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Balancing highs, lows of thyroid- related ailments
Published on: Wednesday, September 13, 2023
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Dr Serena Khoo who is a Consultant Endocrinologist and Physician at Gleneagles Hospital Kota Kinabalu.
“DOCTOR, I felt a lump on my neck” … “I have lost a lot of weight” …“I feel exhausted and tired”…”My thyroid function test looks odd”

These are common symptoms encountered in my clinical practice. Some may be related to a true thyroid disorder and some otherwise.

Thyroid disorder is the second most common endocrine disorder following diabetes with 3.6 per cent of the Malaysian population suffering from hyperthyroidism (overactive thyroid) and 2.1 per cent from hypothyroidism (underactive thyroid).

An estimated close to 10 per cent of the population experiences an abnormal thyroid swelling (goiter) with 3.6 per cent detectable thyroid nodules. Women are 2-3 times more likely affected compared to men (pic).

Despite the vast number of people diagnosed, the awareness of thyroid disorders amongst the public is inadequate. In this article, we will dive into the realm of the thyroid discussing detection and treatment of common thyroid disorders to raise awareness of its potentially harmful consequences if left untreated.

Purpose of thyroid gland

First, let’s get to know the thyroid gland. The thyroid gland is a small butterfly shaped gland located in front of the lower neck and is usually not felt unless enlarged.

Under the control of thyroid stimulating hormone (TSH) from the pituitary gland in the brain, it secretes thyroid hormones (T4 and T3) which are released into the blood stream and carried throughout the body to act on various tissues and organs. The main function of thyroid hormones is to regulate the body’s metabolism (the process of how the body converts food consumed into energy).

Therefore, this can potentially impact your entire body system if an imbalance in the thyroid hormones levels was detected.

Hyper-thyroid

An overactive thyroid gland or commonly referred as hyper-thyroid is a result of excessive secretion and release of thyroid hormones. Excessive thyroid hormone production may cause patients to experience a rapid or irregular heartbeat, tremors, heat intolerance, weight loss despite a voracious appetite, nervousness and mood swings, menstrual irregularities, change in bowel habits, thyroid swelling, and occasionally bulging eyes.

However, some may not notice any symptoms at all except for elevated thyroid hormones from their blood tests.

Graves’ disease, an autoimmune thyroid disorder is the commonest cause of an overactive thyroid gland due to a malfunctioning antibody (TSH Receptor antibody), attacking the thyroid gland resulting in excess thyroid hormone production and may develop bulging or inflamed eyes.

Inflammation of the thyroid gland (thyroiditis) or excessive thyroid hormone production from thyroid nodules, or pregnancy related hyperthyroidism are less common causes.

You are encouraged to go for a simple blood test if you have these symptoms, and if found abnormal to consult an endocrinologist to obtain a clinical assessment including measurement of your thyroid autoantibodies and a thyroid ultrasound.

Once confirmed hyperthyroidism on blood tests, patients would be commenced on antithyroid medication (carbimazole, propylthiouracil) to control the production of thyroid hormones and beta blockers to manage symptoms such as nervousness, rapid heartbeat, or tremors.

Antithyroid medications may cause itchy skin rash in 5 per cent of patients and rarely lowering of the white blood cell and liver dysfunction. These medications are prescribed for a period of time with interval thyroid function testing for monitoring.

Radioactive iodine therapy is a nuclear medicine therapy to permanently treat hyperthyroidism. A radioactive drug bound to iodine given in a capsule or liquid form is consumed and is released into the thyroid gland over time, slowly destroying the gland resulting in lowering of thyroid hormone levels and shrinking goiter.

Once hypothyroidism develops, thyroxine, a thyroid hormone tablet is commenced and continued long term. Thyroid surgery involving complete or partial removal of

the thyroid gland may be recommended if the goiter is very large or patients have concomitant suspicious thyroid nodules.

Radioactive iodine treatment and surgery may be recommended if patients do not respond well or are intolerant to antithyroid medication or require prompt and urgent control of their thyroid function.

The disastrous consequences of an undetected and untreated overactive thyroid gland may lead to a risk of thyroid storm, a thyroid emergency with a mortality rate as high as 10-30 per cent.

Uncontrolled hyperthyroid cases may develop heart failure, atrial fibrillation (irregular heartbeat with an increased risk for stroke), osteoporosis and increased risk of fractures, infertility, miscarriages, and complicated pregnancies.

Hypo-thyroid

An underactive thyroid gland produces insufficient thyroid hormones for the body’s needs. As a result, the metabolism rate slows down and patients may experience tiredness, weight gain, swelling, dry skin, constipation, cold intolerance, heavy menses, thyroid swelling, depression and in the long term has consequences on the heart. Symptoms are often nonspecific and vague, often leading to delays in detection.

