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Understanding

Thyroid Disorders
Dr Anthony Toft
Published by Family Doctor Publications Limited in association with the British Medical Association IMPORTANT This book is intended not as a substitute for personal medical ad ice but as a supplement to that ad ice for the patient who wishes to understand more about his or her condition! Before taking any form of treatment "#U $%#ULD AL&A"$ '#($ULT "#U) M*D+'AL P)A'T+T+#(*)! +n particular ,without limit- you should note that ad ances in medical science occur rapidly and some information about drugs and treatment contained in this booklet may ery soon be out of date! All rights reser ed! (o part of this publication may be reproduced. or stored in a retrie al system. or transmitted. in any form or by any means. electronic. mechanical. photocopying. recording and/or otherwise. without the prior written permission of the publishers! The right of Dr Anthony Toft to be identified as the author of this work has been asserted in accordance with the 'opyright. Designs and Patents Act 0122. $ections 33 and 32! Family Doctor Publications 011456778 Updated 0114. 0118. 0113. 0112. 0111. 6777. 6770. 6776. 6779. 677:. 6778 Family Doctor Publications. P# Bo; :88:. Poole. Dorset B%04 0(( ISBN: 1 903474 19 1

'ontents
+ntroduction !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! !!!!!!!!!!!!!!!!!!!!!!! 0 # eracti e thyroid !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! !!! 2 Underacti e thyroid !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! 9: Thyroid disease and pregnancy !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! :8 *nlarged thyroid !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! !!! 48 Thyroid

cancer !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! !!!!!! 81 Thyroid blood tests !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! 20 <%ypothyroidism= with normal blood tests !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! 28 >uestions and answers! ! !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! 10 ?lossary !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! !!!!!!!!!!!!!!!!!! 18 Useful addresses !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! !!! 070

About the author

Dr Anthony Toft B!" MD" #R P is a 'onsultant Physician and *ndocrinologist at the )oyal +nfirmary of *dinburgh where he specialises in the diagnosis and management of patients with thyroid disease! Dr Toft has been President of the British Thyroid Association and President of the )oyal 'ollege of Physicians of *dinburgh!

+ntroduction
$h%t is the thyroid &'%nd(
The thyroid gland lies in the front of the neck between the skin and the oice bo;! +t has a right and left lobe each about fi e centimetres in length and @oined in the midline! The entire gland weighs less than an ounce ,about 67 grams-! Despite its small siAe it is an e;tremely important organ which controls our metabolism and is responsible for the normal working of e ery cell in the body!

Thyroid hor)ones
The thyroid gland achie es this control by manufacturing the hormones ,see ?lossary. page 18- thyro;ine ,T:- and triiodothyronine ,T9- and secreting them into the bloodstream! +odine is an important constituent of these hormones! There are four atoms of iodine in each molecule of thyro;ine. hence the abbre iation T :. and three atoms of iodine in each molecule of triiodothyronine or T9! Doctors belie e that T: starts to be acti e only when it is con erted. mainly in the li er. to T9 by the remo al of one atom of iodine! +n parts of the world where there is a se ere lack of iodine in the diet. such as the 0

The red areas on this world map show the regions of the world in which iodine5deficiency goitre is a common disorder! This occurs largely as the soil. and conseBuently food. lacks sufficient iodine! %imalayas. there is not enough iodine for the thyroid gland to make adeBuate amounts of T9 and T:! +n an attempt to compensate. the thyroid gland enlarges to form what is known as a goitre. which is isible! +f this e;tra manufacturing capacity is still inadeBuate. the patient de elops an underacti e thyroid gland ,see page 9:-! +odine deficiency is not present in the UC! $ometimes too much iodine in the diet causes the thyroid gland to produce e;cessi e amounts of thyroid hormones! This can also be a result of medication!

B%'%n*in& the hor)ones

+n healthy people the amounts of T9 and T: in the blood are maintained within narrow limits by a hormone known as thyroid5stimulating hormone ,T$%- or thyrotrophin! T$% is secreted by the anterior pituitary gland which is a pea5siAe structure. hanging from the 6

Thyroid &'%nd
The thyroid gland lies in the neck between the skin and the oice bo; ,laryn;-! The thyroid gland is a butterfly5shaped gland consisting of two lobes. one on each side of the trachea ,windpipe-! 9 undersurface of the brain @ust behind the eyes. and enclosed in a bony depression in the base of the skull! &hen thyroid disease causes thyroid hormone le els in the blood to fall. T$% secretion from the pituitary is increasedD when thyroid hormone le els rise. T$% secretion is switched off E a relationship known as <negati e feedback=. familiar to engineers and biologists!

+y,othyroidis) %nd hy,erthyroidis)

+f your ?P suspects that you may ha e an underacti e thyroid gland ,hypothyroidism-. his or her diagnosis can be confirmed by sending a sample of your blood to the laboratory for analysis! Low le els of T 9 and T: and high le els of T$% in your blood mean that your doctor was : right! $imilarly. the diagnosis of an o eracti e thyroid gland ,hyperthyroidismis confirmed by high le els of T9 and T: and low le els of T$%! The results will be a ailable within a few days! Patients with uncomplicated hypothyroidism will not usually be referred to hospital and your ?P can prescribe and monitor your treatment! Most patients with hyper5thyroidism or with abnormal growth of the thyroid gland will be referred to a hospital specialist for further in estigation and ad ice about treatment! Thyroid disease is common and hyperthyroidism. hypothyroidism or abnormal

growth or enlargement of the gland ,goitre or thyroid nodule- affects about one in 67 people! Most diseases of the thyroid can be successfully treated. and e en thyroid cancer. which is rare. may not lead to a reduction in life e;pectancy if detected early and treated appropriately! Thyroid disease often runs in families but in an unpredictable manner. and certain forms are associated with an increased risk of de eloping conditions such as diabetes mellitus or pernicious anaemia! All types of thyroid disease are more common in women! The following chapters deal with each of the most common thyroid disorders indi idually!

%se history
Ahmed was born in a illage in the high mountains of northern Pakistan where he spent most of his childhood! At the age of 67 he came to London to study engineering when. at a routine medical e;amination. he was noticed to ha e a goitre! %e felt well and all the thyroid tests were normal! The cause of the goitre was attributed to iodine deficiency when Ahmed told the doctor that most of 4

the people in his illage also had a goitre! %is diet had contained enough iodine to pre ent the de elopment of hypothyroidism. but his goitre is likely to remain. e en though he has decided to li e the rest of his life in a part of the world where there is an adeBuate amount of iodine in his diet! 8

-!. POINTS
/ Thyroid disease is common. affecting around one in 67 people / More women than men are affected / "our ?P can diagnose the condition with a simple blood test / Treatment is usually successful. and e en thyroid cancer can be cured if caught early 3

