers: hypothyroid ism is four times as common among women as among men.[15] Estimates of subclinical hypothyroidism range between 38%, increasing with age; t he median age of someone with hypothyroidism is 58.[15][28] Causes Iodine deficiency is the most common cause of hypothyroidism worldwide.[4][29] I

Even mild or subclinical hypothyroidism is Epidemiology

nown to adversely affect fertility.

n iodine-replete individuals hypothyroidism is fre uently caused by Hashimoto's thyroiditis,[29][30] or otherwise as a result of either an absent thyroid gland or a deficiency in stimulating hormones from the hypothalamus or pituitary. Exposure to iodine-131 from nuclear fallout, which is chemically indistinguishab le from non-radioactive isotopes and ta en up by the thyroid gland with them, de stroys thyroid cells and increases the ris of hypothyroidism. Congenital hypothyroidism is very rare, accounting for approximately 0.2% of cas es, and can have several causes such as thyroid aplasia or defects in the hormon e metabolism. Thyroid hormone insensitivity (most often T3 receptor defect) also falls into this category, although in this condition levels of thyroid hormones may be normal or even mar edly elevated. Hypothyroidism can result from postpartum thyroiditis up to 9 months after givin g birth, characterized by transient hyperthyroidism followed by transient hypoth yroidism. The syndrome is seen in 5 to 9% of women. The first phase is typically hyperthyroidism; the thyroid then either returns to normal, or a woman develops hypothyroidism. Of those women who experience hypothyroidism associated with po stpartum thyroiditis, 25 to 30% will develop permanent hypothyroidism re uiring lifelong thyroxin replacement therapy.[31] Hypothyroidism can result from de Quervain's thyroiditis, which, in turn, is oft en caused by having bad case of flu that infects and destroys part, or all, of t he thyroid.[32] Hypothyroidism can also result from sporadic inheritance, sometimes autosomal re cessive.[citation needed] Temporary hypothyroidism can be due to the Wolff-Chai off effect. A very high in ta e of iodine can be used to temporarily treat hyperthyroidism, especially in a n emergency situation. Although iodide is a substrate for thyroid hormones, high levels reduce iodide organification in the thyroid gland, decreasing hormone pr oduction. The antiarrhythmic agent amiodarone can cause hyper- or hypothyroidism due to its high iodine content. Hypothyroidism can be caused by lithium-based mood stabilizers, usually used to treat bipolar disorder (previously nown as manic depression).[4] In fact, lithi um has occasionally been used to treat hyperthyroidism.[33] Other drugs that may produce hypothyroidism include interferon alpha, interleu in-2, and thalidomide .[4] Stress and hypothyroidism Stress is nown to be a significant contributor to thyroid dysfunction; this can be environmental stress as well as lesser-considered homeostatic stress such as fluctuating blood sugar levels and immune problems.[citation needed] Stress's e ffect on thyroid function can be indirect, through its effects on blood sugar le vels (dysglycemia),[34] but it can also have more direct effects. Stress may cau se hypothyroidism or reduced thyroid functioning by disrupting the HPA axis whic h down-regulates thyroid function,[35] reducing the conversion of T4 to T3,[36] wea ening the immune system thus promoting autoimmunity,[37] causing thyroid hor mone resistance,[38] and resulting in hormonal imbalances. Indeed, excess estrog en in the blood caused by chronic cortisol elevations can result in hypothyroid symptoms by decreasing levels of active T3.[39] Stress also affects thyroid func tioning through the sympathetic nervous system.[40] A 1994 study of refugees fro m East Germany who experienced chronic stress found them to have a very high rat e of hypothyroidism or subclinical hypothyroidism, although not all refugees dis played clinical or behavioral symptoms associated with this reduced thyroid func tioning.[41] TSH levels correlate positively with physiological stress.[42][43]