Hashimoto’s thyroiditis is a common cause of hypothyroidism, linked to a destructive antibody that destroys cells and enzymes necessary to produce thyroid hormones. It commonly affects women more than men.

Thyroid surgery, radioactive iodine therapy, radiation therapy, thyroid inflammation and certain drugs can causean underactive thyroid gland.

A clear clinical history, low thyroid hormones on thyroid function tests and occasionally a positive thyroid antibody test (Anti Thyroid Peroxidase Antibody test) will lead to the diagnosis.

Thyroxine, a thyroid hormone medication, is a simple treatment taken daily to replace and realign thyroid hormone levels. It is a safe treatment that can be consumed long term. It is best consumed on an empty stomach and interfering medication such as iron, calcium supplements or gastric medication to be consumed 4 hours apart.

If left untreated it may lead to a thyroid emergency known as myxedema coma, where patients present with a change in mental status, low blood pressure, slow heartbeat, low body temperature and blood glucose levels along with heart failure.

The mortality rate in ICU is as high as 26 per cent.

Pregnancy and the thyroid gland

Occasionally some women in their first pregnancy may present with symptoms of an overactive thyroid or found to have high thyroid hormone levels.

The elevated thyroid hormones may be related to pregnancy hormones , a condition called gestational thyrotoxicosis and resolves without additional treatment as the pregnancy progresses. However, Graves’ disease needs to be explored and excluded because of its frequent occurrence among women in the childbearing age group.

Patients with hyperthyroidism are advised to consult a doctor before attempting to conceive. This is to ensure thyroid hormone levels are well controlled and a switch to a safer anti thyroid drug for pregnancy to ensure a safe and successful pregnancy for both mother and baby.

The mother will have her thyroid function tests and thyroid autoantibodies monitored periodically and an ultrasound to monitor fetal growth and complications.

Patients with hypothyroidism are advised to consult their doctor immediately once pregnant and to increase their thyroxine doses to ensure adequate thyroxine replacement for both mother and baby.

During pregnancy, higher thyroxine requirement is needed and upon delivery the mother returns to taking her pre pregnancy doses. Thyroid function tests would be monitored at 4-8 weekly intervals during pregnancy.

Patients with hyperthyroidism or hypothyroidism can have a safe pregnancy and delivery provided they receive preconception counselling and are well managed prior to conceiving and during pregnancy.

Biotin and the thyroid gland

Biotin is a dietary supplement that belongs to vitamin B family frequently taken to improve hair and nail quality or found in multivitamin supplements. Biotin itself has no effect on thyroid function in the body but may interfere with the measurement of thyroid hormone levels, making them inaccurate.

This is because biotin is added as a reagent during some of the laboratory methods and the hormone measurements that may be affected are the Free T3, Free T4, TSH and thyroglobulin.

As a result, patients on biotin may be asymptomatic but have abnormal thyroid function test results and may be inappropriately started on antithyroid drugs. An awareness of this phenomenon may prevent misdiagnosis and unnecessary treatment.

Diet and the thyroid gland

Iodine is a mineral and integral in the making of thyroid hormones. The recommended amount of iodine intake for adults is 150 mcg daily and 200 mcg daily in pregnant or breastfeeding mothers. The richest dietary sources are from seaweed, kelp, seafood, dairy products like milk, cheese, yoghurt, and eggs.

Majority of the salt in Sabah are iodised. If patients are preparing for radioactive iodine treatment, they are generally advised to go on a low iodine diet prior to the treatment. Similar with patients suffering from overactive thyroid disorder, it is best to avoid excessive iodine intake. There is no additional benefit to consuming a high iodine diet in patients with hypothyroidism (underactive thyroid) on thyroxine.

The Brassica family of plants such as cauliflower, broccoli and kale may interfere with thyroid hormone manufacturing and result in a goiter (thyroid swelling). This occurrence is very rare and only occurs if consumed in very large amounts coupled by iodine deficiency in the diet.

Therefore, a healthy balanced diet consisting of at least 5 portions of fruits and vegetables a day, high fibre carbohydrates, adequate protein and unsaturated fats along with at least 8 glasses of water a day is recommended.

Conclusion

Reassuringly, thyroid disorders, although common are relatively straight forward to investigate and treat. Consult a doctor should you present with symptoms of an overactive or underactive thyroid or noticed a thyroid swelling.

Avoid relying on herbal treatment and supplements alone to treat your condition. Once diagnosed it is important to maintain a continuous follow up with your doctor as thyroid disorders usually require longer term interval blood tests for monitoring and treatment.

Additionally, for patients with thyroid disorder planning pregnancy, it is important to consult your doctor promptly.

This article was contributed by Dr Serena Khoo who is a Consultant Endocrinologist and Physician at Gleneagles Hospital Kota Kinabalu.

 

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