# eracti e thyroid
0r%1es2 dise%se
An o eracti e thyroid gland ,hyperthyroidism or thyroto;icosis- results from the o er5production of the thyroid hormones. thyro;ine or T : and triiodothyronine or T9. by the thyroid gland! +n three5Buarters of patients this is the result of the presence in the blood of an antibody ,see ?lossary. page 18- that stimulates the thyroid. not only to secrete e;cessi e amounts of thyroid hormones but also. in some. to increase the siAe of the thyroid gland. producing a goitre! This type of hyperthyroidism is known as ?ra es= disease. named after one of the physicians who described the condition in considerable detail o er 677 years ago! The cause of the antibody production is not known but. as ?ra es= disease

runs in families. genes ,see ?lossary. page 18- must play a part! There is thought to be some en ironmental trigger that starts off the disease in genetically susceptible indi iduals. but the culprit has not been identified! $tress. in the form of ma@or life e ents. such as di orce or death of a close relati e. may play a role! $ome patients with ?ra es= disease de elop prominent eyes ,e;ophthalmos or proptosis- and a few 2

also suffer from raised. red. itchy areas of skin on the front of the lower legs or on the top of the feet. which are known as pretibial my;oedema! These. like the production of the thyroid5stimulating antibodies. are caused by an abnormality in the patient=s immune system which doctors don=t yet fully understand! Most other patients with hyperthyroidism ha e a goitre containing one or more nodules or <lumps=! These o er5produce thyroid hormones in their own right and are not under the control of T$%. as is the normal thyroid gland! ?ra es= disease can come on at any age but most commonly affects women aged :7 to 47 years! Between a third and a half of all patients will ha e a single episode of hyperthyroidism lasting se eral months! The rest will ha e successi e episodes of hyperthyroidism o er many years! Unfortunately. it is not possible to predict the 1 pattern of hyperthyroidism when it first occurs! %yperthyroidism resulting from a nodular goitre is unusual before the age of :7 and. unlike in some patients with ?ra es= disease. it persists indefinitely once it has de eloped!

$h%t is the ,%ttern of de1e'o,)ent(

+n retrospect. most patients will ha e had symptoms for at least si; months before they go to see their doctors. but in some. usually teenagers. the onset is more rapid with symptoms present for only a few weeks! (ot all patients with hyperthyroidism ha e all the symptoms listed below! +n elderly people the predominant features. in addition to weight loss. are often a reduction in appetite. muscle weakness and apathy! A young woman. on the other hand. may appear to be full of energy and be unable to sit still for more than a few seconds!

Sy),to)s of %n o1er%*ti1e thyroid

&eight loss This happens to almost all patients as a result of a <burning off= of calories caused by the high le els of thyroid hormones in the blood! "ou will probably find you=re hungry all the time. and that you e en ha e to get up in the night to get something to eat! The degree of weight loss aries from 6E9 kilograms to as much as 94 kilograms or more. but a few people find that their appetite increases to such an e;tent that they may gain a little weight! +f you are se erely o erweight when the condition first starts. you=ll probably be delighted to find that you=re losing weight and put it down to dieting. but sadly you=ll put the weight back on once you=re being treated! 07 %eat intolerance and sweating

As metabolism is increased. your body produces e;cessi e heat which it then gets rid of by sweating! "ou won=t en@oy warm weather or a centrally heated en ironment and may feel comfortable scantily dressed on a crisp winter=s day! +n e;treme cases. your inability to tolerate heat may lead to disagreements with friends and colleagues as you=re constantly turning heating thermostats down. opening windows and tossing blankets or du et off the bed! +rritability This most often affects women with a young family! "ou may find yourself increasingly unable to cope with the demands and stresses of looking after the children. lose your temper freBuently. and find that you=re abnormally sensiti e to criticism. bursting into tears for no apparent reason! "ou may find it difficult to concentrate. which can ad ersely affect your performance at school. college or work! Palpitations Most patients e;perience palpitations ,rapid or fluttering heart beat-. or you may be aware of your heart beating at a faster rate than normal! +n se ere. long5standing. untreated hyperthyroidism. particularly in elderly people. there may be an irregular heartbeat. known as atrial fibrillation. and e en heart failure! Breathlessness This is most likely to be noticeable when you= e e;erted yourself. for e;ample. after climbing two or three short flights of stairs! +ndi iduals with asthma may notice a worsening of their symptoms! 00 Tremor Most patients complain of shaky hands which may be mistaken by friends and relati es for the tremor of alcoholism! "ou=ll find it difficult to hold a cup still or insert a key into a lock and your handwriting may deteriorate! Muscle weakness 'haracteristically. the thigh muscles become weak. making it hard to climb stairs or to get up from a sBuatting position or a low chair without using your arms! Bowel mo ements There tends to be an increase in their freBuency such that you pass a softer than normal stool two or three times daily! Diarrhoea can occasionally be a problem! Menstruation Periods are often irregular. light or e en absent! Until the hyperthyroidism is adeBuately treated it may be difficult to concei e! $kin. hair and nails "ou may find that your whole body itches. and people with ?ra es= disease. as mentioned earlier. may de elop raised itchy patches on their lower legs and feet ,pretibial my;oedema-! "our hair will probably become thinner and finer than usual and won=t take a perm ery well! "our nails will be brittle and become rather unsightly! *yes +t is only those patients with ?ra es= disease who ha e trouble with their eyes!

Problems include e;cessi e watering made worse by wind and bright light. pain 06 and grittiness as if there is sand in the eyes. double ision and blurring of ision! Many sufferers are also naturally upset because they de elop e;ophthalmos ,protruding eyes- as well as <bags= under their eyes! ?oitre Although you will ob iously be able to see when you ha e a goitre. it=s unlikely to cause any actual symptoms other than a sensation that there is something in your neck that shouldn=t be there!

onfir)in& the di%&nosis B'ood test

"ou=ll probably ha e had a blood test taken at your health centre or ?P=s surgery. but you may well ha e more done for confirmation when you go to the outpatients= clinic at the hospital!

Thyroid s*%n
The specialist may also wish to carry out a thyroid scan to obtain more information about the cause of the hyperthyroidism as this may affect the type of treatment that you will need! A thyroid scan reBuires a tiny dose of radioacti e iodine or technetium to be gi en either by mouth or by in@ection into a ein! The dose is so small that it can e en be gi en to someone who is known to be allergic to iodine! Most specialists. howe er. would try to a oid radioacti e scanning if you are pregnant or breast5feeding! After your ?P has made the initial diagnosis. you=ll probably ha e to wait for a bit before you can see the hospital specialist! +n the meantime. your symptoms may be eased by taking one of the beta5blocker drugs 09

For a blood test a ein is chosen and the in@ection site cleaned! A hollow needle attached to a syringe is inserted into the ein and blood drawn out for testing! such as propranolol. which counteracts to some e;tent the actions of thyroid hormones! This is most likely to be in a dose of :7 milligrams to be taken three or four times daily or in the form of propranolol ,+nderal LA- 087 milligrams daily as a single dose by mouth! Beta5blocking drugs should not be taken by indi iduals with asthma!