Adrenal insufficiency can also result in hypothyroid symptoms without affecting the thyroid itself.[44] Diagnosis Main article: Thyroid function tests The only validated test to diagnose primary hypothyroidism, is to measure thyroi d-stimulating hormone (TSH) and free thyroxine (T4).[45] However, these levels c an be affected by non-thyroidal illnesses. High levels of TSH indicate that the thyroid is not producing sufficient levels of thyroid hormone (mainly as thyroxine (T4) and smaller amounts of triiodothyro nine (T3)). However, measuring just TSH fails to diagnose secondary and tertiary hypothyroidism, thus leading to the following suggested blood testing if the TS H is normal and hypothyroidism is still suspected: Free triiodothyronine (fT3) Free thyroxine (fT4) Total T3 Total T4 Additionally, the following measurements may be needed: Free T3 from 24-hour urine catch[46] Antithyroid antibodies for evidence of autoimmune diseases that may be damag ing the thyroid gland Serum cholesterol which may be elevated in hypothyroidism Prolactin as a widely available test of pituitary function Testing for anemia, including ferritin Basal body temperature Treatment Main article: Medical use of thyroid hormones Hypothyroidism is treated with the levorotatory forms of thyroxine (levothyroxin e) (L-T4) and triiodothyronine (liothyronine) (L-T3). Synthroid, produced by Abb ott Laboratories, is the brand name counterpart to the generic Levothyroxine. Sy nthroid is also the most common pill prescribed by doctors that has the syntheti c thyroid hormone in it, and it is ta en by over 40% of people with hypothyroidi sm.[15] This medicine can improve symptoms of thyroid deficiency such as slow sp eech, lac of energy, weight gain, hair loss, dry s in, and feeling cold. It als o helps to treat goiter. It is also used to treat some inds of thyroid cancer a long with surgery and other medicines. Both synthetic and animal-derived thyroid tablets are available and can be prescribed for patients in need of additional thyroid hormone. Thyroid hormone is ta en daily, and doctors can monitor blood l evels to help assure proper dosing. Levothyroxine, the generic form of synthroid , is best ta en 3060 minutes before brea fast, as some food can diminish absorpti on. Calcium can inhibit the absorption of levothryoxine.[47] Compared to water, coffee reduces absorption of levothyroxine by about 30 percent.[48] Some patient s might appear to be resistant to levothyroxine, when in fact they do not proper ly absorb the tablets a problem which is solved by pulverizing the medication.[4 9] There are several different treatment protocols in thyroid-replacement therap y: T4 only This treatment involves supplementation of levothyroxine alone, in a synthet ic form. It is currently the standard treatment in mainstream medicine.[50] T4 and T3 in combination This treatment protocol involves administering both synthetic L-T4 and L-T3 simultaneously in combination.[51]

Desiccated thyroid extract Desiccated thyroid extract is an animal-based thyroid extract, most commonly from a porcine source. It is also a combination therapy, containing natural for ms of L-T4 and L-T3.[52] Treatment controversy The potential benefit from substituting some T3 for T4 has been investigated, bu t no conclusive benefit for combination therapy has been shown.[53][54] The 2002 Laboratory Medicine Practice Guidelines of the National Academy of Clin ical Biochemistry state that during pregnancy, "The L-T4 dose should be increase d (usually by 50 mcg/day) to maintain a serum TSH between 0.5 and 2.0 mIU/L and a serum FT4 in the upper third of the normal reference interval." Doctors howeve r often assume that if your TSH is in the "normal range", sometimes defined as h igh as 5.5 mIu/L, it has no effect on fertility. Healthy pregnant women however have a TSH level of around 1.0 mIU/L. Subclinical hypothyroidism There is a range of opinion on the biochemical and symptomatic point at which to treat with levothyroxine, the typical treatment for overt hypothyroidism. Refer ence ranges have been debated as well. As of 2003, the American Association of C linical Endocrinologists (ACEE) considers 0.33.0 mIU/L within normal range.[55] There is always the ris of overtreatment and hyperthyroidism. Some studies have suggested that subclinical hypothyroidism does not need to be treated. A 2007 m eta-analysis by the Cochrane Collaboration found no benefit of thyroid-hormone r eplacement except "some parameters of lipid profiles and left-ventricular functi on."[56] A 2002 meta-analysis loo ing into whether subclinical hypothyroidism ma y increase the ris of cardiovascular disease, as has been previously suggested, [57] found a possible modest increase and suggested further studies be underta e n with coronary-heart disease as an end point "before current recommendations ar e updated."[58] Alternative treatments Compounded slow-release T3 has been suggested for use in combination with T4, wh ich proponents argue will mitigate many of the symptoms of functional hypothyroi dism and improve uality of life. This is still controversial and is rejected by the conventional medical establishment.[59] Non-human presentation Hypothyroidism is also a relatively common disease in domestic dogs, with some s pecific breeds having a definite predisposition.[60] See also Adrenal insufficiency Hyperthyroidism Pituitary disease Subacute lymphocytic thyroiditis Thyroid hormone resistance

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