Overactive Thyroid (Hyperthyroidism)

Your thyroid gland is located in the front of your neck. Hormones released by the thyroid
affect nearly every part of your body from your brain to your skin and muscles. They play a
crucial role in controlling how your body uses energy, a process called metabolism. This
includes how your heart beats and even how you burn calories.
Women are five to 10 times more likely to develop hyperthyroidism than men.
Thyroid Hormone Regulation The Chain of Command
The thyroid itself is regulated by another gland located in the brain, called the pituitary. n
turn, the pituitary is regulated in part by thyroid hormone that is circulating in the blood !a
"feedback" effect of thyroid hormone on the pituitary gland# and in part by another gland
called the hypothalamus, also a part of the brain. The hypothalamus releases a hormone
called thyrotropin releasing hormone !T$H#, which sends a signal to the pituitary to release
thyroid stimulating hormone !T%H#. n turn, T%H sends a signal to the thyroid to release
thyroid hormones. f overactivity of any of these three glands occurs, an e&cessive amount of
thyroid hormones can be produced, thereby resulting in hyperthyroidism. The rate of thyroid
hormone production is controlled by the pituitary gland. f there is an insufficient amount of
thyroid hormone circulating in the body to allow for normal functioning, the release of T%H
is increased by the pituitary in an attempt to stimulate the thyroid to produce more thyroid
hormone. n contrast, when there is an e&cessive amount of circulating thyroid hormone, the
release of T%H is reduced as the pituitary attempts to decrease the production of thyroid
hormone.
Causes of Hyperthyroidism
The causes of hyperthyroidism include'
Graves' disease. The most common cause of hyperthyroidism is an autoimmune
condition called (raves) disease. The body)s immune system creates an antibody that
causes the gland to make an e&cessive amount of thyroid hormone. (raves) disease
runs in families, and usually affects younger women.
Thyroiditis. Thyroiditis is inflammation of the thyroid. * virus or problem with the
immune system causes the gland to swell, leaking thyroid hormone into the
bloodstream. There are several types of thyroiditis.
o u!acute" * sudden, painful form of thyroiditis of unknown cause. The thyroid
usually heals on its own after a few months. The thyroid can become
underactive for a while before it returns to normal.
o #ostpartum" This type of thyroiditis affects women after pregnancy. +ne to two
women out of every 10 women develop hyperthyroidism after having a baby. t
usually lasts a month or two, followed by several months of underactive thyroid
!hypothyroidism#. n most women, the thyroid returns to normal.
o ilent" This type is similar to postpartum thyroiditis but is not related to
pregnancy. The thyroid produces too much hormone but patients do not develop
a painful thyroid gland. %ome people may develop hypothyroidism afterwards.
Thyroid nodule. +ne or more lumps, or nodules, can grow in the thyroid gland,
gradually increasing the gland)s activity and the amount of thyroid hormone in your
blood.
f one nodule causes hyperthyroidism, it is called a single to&ic nodule.
$f several nodules cause the thyroid to !ecome overactive% the condition is called
to&ic multinodular goiter.
'&cess iodine. You may also develop hyperthyroidism if you eat, drink, or are
otherwise e&posed to substances that contain a high amount of iodine. odine is used
by the body to make thyroid hormone. ,elp or seaweed supplements and the
medication amiodarone !-ordarone, .acerone#, once used to treat irregular heartbeats,
are e&amples of medicines that contain a lot of iodine.
Thyroid medications. Taking too much thyroid hormone medication can wreak
havoc on your thyroid gland and cause hyperthyroidism. f you have been prescribed
thyroid replacement hormone !for hypothyroidism#, never take an e&tra dose, even if
you missed one, without first talking to your doctor.
(OT'"
f a nodule causes hyperthyroidism, it is usually noncancerous. Treatment is aimed at
preventing the signs, symptoms, and complications of hyperthyroidism, such as heart failure,
osteoporosis,, and rapid heart rate. Treatments include destroying the gland using radioactive
iodine !1/10iodine#, blocking production of thyroid hormone with medications, or
conservatively following the patient with mild hyperthyroidism. "%ubclinical
hyperthyroidism" refers to an adult patient with a hyperfunctioning nodule, but T%H is
minimally suppressed and the blood levels of thyroid hormones are normal. Treatment is
individuali1ed based on age, presence of other medical conditions, and patient preference.
)hat Causes Hyperthyroidism*
%ome common causes of hyperthyroidism include'
(raves) 2isease
3unctioning adenoma !"hot nodule"# and To&ic 4ultinodular (oiter !T45(#
6&cessive intake of thyroid hormones
*bnormal secretion of T%H
Thyroiditis !inflammation of the thyroid gland#
6&cessive iodine intake
We)ll take a look at the causes of each of these conditions on the following slides.