Tre%t)ent for 0r%1es2 dise%se

There are three forms of treatment for the hyperthyroid5ism caused by ?ra es= disease! These are drugs. surgery and radioacti e iodine! 0:

Thyroid s*%n
+sotope scanning uses a gamma camera to create a picture from radiation emitted from the body after a radioacti e isotope. such as technetium511m.

has been in@ected! 04

+o3 %ntithyroid dr4&s 3or5

Antithyroid drugs interfere with the manufacture of thyroid hormones. bringing the high le els found in hyperthyroidism back to normal! Before dr4& Thyroid gland is o er5producing thyroid hormones Drugs Antithyroid drugs are usually gi en to younger patients who go to their doctor when they ha e their first episode of hyperthyroidism! The most commonly used drug in the UC is carbimaAole which reduces the amount of hormones made by the thyroid gland! +t is a ailable as 4 milligram and 67 milligram tablets! A high dose ,:7 to :4 milligrams daily- is used initially and your symptoms should start to impro e after 07 to 0: days! 08 (ormally treatment is continued for 8 to 02 months. after which up to half the patients will ha e reco ered and remain well! To start with. your specialist will re iew your treatment e ery four to si; weeks. and the dose of carbimaAole will be reduced in stages down to 4 to 04 milligrams daily in a single dose. depending upon the results of measurements of your blood le els of T 9. T: and T$%! $ome specialists prefer to gi e a high dose of carbimaAole throughout treatment. usually as :7 milligrams daily. in the form of two 67 milligram tablets! +f this high dose were to continue for se eral weeks or more. you would e entually de elop an underacti e thyroid gland and therefore thyro;ine is added to the carbimaAole once thyroid hormone le els ha e returned to normal! The ad antage of this type of treatment is that it doesn=t need to be re iewed so often! +t can also be particularly beneficial for patients with se ere eye disease. but isn=t any more effecti e in controlling symptoms of hyperthyroidism than carbimaAole alone! What you should know about drugs: few people will e;perience any side effects from taking carbimaAole. but those who do usually de elop them within three to four weeks of starting treatment! A skin rash affects two per cent of patients! +t is ery itchy. co ers the whole body and looks as if you ha e been stung by a nettle! Doctors call the blisters urticaria! "ou should stop the carbimaAole and inform your doctor! The rash will disappear within a few days and the itch will be helped by antihistamine tablets! The most serious side effect is a reduction in the number of white blood cells ,agranulocytosis- which results in a ery sore throat with mouth ulcers and a high fe er! 03 The low white cell count makes you prone to infection with bacteria! Agranulocytosis is a medical emergency and you must contact your doctor immediately and insist on an appointment that day! Fortunately it is rare. de eloping in one in 977 to 477 patients! Although the white cell count always After dr4& Thyroid hormone le els restored to normal

reco ers. you will need to take antibiotics and may e en be admitted to hospital for a short period! Most sore throats are the result of run5of5the5mill iral infections. but. e en if you think that your sore throat is tri ial. you should reBuest a blood count for reassurance! #ther side effects include sore @oints. slight scalp hair loss and headache! +f you do de elop a side effect while taking carbimaAole. you can be gi en an alternati e drug called propylthiouracil. which works in the same way! $urgery Unfortunately. despite taking carbimaAole or propylthiouracil alone or in combination with thyro;ine for up to 02 months. about half of all patients will de elop hyperthyroidism again and usually within two years of stopping the drug! +f you=re under :4 when you ha e your second bout of the condition. it may be treated surgically by remo ing about three5Buarters of your thyroid gland! Before this operation can be done. howe er. it is necessary to restore thyroid hormone le els in your blood to normal with carbimaAole! #nce you= e been gi en a date for the operation. you may be asked to take an iodine5containing medication for 07 to 0: days before surgery to reduce the siAe of the thyroid and its blood flow. which makes the @ob technically simpler for the surgeon! "ou=ll usually go into hospital the day before your operation. which lasts 02

$urgery may be the treatment of choice in a young patient with ?ra es= disease and a large goitre! about one hour. and you=ll be allowed home two days later! What you should know about surgery: the disad antage is that you will ha e a scar. but this usually becomes pale and unnoticeable among the other wrinkles in the neck! Alternati ely you can wear @ewellery or scar es to hide it! +n ery rare cases ,less than one per cent-. the parathyroid glands. which lie close to the thyroid and control the le el of calcium in the blood. may be 01 damaged. in which case long5term treatment with itamin D tablets will be necessary! *Bually rare is damage to one of the ner es supplying the oice bo; which may result in significant alteration to the Buality of the oice! Although this wouldn=t matter ery much to most people. it could make surgery a less acceptable option to anyone who depends upon their oice for a li ing E an opera singer. for e;ample! +n e;perienced hands the initial results of surgery are good! *ighty per cent of sufferers will be cured immediately! %owe er. 04 per cent will ha e had too much thyroid tissue remo ed and so will be hypothyroid. whereas fi e per cent will ha e had insufficient thyroid tissue remo ed and remain hyperthyroid! These failures are not the result of surgical incompetence. but ha e more to do with the nature of the underlying thyroid disease! &hat=s more. o er the passage of time. an increasing proportion of those patients whose hyperthyroidism was originally cured by surgery will de elop an underacti e thyroid gland! )ecurrence of hyperthyroidism may e en de elop 67 to :7

years after apparently successful surgery! +n the e ent of recurrent hyperthyroidism. it is unusual to consider a second operation because surgery will be technically difficult and the risk of damage to surrounding structures increased! )adioacti e iodine ,iodine5090Traditionally this form of treatment is reser ed for patients aged o er :7 to :4 and beyond child5bearing age or for younger indi iduals who ha e been sterilised! This conser ati e approach was originally adopted because of concern that radioacti e iodine might lead 67

R%dio%*ti1e iodine tre%t)ent

)adioacti e iodine is taken up by the thyroid gland. where it destroys part or all of the thyroid tissue. reducing the production of thyroid hormones! 60 to any children concei ed after treatment being born with abnormalities! +n fact. there is no e idence for this. and in some hospitals there is a mo e towards using radioacti e iodine in younger patients as it is cheap and easy to administer! )adioacti e iodine is taken as a capsule or a drink that tastes like water. and is usually administered in hospital in a department of medical physics! Before recei ing treatment you may be asked to sign a consent form. and will ha e recei ed instructions about a oiding places of entertainment and close contact with colleagues and young children for a period of a few days after therapy! )adioacti e iodine is ne er prescribed for pregnant women as it will ad ersely affect the fetal thyroid gland and women are ad ised to a oid pregnancy for four months after treatment! )adioacti e iodine acts by destroying some of the thyroid cells and by pre enting others from di iding. which is how they are normally replaced at the end of their lifespan! The treatment takes si; to eight weeks to work and in the interim. depending upon the se erity of the hyperthyroidism. you may be gi en propranolol or carbimaAole to relie e your symptoms! "ou=ll be asked to come back to hospital for a check5up in two to three months and. if you=re one of the minority of people who is found to be still hyperthyroid. you=ll be gi en a second dose of radioacti e iodine! What you should know about treatment with radioctive iodine: the ma@or problem with this treatment is. howe er. the de elopment of hypothyroidism! +t=s most likely to appear in the first year after treatment. affecting about 47 per cent of people in some centres! +n each year after that. around two to four per cent of 66

people will be affected! +t follows that the great ma@ority become hypothyroid e entually and it is essential that you should ha e regular check5ups either at the hospital or with your ? P! #nce hypothyroidism has de eloped treatment is

with thyro;ine. ultimately in a dose of 077 to 047 micrograms daily! There are no side effects with thyro;ine if the appropriate dose is taken regularly! 69

%se history
Although 375year5old Fohn Parry considered himself to be generally ery healthy. he had recently noticed that his ankles were swelling! To start with. it was @ust at night. but then it happened all the time and his legs felt ery hea y! #ne night at 0am he woke up gasping for breath and coughing up white frothy spit! %is wife called an ambulance. and Fohn was admitted to the local hospital within 67 minutes! The doctor on duty. Dr MackenAie. correctly diagnosed heart failure as the cause of the fluid accumulation in Fohn=s legs and lungs! %e also noticed that Fohn=s pulse rate was ery rapid and irregular and an electrocardiogram showed this to be caused by atrial fibrillation! Mr Parry was gi en o;ygen using a facemask. an in@ection of a drug called furosemide ,Lasi;- to get rid of the e;cess fluid. and digo;in tablets to reduce the speed of his heart beat! As patients with atrial fibrillation are at risk of throwing off blood clots from the heart. resulting in a stroke or a blocked artery in a leg. he was also gi en tablets called warfarin to thin the blood! Dr MackenAie had at one time worked with an eminent endocrinologist and knew that atrial fibrillation could sometimes occur as a complication of an o eracti e thyroid gland. particularly in older patients! Mr Parry did indeed ha e hyperthyroidism which turned out to be caused by ?ra es= disease and he was treated with radioacti e iodine! %e was also gi en the antithyroid drug. carbimaAole. for si; weeks until the radioacti e iodine had time to take effect! Although to begin with Mr Parry was concerned about the number of tablets he was taking when he left hospital. these had all been stopped within si; months 6: as his thyroid gland came under control! * en his heart is now beating regularly and he is as fit as e er! %is ?P carries out thyroid blood tests regularly to make sure that Mr Parry is not de eloping an underacti e thyroid gland as a result of the radioacti e iodine treatment!

%se history
Anna )obinson had had a pre ious episode of hyperthyroidism caused by ?ra es= disease in her mid567s. for which she had been gi en an 025month course of carbimaAole! At the age of :4. she noticed that she was troubled by the heat. but put this symptom down to the <change of life=! %owe er. when she began to lose weight and her hands became shaky. she realised that her thyroid gland was o eracti e again! At the local hospital the specialist suggested that she should be treated with radioacti e iodine! +n spite of reassurances and the e idence that this form of treatment was not associated with any risk other than the e entual onset of an underacti e thyroid gland. Mrs )obinson was uneasy! $he was aware from articles in the newspapers of a possible link between radiation and leukaemia in those li ing near to nuclear power stations. and she did not like the thought of a oiding her new grand5daughter albeit only for a few days after treatment! As she was a keen singer in the local church choir. thyroid surgery was felt not to be appropriate because of the possibility of a change in the Buality of her

oice! Mrs )obinson was relie ed to learn that there was no reason why she could not be treated with carbimaAole now or in the future! 64

0r%1es2 dise%se %nd the eyes

&hat is happening in the eyesG +f the doctor looks hard enough. most patients with ?ra es= disease ha e changes to their eyes known as ophthalmopathy or orbitopathy! Both eyes are usually affected. but often one more than the other! +t is better to think of the ophthalmopathy as a separate autoimmune condition that freBuently coe;ists with ?ra es= disease. rather than as a complication of the thyroid disease itself! This helps to e;plain why eye disease may occur before the onset of the o eracti e thyroid gland or e en for the first time after you ha e been successfully treated! There are three phases to the ophthalmopathyH the initial de elopment and worsening. followed by a period of relati e stability and then by a ariable degree of impro ement! 'omplete disappearance of the eye disease is rare and. e en if you feel that your eyes are back to normal. there will be subtle abnormalities e ident to a specialist. if not to friends and family! An early sign is retraction of the upper eyelid which appears as if it has been pulled up. e;posing more of the white of the eye and causing a staring appearance! This may impro e after the raised le els of thyroid hormone ha e been restored to normal with treatment! $ome patients complain of dry. gritty eyes. as if there is sand in them. and of constant blinking. others of e;cessi e watering! The other features of thyroid eye disease result from a build5up of pressure behind the eyeball. which sits in a bony socket known as the orbit! The space between the eyeball and the back of the orbit contains the muscles that mo e the eye. the optic ner e which relays messages from the retina to the brain. and fat! 68

Most patients with ?ra esI disease will ha e changes to their eyes! Both eyes are usually affected but often one more than the other! +n patients with thyroid eye disease. among other changes there is an accumulation of e;cessi e amounts of water behind the eyeball. and the muscles and fat become swollen and boggy! The muscles double or treble in bulk and cease to work efficiently! As a result. the normal mo ement of the eyes may be restricted and uncomfortable. with double ision ,diplopia- and e en the de elopment of a sBuint! The increase in pressure behind the eyeballs pushes them forwards. producing the <pop5eye= appearance known as e;ophthalmos or proptosis! The increased e;posure of the protruding eyeballs makes them more prone to irritation from dust. grit. wind and sun. and the cornea may be damaged! +n addition. some of the 63

fat behind the eyeballs may be forced into the eyelids. contributing to their puffiness and the appearance of <bags under the eyes=! Jery rarely. in se erely affected patients. the increased pressure may damage the optic ner e and cause partial or total loss of ision! Treatment Treatment of the eye disease is not as satisfactory as that of the o eracti e thyroid gland! $moking is thought to make it worse as does poor control of the hyperthyroidism! +t is ery important. therefore. that you stop smoking completely and are careful to follow your doctor=s instructions about dosage of tablets. such as carbimaAole or thyro;ine! #f the three treatments for an o eracti e thyroid gland. deterioration of the ophthalmopathy is thought to occur most often after radioacti e iodine! $ome Thyroid5related eye disease usually has three phases. each of ariable duration! After an initial deterioration the condition should stabilise o er a period of two to three years! Thereafter relati ely minor surgery should correct any double ision and impro e the cosmetic appearance of the eyes! 62

61 specialists will not wish to prescribe this form of therapy for you if your eyes are badly affected. or they might ad ise a course of steroids. such as prednisone for si; to eight weeks. immediately after the radioacti e iodine has been gi en! +f you ha e dry eyes. you may find that a prescription for artificial tears helps. as it also does parado;ically for those with e;cessi e watering! +t is also worth wearing dark glasses when it is sunny! Double ision may be helped by ha ing prisms fitted to your spectacles! Those with more ad anced disease that threatens ision may need treatment with prednisone. often coupled with radiotherapy which damps down the Tears are produced by the lacrimal ,tear- glands! +n ?ra es= disease they may not work as well as normal! +f you ha e dry eyes a prescription for artificial tears may help relie e the discomfort! 97 poorly understood processes leading to accumulation of water behind the eyeball! Alternati ely. an operation may be reBuired to remo e part of the wall of the orbit. thereby reducing the pressure behind the eyeball! $uch a ma@or undertaking is rarely necessary. howe er. and would be carried out only after close collaboration between thyroid and eye specialists! Most people with ?ra es= disease find that their eye problems settle down considerably o er a period of two to three years! At that stage. relati ely minor surgery will correct double ision and reduce the <staring= look and the bags under the eyes!