Graves' +isease
(raves) disease, which is caused by a generali1ed overactivity of the thyroid gland, is the
most common cause of hyperthyroidism. n this condition, the thyroid gland usually is
renegade, which means it has lost the ability to respond to the normal control by the pituitary
gland via T%H. (raves) disease is hereditary and is up to five times more common among
women than men. The triggers for (raves) disease include stress, smoking, radiation to the
neck, medications, and infectious organisms such as viruses. (raves) disease can be
diagnosed by a nuclear medicine thyroid scan and blood test. (raves) disease may be
associated with eye disease !(raves) ophthalmopathy# and skin lesions !dermopathy#.
,unctioning -denoma and To&ic .ultinodular Goiter
The thyroid gland !like many other areas of the body# becomes lumpier as we get older. n the
ma7ority of cases, these lumps do not produce thyroid hormones and re8uire no treatment.
+ccasionally, a nodule may become "autonomous," which means that it does not respond to
pituitary regulation via T%H and produces thyroid hormones independently. This becomes
more likely if the nodule is larger than / cm. When there is a single nodule that is
independently producing thyroid hormones, it is called a functioning nodule. f there is more
than one functioning nodule, the term to&ic, multinodular goiter is used. 3unctioning nodules
may be readily detected with a thyroid scan.
'&cessive $nta/e of Thyroid Hormones
Taking too much thyroid hormone medication is actually 8uite common. 6&cessive doses of
thyroid hormones fre8uently go undetected due to the lack of follow0up of patients taking
thyroid medicine. +ther persons may be abusing the drug in an attempt to achieve other goals
such as weight loss. These patients can be identified by having a low uptake of radioactively0
labeled iodine !radioiodine# on a thyroid scan.
-!normal ecretion of TH
* tumor in the pituitary gland may produce an abnormally high secretion of T%H !the thyroid
stimulating hormone#. This leads to e&cessive signaling to the thyroid gland to produce
thyroid hormones. This condition is very rare and can be associated with other abnormalities
of the pituitary gland. To identify this disorder, an endocrinologist performs elaborate tests to
assess the release of T%H.
Thyroiditis (inflammation of the thyroid)
nflammation of the thyroid gland may occur after a viral illness !subacute thyroiditis#. This
condition is association with a fever and a sore throat that is often painful on swallowing. The
thyroid gland is also tender to touch. There may be generali1ed neck aches and pains.
nflammation of the gland with an accumulation of white blood cells known as lymphocytes
!lymphocytic thyroiditis# may also occur. n both of these conditions, the inflammation leaves
the thyroid gland "leaky," so that the amount of thyroid hormone entering the blood is
increased. 9ymphocytic thyroiditis is most common after a pregnancy and can actually occur
in up to :; of women after delivery. n these cases, the hyperthyroid phase can last from < to
1= weeks and is often followed by a hypothyroid !low thyroid output# phase that can last for
up to > months. The ma7ority of affected women return to a state of normal thyroid function.
Thyroiditis can be diagnosed by a thyroid scan.
'&cessive $odine $nta/e
The thyroid gland uses iodine to make thyroid hormones. *n e&cess of iodine may cause
hyperthyroidism. odine0induced hyperthyroidism is usually seen in patients who already
have an underlying abnormal thyroid gland. -ertain medications, such as amiodarone
!-ordarone#, which is used in the treatment of heart problems, contain a large amount of
iodine and may be associated with thyroid function abnormalities..
)hat are the symptoms of hyperthyroidism*
Hyperthyroidism is suggested by several signs and symptoms? however, patients with mild
disease usually e&perience no symptoms. n patients older than @0 years, the typical signs and
symptoms also may be absent. n general, the symptoms become more obvious as the degree
of hyperthyroidism increases. The symptoms usually are related to an increase in the
metabolic rate of the body. n older patients, irregular heart rhythms and heart failure can
occur. n its most severe form, untreated hyperthyroidism may result in "thyroid storm," a
condition involving high blood pressure, fever, and heart failure. 4ental changes, such as
confusion and delirium, may also occur.