Nod4'%r &oitre
This is treated either with surgery or with radioacti e iodine! Unlike someone with ?ra es= disease. you=re unlikely to de elop hypothyroidism! +t used to be fashionable after surgery to prescribe thyro;ine to pre ent regrowth of the goitre. which is common o er a period of some 67 years. but this is not really useful unless you= e de eloped hypothyroidism!

+y,erthyroidis) %nd e'der'y ,eo,'e

Those in their 37s and 27s or beyond may not ha e the classic features of an o eracti e thyroid gland! Although there is usually weight loss. the appetite is often reduced. and the thigh muscles become weak. causing difficulty in climbing stairs. getting out of the bath or rising from a low chair! +nstead of being @umpy and fidgety. older patients become apathetic and cannot be bothered doing things! They may be thought. by relati es. to be depressed! #ften there is 90 no goitre and there are no eye signs! As a result of this less typical presentation of an o eracti e thyroid gland. the diagnosis may be delayed. by which time the pulse may be irregular from atrial fibrillation and there may e en be heart failure!

6i1in& 3ith so)eone 3ith %n o1er%*ti1e thyroid

+t is the irritability. the short fuse and the emotional rollercoaster that make life difficult for friends and family! (o one Buite knows what to e;pect and there is a feeling of walking on eggshells all the time! Mum ,and it is usually mumcannot sit still. and seems to be doing se eral things at once. although none of them to her usual standard! Despite being e;hausted. she does not sleep and gets up early to do the ironing or clean the house! (othing pleases her! Tri ial incidents. such as breaking a cup or burning the toast. make her <fly off the handle= or burst into tears! There is often talk of separation and e en di orce as the charged atmosphere in the household o er many months takes its toll! +f the o eracti e thyroid de elops at the time of the menopause. as it often does. there is freBuently delay in diagnosis because the symptoms are ine itably attributed to the change of life! +t is only when hormone replacement therapy fails to help that the penny drops! #nce the hyperthyroidism is diagnosed. the family will feel guilty. but tolerance is needed for se eral weeks or e en months after treatment before mum is restored to her old self! 96

99

Underacti e thyroid
$h%t is %n 4nder%*ti1e thyroid(
An underacti e thyroid ,hypothyroidism- occurs when the thyroid gland stops

producing enough of the thyroid hormones. triiodothyronine or T 9 and thyro;ine or T:! +n its most common form. affecting one per cent of the population. mainly middle5aged and elderly women. the thyroid gland shrinks as its cells are all destroyed by a subtle defect in the patient=s immune system! Less often this defect leads not only to hypothyroidism but to thyroid enlargement and the formation of a goitre! This is known as %ashimoto=s thyroiditis! These types of hypothyroidism are associated. as is ?ra es= disease. with the other so5called <autoimmune diseases= ,see ?lossary. page 18- shown in the bo; on page 94! Although ha ing hypothyroidism makes you more likely to de elop one or more of these conditions than other people. the risk is still small! The other reason why people de elop hypothyroidism is as a result of treatment of ?ra es= disease by surgery or with radioacti e iodine!

$h%t is the ,%ttern of de1e'o,)ent(

%ypothyroidism does not come on o ernight but slowly o er many months and you and your family may not 9: notice the symptoms at first. or may simply put them down to ageing! ?Ps now ha e ready access to the appropriate laboratory tests and. as a result. hypothyroidism is increasingly likely to be diagnosed at a relati ely early stage when symptoms are mild! %ypothyroidism in its ad anced state is sometimes known as <my;oedema=! +t would be unusual to ha e all the symptoms mentioned below unless the diagnosis had been delayed for some reason for months or e en years! "ou=re more likely to go to your ?P with rather ague complaints such as tiredness and weight gain. which could be due to a ariety of causes! 94 "ou=ll ha e a blood test and. if the result shows that you ha e low T : and high thyroid5stimulating hormone ,T$%- le els. this will be confirmation that you are suffering from hypothyroidism! Unless there is a complication. such as angina. you will be treated by your family doctor!

Sy),to)s of hy,othyroidis)
&eight gain Most patients gain from fi e to ten kilograms. although your appetite is normal or e en less than usual! $ensiti ity to the cold "ou=ll feel the cold ery badly. and want to wear e;tra layers of clothing and sit close to the fire! "ou may well suffer from muscle stiffness and spasm when you mo e suddenly. especially when it=s cold! Mental problems Tiredness. sleepiness and slowing down intellectually! "our reactions get slow. but. fortunately. your sense of humour is unaffected! #lder patients may be wrongly thought to be suffering from dementia. while some people e;perience depression and paranoia. which are the basis for

what is popularly known as <my;oedema madness=! $peech "our oice becomes slow and husky and speech is often slurred! %eart +n contrast to a person with an o eracti e thyroid gland. your pulse rate is slow at around 87 beats per minute! 98 "ou may ha e high blood pressure and an elderly patient with se ere long5 standing hypothyroidism is at risk of heart failure! Angina may be the first symptom of hypothyroidism! Bowel mo ements "ou probably suffer from constipation! Menstruation "our periods become hea ier ,menorrhagia- if you ha en=t yet had your menopause! $kin and hair "our skin is likely to be rough and dry and to flake readily! +t tends to be pale and your eyelids. hands and feet swell! $ome people may find that their skin has a lemon5yellowish tint and prominent blood essels in the cheeks add a purplish flush! $itting too close to the fire can cause a <granny=s tartan= to appear on the skin of your legs! $ome people get the skin condition known as itiligo! "our hair becomes dry and brittle and the outer part of your eyebrows may be missing! (er ous system "ou may become a little deaf and ha e trouble with your balance! +f your fingers tingle. especially during the night. shaking your hands igorously should relie e it!

Tre%t)ent
This is with thyro;ine which is a ailable in the UC as 64. 47 and 077 microgram tablets! (ormally. thyro;ine treatment is begun slowly and you=ll be prescribed a daily dose of 47 micrograms for three to four weeks. 93 increasing to 077 micrograms daily for a further three to four weeks and then to 047 micrograms daily! "ou=ll then ha e another blood test some three months after starting treatment to assess whether any further minor ad@ustment of dose is necessary! The aim is to restore le els of T: and T$% in the blood to normal! "ou should start to feel better within two to three weeksD you=ll lose weight and notice the puffiness around your eyes disappearing Buite soon. but your

Tre%t)ent for %n 4nder%*ti1e thyroid &'%nd 7hy,othyroidis)8

92

skin and hair te;ture may take three to si; months to reco er fully! (ormally you=ll ha e to e;pect to stay on thyro;ine treatment for life!

%se history
Fean $pencer was 03 and in her final year at school. hoping to go to uni ersity to study law! $he had had diabetes since she was 00 and ga e herself insulin in@ections twice each day! 'ontrol of her diabetes had always been ery satisfactory and her dose of insulin did not ary much! $he had been puAAled. howe er. for the last three months because she did not seem to reBuire as much insulin as before! #n four occasions she had almost become unconscious in class because of a low le el of glucose in her blood but had been brought round with sugary drinks by her teacher! #nce she did not respond and was rushed to hospital and gi en a glucose drip into a ein and kept in o ernight! Fean=s parents and her teacher were also concerned because she was not concentrating in class and her results in the mock e;ams had not been nearly as good as e;pected! $he had also begun to complain of the cold and had not been able to sing in the school 'hristmas 'oncert because her oice had become husky! +t was her aunt. isiting from 'anada. who recognised the change in Fean=s appearance since her isit the pre ious year! The aunt had de eloped an underacti e thyroid gland 07 years earlier and suggested to Fean that she ha e a blood test! Fean is now taking thyro;ine tablets. like her aunt. and her insulin dose has returned to its pre ious le el! $he passed her A le els with flying colours and is now in her first term at uni ersity studying law! 91

S,e*i%' sit4%tions An&in%

The le el of arious fats or lipids in the blood is increased in hypothyroidism and. in people who ha e had the condition unrecognised for a long time. the coronary arteries can become narrowed by fatty deposits. a process called atherosclerosis! +nsufficient blood reaches the heart muscle. especially during e;ercise. and the sufferer will get pain in the middle of the chest ,angina-! Treatment with thyro;ine may worsen the angina and someone with this problem will be started on a lower dose and ha e it increased more slowly than normal! +t may be necessary to ha e an operation to impro e the blood flow through the coronary arteries before or after starting thyro;ine treatment!

Te),or%ry hy,othyroidis)
Treatment with thyro;ine is usually for life! %owe er. if you de elop hypothyroidism in the first three to four months after surgery or radioacti e iodine treatment for ?ra es= disease it may be short5li ed. lasting only a few weeks. and you may not need any treatment! The same is true for the hypothyroidism that is a complication of postpartum ,after childbirth- thyroiditis ,see page 46- or de >uer ain=s thyroiditis ,see page 61-!

Mi'd hy,othyroidis)
Most ?Ps will arrange for someone to ha e a blood test e en when they only suspect thyroid problems. so Buite minor abnormalities are often picked up in patients who come because of a ariety of rather ague symptoms. such as

tiredness. or in people who ha e a family history of autoimmune disease! :7

The ,ro*ess of %theros*'erosis

Atherosclerosis. atheroma and hardening of the arteries are all the same thing E the process leading to the blockage or weakening of arteries! :0 The most common finding is the combination of a <normal= T: but raised T$% le el. known among doctors as subclinical hypothyroidism! +t is known that around 4 to 67 per cent of these people will de elop more ob ious hypothyroidism in each following year! For this reason. it is now common practice to <nip things in the bud= by prescribing thyro;ine when the abnormality has been found on more than one occasion! This may not ha e any dramatic effect on the indi idual concerned. but pre enti e medicine is better than cure!

+y,othyroidis) *%4sed 9y dr4&s

#ne drug. called lithium carbonate. which is widely used for depression and mania. may cause goitre and hypothyroidism! &hen. as normally happens. a person needs to keep taking lithium carbonate. continued treatment with thyro;ine will be necessary! Amiodarone. used in the treatment of certain heart irregularities. may cause not only hyperthyroidism but also hypothyroidism and anyone who is taking it will need regular thyroid blood tests!

h%n&e to yo4r 4s4%' dose of thyro:ine

The dose of thyro;ine may need to be increased during pregnancy ,pages :8E 44-. if there is malabsorption of food by the bowel. such as in coeliac disease. or if you start to take medicines that reduce the absorption of thyro;ine or speed up its breakdown by the body! +f you need more thyro;ine. the T$% le el will increase significantly. ha ing pre iously been normal! Thyro;ine is now manufactured in the UC by a ariety of companies! This is known as generic thyro;ine and. despite rigorous controls. doctors and patients ha e noticed from blood test results and from symptoms :6

that there may be a ariation in tablet strength between different manufacturers! For this reason. it is wise to insist that the same make of thyro;ine is dispensed by the pharmacist when you renew the prescription! +f it is not possible to pro ide the same make. you should consider ha ing a blood test some si; to eight weeks after starting the new preparation!

Possi9'e f4t4re tre%t)ent

Most patients with hypothyroidism feel perfectly well while taking an appropriate amount of thyro;ine. as @udged by measurement of T : and T$% in the blood! %owe er. some patients do not achie e the sense of well5being e;pected. e en if a little e;tra thyro;ine is taken. which results in a low rather than a normal T$% le el! +f you are one of this small group of patients. there is

some e idence. which needs to be confirmed. that a :9 combination of thyro;ine and the other thyroid hormone. T 9 ,triiodothyronine-. may be beneficial! +f you change to this combined treatment. the dose of thyro;ine should be reduced by 64E47 micrograms and half a tablet ,07 micrograms- of T 9. also known as liothyronine. added! +n the interim some patients are turning to an old5fashioned medicine. thyroid e;tract. made from the thyroid gland of animals. which contains both T 9 and T: ,Armour thyroid-! These tablets are not readily a ailable in the UC and. because of continuing an;ieties about the reliability of their hormone content. their use is not recommended! +t makes sense to replace what is missing when the thyroid gland stops working and the ideal replacement tablet would contain about 077 micrograms T: and 07 micrograms T9. the latter in a slow5release form! This would a oid peak le els of T9 in the blood after taking the medication. which can produce troublesome palpitations! Unfortunately such an ideal medicine has not yet been produced by the pharmaceutical industry! ::

-!. POINTS
/ %ypothyroidism usually comes on slowly and your symptoms are likely to be ague at first / "our ?P will be able to confirm the diagnosis with a simple blood test / Treatment is with tablets. which you=ll probably need to take for the rest of your life / $ome people who ha e been hypothyroid for many years may suffer from chest pain caused by angina and. because thyro;ine aggra ates the problem. their dosage will need careful monitoring! +f you already ha e angina when your thyroid condition is first disco ered. your treatment will be ad@usted to take account of this / +f your thyroid blood test is only slightly abnormal. you may be gi en pre enti e treatment with thyro;ine :4