Ho0 is hyperthyroidism diagnosed*
Hyperthyroidism can be suspected in patients with' tremors, e&cessive sweating, smooth
velvety skin, fine hair, rapid heart rate, and an enlarged thyroid gland. There may be puffiness
around the eyes and a characteristic stare due to the elevation of the upper eyelids. *dvanced
symptoms are easily detected, but early symptoms, especially in the elderly, may be 8uite
inconspicuous. n all cases, a blood test is needed to confirm the diagnosis. The main tool for
detection is measurement of the blood T%H level. *s mentioned earlier, T%H is secreted by
the pituitary gland. *lthough the blood tests mentioned previously can confirm the presence
of e&cessive thyroid hormone, they do not point to a specific cause. f there is obvious
involvement of the eyes, a diagnosis of (raves) disease is almost certain. * combination of
antibody screening !for (raves) disease# and a thyroid scan using radioactively0labelled
iodine !which concentrates in the thyroid gland# can help diagnose the underlying thyroid
disease. These investigations are chosen on a case0by0case basis.
Ho0 is hyperthyroidism treated*
The options for treating hyperthyroidism include'
Treating the symptoms
*ntithyroid drugs
$adioactive iodine
%urgery
Treating ymptoms
There are medications available to immediately treat the symptoms caused by e&cessive
thyroid hormones, such as a rapid heart rate. +ne of the main classes of drugs used to
treat these symptoms is a beta0blocker Afor e&ample, propranolol !nderal#, atenolol
!Tenormin#, metoprolol !9opressor#B. These medications counteract the effect of thyroid
hormone to increase metabolism, but they do not alter the levels of thyroid hormones in
the blood. * doctor determines which patients to treat based on a number of variables
including the underlying cause of hyperthyroidism, the age of the patient, the si1e of the
thyroid gland, and the presence of coe&isting medical illnesses.
-ntithyroid +rugs
There are two main antithyroid drugs available for use in the Cnited %tates,
methima1ole !Tapa1ole# and propylthiouracil ! .TC#. These drugs accumulate in the
thyroid tissue and block production of thyroid hormones. .TC also blocks the
conversion of T< hormone to the more metabolically active T/ hormone. The ma7or
risk of these medications is occasional suppression of production of white blood cells
!needed to fight infection# by the bone marrow !agranulocytosis#. f patients develop a
fever, a sore throat, or any signs of infection while taking methima1ole or
propylthiouracil, they should see a doctor immediately. While a concern, the actual risk
of developing agranulocytosis is less than 1;. The dose of antithyroid medication is
ad7usted to maintain the patient in as close to a normal thyroid state as possible
!euthyroid#. Csually, long0term antithyroid therapy is only used for patients with
(raves) disease.
Radioactive $odine
$adioactive iodine is given orally !either by pill or li8uid# on a one0time basis to ablate
a hyperactive gland. The iodine given for ablative treatment is different from the iodine
used in a scan. $adioactive iodine is given after a routine iodine scan, and uptake of the
iodine is determined to confirm hyperthyroidism. The radioactive iodine is picked up
by the active cells in the thyroid and destroys them. %ince iodine is only picked up by
thyroid cells, the destruction is local, and there are no widespread side effects with this
therapy. $adioactive iodine ablation has been safely used for over D0 years, and the
only ma7or reasons for not using it are pregnancy and breast0feeding. n general, more
than :0; of patients are cured with a single dose of radioactive iodine. t takes between
: to 1= weeks for the thyroid to become normal after therapy.
.ermanent hypothyroidism is the ma7or complication of this form of treatment. While a
temporary hypothyroid state may be seen up to si& months after treatment with
radioactive iodine, if it persists longer than si& months, thyroid replacement therapy
!with T< or T/# usually is begun.
urgery
%urgery to partially remove the thyroid gland !partial thyroidectomy# was once a
common form of treatment for hyperthyroidism. The goal is to remove the thyroid
tissue that was producing the e&cessive thyroid hormone. However, if too much tissue
is removed, an inade8uate production of thyroid hormone !hypothyroidism# may result.
n this case, thyroid replacement therapy is begun. The ma7or complication of surgery is
disruption of the surrounding tissue, including the nerves supplying the vocal cords and
the four tiny glands in the neck that regulate calcium levels in the body !the parathyroid
glands#. *ccidental removal of these glands may result in low calcium levels and
re8uire calcium replacement therapy. With the introduction of radioactive iodine
therapy and antithyroid drugs, surgery for hyperthyroidism is not as common as it used
to be.
)hat's 1est for 2ou*
f you are concerned that you may have an e&cess amount of thyroid hormone, you should
mention your symptoms to your doctor. * simple blood test is the first step in the diagnosis.
3rom there, both you and your doctor can decide what the ne&t step should be. f treatment is
warranted, it is important for you to let your doctor know of any concerns or 8uestions you
have about the options available. $emember that thyroid disease is very common, and in
good hands, the diseases that cause an e&cess of thyroid hormones can be easily diagnosed
and treated.