Thyroid disease and pregnancy

0r%1es2 dise%se %nd ,re&n%n*y
%yperthyroidism occurring during pregnancy is almost always the result of ?ra es= disease! +t is not a common e ent. howe er. as autoimmune diseases ,see ?lossary. page 18-. of which ?ra es= disease is an e;ample. tend to impro e of their own accord during pregnancy! Also. women with an o eracti e thyroid gland are relati ely infertile because there is an increase in the number of menstrual cycles during which an egg is not released from the o aries! As the thyroid5stimulating antibody responsible for the hyperthyroidism of

?ra es= disease crosses the placenta and passes from the blood of the mother to that of the de eloping child. it too will ha e an o eracti e thyroid gland like its mother! Fortunately. the antithyroid drugs also cross the placenta and good control of hyperthyroidism in the mother will ensure that the fetus comes to no harm! Failure to recognise hyperthyroidism or to treat it adeBuately in a pregnant woman may lead to miscarriage! # ertreatment with :8

The ,'%*ent%
The fetus is reliant on the mother for o;ygen and nutrients! The placenta allows the e;change of o;ygen and nourishment between the mother and the fetus! :3 antithyroid drugs may lead to goitre de elopment in the fetus! +t is important. therefore. that the patient is prescribed the lowest dose of carbimaAole possible to restore thyroid hormone le els in the blood to normal! These le els are checked e ery four to si; weeks. in close cooperation with the obstetrician who is caring for her! The carbimaAole is usually stopped four weeks before the e;pected date of deli ery to make sure that there is no possibility of the fetus being hypothyroid at a crucial time in its de elopment! +f hyperthyroidism recurs in the mother after the baby is born. and she is breast5feeding. she will be treated with propylthiouracil rather than carbimaAole because it is e;creted in the breast milk much less and will not therefore affect the baby! There are some reports from (orth America that carbimaAole is associated with a rare disease in the newborn baby. known as aplasia cutis. in which there is a defect in the skin co ering a small part of the scalp! The iew in the UC is. howe er. that the risk has been o erestimated. if it is present at all! Most specialists in this country are happy to prescribe carbimaAole during pregnancy! $ome. howe er. may prefer to use propylthiouracil and to change from carbimaAole before conception. if possible! The dose of propylthiouracil is ten times that of carbimaAole. and it is a ailable as 47 milligram tablets only! )adioacti e iodine treatment is ne er gi en during pregnancy! $urgery is occasionally ad ised around week 67 of pregnancy for patients who de elop side effects to the drugs or who take them irregularly. thereby putting the fetus at risk! :2

+y,erthyroidis) in the ne39orn 7neon%t%' thyroto:i*osis8

+n most women with ?ra es= disease during pregnancy. the thyroid5stimulating antibody disappears or its le el in the blood becomes low! +n some. howe er. the le el remains high and. as blood from the mother is e;changed with that of the fetus until the moment of birth. these high le els are also present in the blood of the newborn and may cause hyperthyroidism! Although it is possible to predict those babies most likely to de elop hyper5thyroidism by finding high le els of antibodies in the mother=s blood towards the end of pregnancy. all newborns in the UC ha e a blood test shortly after birth to check thyroid

hormone le els! %yperthyroidism in the newborn. if detected at this stage. is easily treated and lasts only two to three weeks until the antibody from the mother is broken down and inacti ated! Jery occasionally. mothers who ha e been treated successfully for ?ra es= disease in the past con5tinue to produce thyroid5 stimulating antibody and their offspring are at risk of de eloping neonatal hyperthyroidism!

%se history
)ebecca and her husband had been trying to ha e a second child for three years without success! )ebecca had concei ed twice but. unfortunately. on each occasion had miscarried at about ten weeks! $he felt and looked well and. although she had lost a few pounds in weight. she put this down to her busy lifestyle of running the home. looking after an acti e fi e5year5old son. and working part5time as a secretary! $he was a little an;ious that her periods. which used to be as regular as clockwork. had become much lighter and. on occasion. were missing! :1 During her weekly telephone call to her mother. she learned that her cousin in Australia had recently been diagnosed as ha ing an o eracti e thyroid gland! $he consulted her ?P and. despite her lack of ob ious signs and ha ing neither a goitre nor bulging eyes. the blood test showed the presence of mild hyperthyroidism and this was confirmed as being caused by ?ra es= disease at the local hospital! Treatment was started with carbimaAole. initially in a dose of 97 milligrams daily and. after fi e months of treatment. )ebecca was pregnant! $he was re iewed by the endocrinologist e ery four weeks and. by the middle of her pregnancy. she needed to take only fi e milligrams of carbimaAole e ery day! The drug was stopped four weeks before the e;pected date of deli ery and she ga e birth to a healthy girl whose heel5prick blood test at se en days was normal. with no e idence of thyroid abnormality! )ebecca breast5fed her daughter but. after four months. de eloped hyperthyroidism. again as a result of ?ra es= disease because the thyroid5stimulating antibody was present in her blood! $he decided to change to bottle5feeding and her hyperthyroidism was therefore treated with carbimaAole as before! %ad she opted to continue breast5feeding. propylthiouracil would ha e been prescribed instead!

+y,othyroidis) %nd ,re&n%n*y

Most women with hypothyroidism are already taking thyro;ine when they become pregnant! Although mild hypothyroidism is unlikely to affect fertility. women with se ere thyroid deficiency of prolonged duration are unlikely to become pregnant and. if they concei e. to maintain their pregnancy! 47 The dose of thyro;ine may need to be increased in pregnancy! )ecent research shows that the increase is most important to the fetus in early pregnancy! As soon as you know that you are pregnant you should increase your dose by 64 micrograms daily. and reBuest a blood test from your doctor! "ou will be tested e ery two months or so during pregnancy and the a erage e;tra dose of thyro;ine needed will be 47 micrograms daily! "ou can return to the dose you were taking before pregnancy after your baby has been born! Although the thyroid gland of the fetus de elops independently of the mother

and makes its own thyroid hormones. a recent study in the U$A has shown that unrecognised or inadeBuately treated hypothyroidism in the mother may cause a slight reduction in the +> of the child! "our baby will not be at risk if you forget the occasional dose. but if you make a habit of not taking it. not only will you face a greater risk of miscarriage. but your baby may not be as intelligent as he or she might ha e been! +t would be sensible for those taking thyro;ine or those who ha e a family history of thyroid disease to check that their thyroid blood tests are normal when planning a pregnancy. and therefore before conception!

+y,othyroidis) in the ne39orn 7*on&enit%' hy,othyroidis)8

#ne in about 9.477 newborn babies has an underacti e thyroid gland as a result of failure of the gland to de elop normally! +n the past. the problem was not recognised until the child was se eral weeks old. by which time he or she would ha e been likely to de elop permanent mental and physical handicap E the 40

condition known then as cretinism! Today. howe er. all newborn babies are screened by a blood test for hypothyroidism between fi e and se en days after they are born! Any affected children are gi en prompt treatment which ensures that they de elop normally! Treatment is usually for life. but in a few babies the hypothyroidism is temporary as a result of being born to a mother with an underacti e thyroid glandD in these women there are blocking antibodies that cross the placenta and ha e the opposite effect of the stimulating antibodies of ?ra es= disease and neonatal thyroto;icosis ,see page :1-!