Thyroid ,ine (eedle -spiration Cytology (,(-C)
The cornerstone in the assessment of a solitary thyroid nodule is a procedure
known as thyroid fine needle aspiration cytology or thyroid biopsy
* thyroid biopsy is a procedure in which a small sample of tissue is removed
from the thyroid gland and looked at under a microscope
Thyroid biopsy is valuable in the assessment of thyroid disease
)hat is a fine needle !iopsy*
* tiny needle, similar to an acupuncture needle, is inserted into the thyroid
nodule and moved up and down a few times
The tip of the needle e&tracts tiny pieces of tissue which can then be placed on
a glass slide, smeared, stained and interpreted by a cytopathologist
The entire nodule cannot be sampled with one tiny needle E two or more
additional needles will have to be inserted into different areas of the nodule to
obtain representative samples
This will enable the cytopathologist to assess whether the nodule should be
removed or not
%ome of the nodules are cystic as a result of previous bleeding into the nodule
E in this situation as much of the fluid as possible will be removed.
Thyroid fine needle aspiration cytology can accurately diagnose several thyroid
conditions including"
Thyroid colloid nodules
Thyroiditis
.apillary thyroid carcinoma
4edullary thyroid carcinoma
*naplastic thyroid carcinoma
9ymphoma
Thyroid !iopsy
When performed properly, the testing has a false negative rate of less than D;
This means that a positive finding, such as cancer, will be missed fewer than
five times out of 100
The fine needle aspiration is also performed to treat thyroid cysts
* thyroid cyst is a fluid0filled sac within the thyroid gland
*spiration of the cyst with a needle and syringe can shrink the swelling from
the cyst and the fluid removed can be analy1ed for cancer
The limitation of thyroid cytology is the inability to distinguish between
benign and malignant follicular neoplasms
*round =0; of thyroid nodules with indeterminate cytology turn out to be
malignant on definitive surgical pathology, therefore surgical treatment
remains the standard of care
Ho0 to prepare for a thyroid !iopsy
Tell your doctor if you"
o Take any medicines regularly E be sure your doctor knows the names and
doses of all your medicines
o *re allergic to any medicines, including anaesthetics
o Have had bleeding problems or take blood0thinners, such as aspirin or
warfarin
o Fefore having a thyroid biopsy, you may need to have blood tests to see
whether you have any bleeding problems or blood0clotting disorders.
To prepare for a thyroid !iopsy"
o You do not need to do anything before a needle biopsy E you will be awake
during the biopsy
o Fefore having a thyroid biopsy, you need to sign a consent form that says you
understand the risks of the thyroid biopsy and agree to have the test done
o Talk to your doctor about any concerns you have regarding the need for the
test, its risks, how it will be done, or what the results will mean
Ho0 long does the thryoid !iopsy ta/e*
o The actual fine needle biopsy takes only a few seconds.
o The whole episode takes about =0 to /0 minutes
o f the nodule is difficult to feel or biopsy, an ultrasound machine may be
necessary to guide the needle into the nodule
(eedle !iopsy"
o Fefore the biopsy, your doctor cleans the skin over your thyroid gland with a
special soap
o Your doctor may use an ultrasound to guide the placement of the needle E he
or she will put a thin needle into your thyroid gland and take out a small
amount of thyroid tissue and fluid and the tissue is looked at under a
microscope
o 2uring a needle biopsy, you may feel a 8uick sting or pinch in your neck
o * small bandage is placed over the area where the needle was inserted
o You may find it uncomfortable to lie still with your head tipped backward after
the biopsy and the biopsy site may be sore and tender for 1 to = days
o You can take panadol for any discomfort
-re there any complications*
o -omplications are uncommon e&cept for bleeding into the nodule
o To minimise the risk of bleeding with fine needle biopsy, tiny needles are used
and the doctor will ask you to hold your breath for a few seconds during the
procedure
o f complications do occur after the fine needle biopsy, please contact your
doctor for advice
o Fleeding more often occurs spontaneously into the nodule and when this
happens a lump may suddenly appear in the neck
o +ngoing bleeding can be a problem for people with bleeding disorders, or
those taking *spirin or warfarin and other blood0thinning medicines 0 your
doctor will give you specific instructions on when to call with problems
1iopsy results
o * thyroid biopsy is a procedure in which a small sample of tissue is removed
from the thyroid gland and looked at under a microscope for nodules,
infection, cancer or other thyroid problems
o $esults from a thyroid biopsy are usually available in a few days
o You will need to make a follow0up appointment with your doctor after the
biopsy to obtain the results