Thyroid dise%se %fter ,re&n%n*y

Although the hyperthyroidism of ?ra es= disease tends to get better on its own during pregnancy. it often returns in a se ere form within a few months of deli ery! There is. howe er. another form of hyperthyroidism that may de elop in the first year after childbirth. almost always in patients who ha e an underlying autoimmune 46 thyroid disease such as %ashimoto=s thyroiditis. which may not ha e been recognised pre iously! The hyperthyroidism is mild and lasts only a few weeksD if treatment is neccessary. only a beta blocker is taken! This phase may be followed by an eBually transient episode of mild hypothyroidism not reBuiring treatment. and then usually by full reco ery! A similar pattern may occur in future pregnancies and many patients ultimately de elop a permanently underacti e thyroid! To distinguish between what is known as postpartum thyroiditis ,see ?lossary. page 18-. not reBuiring treatment. and ?ra es= disease. which reBuires treatment. two measurements may be necessary! #ne is the concentration of thyroid5stimulating antibody in the blood. as this is usually present in ?ra es= disease! The other is the ability of the thyroid gland to concentrate radioacti e iodine or technetium. as this is lacking in postpartum thyroiditis! Postpartum thyroiditis affects about fi e per cent of women but most patients do not complain of symptoms! There does not appear to be any association

between the thyroid blood test abnormalities and postnatal depression!

%se history
Flora $tewart was 64 and happily married to her lawyer husband. &illiam. and they had had their first child. Fane. fi e months earlier! Their relationship began to deteriorate when Flora became weepy and short5tempered. snapping at &illiam for no good reason! $he was also sleeping badly and &illiam noticed that Flora=s hands sometimes trembled! %owe er. they both put all this down to hormonal changes following her pregnancy and the birth of their 49 baby. and assumed that before long e erything would be back to normal! &hen Flora began to complain of palpitations. &illiam persuaded her to isit their ? P! The doctor thought that Flora might ha e an o eracti e thyroid gland and his suspicions were confirmed by a blood test! #n hearing the news Flora was concerned because her mother had suffered from ?ra es= disease when she was in her 97s and her eyes were still ery prominent 67 years later. e en though the hyperthyroidism had been cured! +n order to relie e some of Flora=s symptoms her ?P prescribed a long5acting form of propranolol ,+nderal LA- 27 milligrams. to be taken once daily and he suggested that Flora should see a specialist at the local hospital! By the time her appointment came round four weeks later. Flora felt much better and a repeat blood sample showed that her thyroid gland had become ery slightly underacti e! The diagnosis was not that of ?ra es= disease. but of postpartum thyroiditis. and Flora was reassured that she would not get bulging eyes like her mother! The propranolol was stopped. and another blood test two months later was entirely normal! Flora now knows that she may get the symptoms of postpartum thyroiditis after further pregnancies. and that she has an increased chance of de eloping a permanently underacti e thyroid gland at some stage in the future! %owe er. her ?P will do a thyroid blood test e ery year to make sure that it is detected before she can de elop se ere symptoms! 4:

-!. POINTS
/ +f you are planning a baby. tell your doctor as you may need to take a different drug from your usual one / "our doctor will keep a close watch on you during pregnancy. but your treatment will not harm your de eloping baby / $ome women will de elop mild thyroid disease after ha ing a baby. but this is easily treated! +f you are e;periencing similar symptoms to those described in Flora=s story on page 49. it is worth asking your ?P whether this could be the cause / Although your child may be born with hypothyroidism or hyperthyroidism. if you suffer from either condition. like all newborns he or she will be gi en a routine test shortly after birth and treated if necessary

44

*nlarged thyroid
De1e'o,)ent of % &oitre
An enlarged thyroid gland is known as a goitre! There are many causes. including a shortage of iodine in the diet which occurs in remote mountainous parts of the world. drugs such as lithium carbonate ,Priadel- used to treat patients with manic depression. and autoimmune disorders such as %ashimoto=s thyroiditis ,see page 9:- and ?ra es= disease ,see pages 2E99-! The cause of most goitres in this country is not known. howe er! $uch goitres are called <simple goitres= despite the fact that there are almost certainly comple; reasons for their de elopment! Although the thyroid gland is enlarged it continues to produce normal amounts of hormones and the patient is referred to as <euthyroid= as opposed to hyperthyroid or hypothyroid! At first. in teenagers and young adults. the goitre is e enly or diffusely enlarged! During the ne;t 04 to 64 years. whate er caused the thyroid to grow abnormally in the first place remains and it continues to grow but becomes full of lumps or nodules! By the time the young person reaches middle age. the goitre will ha e 48 become lumpy. when it is known medically as a <multinodular goitre=!

Si),'e diff4se &oitre

Most of those who ha e a simple diffuse goitre are young women between the ages of 04 and 64! +f you are one of them. you ,or your relati es- will ha e noticed a symmetrical. smooth swelling in the front of your neck! "ou may ha e had it for some years but thought it was @ust <puppy fat=! The goitre will mo e up and down when you swallow! +t is not tender. howe er. and does not usually cause difficulty in swallowing but you may e;perience a tight sensation in your neck! The goitre may ary slightly in siAe and be more noticeable at the time of a period or during pregnancy! +t isn=t normally a problem appearance5wise E Buite the opposite as far as some people are concerned! For e;ample. the great se enteenth and eighteenth century artists often added a goitre to the female figure to enhance her beautyK

onfir)in& the di%&nosis

Usually your ?P will want you to be seen by a specialist to e;clude the rarer causes of goitre! %e or she can normally do this by feeling your neck and by taking blood tests!

Tre%t)ent
(o treatment is necessary! +n the past iodine ,often added to milk- or thyro;ine tablets were gi en but neither is effecti e! Many people find that their goitre becomes less noticeable or e en disappears o er a period of two to three years! 43

Si),'e )4'tinod4'%r &oitre

+f you are in your forties or fifties. you will probably first become aware of a swelling in your neck while washing or applying make5up in front of a mirror! +n fact. the goitre will ha e been present for many years but has now reached a critical siAe. or it may be that your neck has become thinner! The goitre is often more ob ious on one side of the neck than the other! +t may ary in siAe from being barely isible to other people to so large that you feel you ha e to hide it by wearing scar es or high5necked sweaters! A few people notice the enlarged thyroid gland for the first time because internal bleeding causes increased swelling which is accompanied by discomfort in the neck. like a bruise. lasting a few days! +f the goitre is large there may be difficulty in swallowing dry. solid food and. if the trachea ,windpipe- is sBuashed to any e;tent. there may be difficulty in breathingD singers. in particular. will notice a change in their oice!

onfir)in& the di%&nosis

"our ?P may take a blood sample to check that your thyroid hormone le els are normal but will usually ask a specialist for ad ice about further in estigations and treatment! The specialist may wish to carry out one or more of the following tests! L5ray and breathing tests These will re eal whether the goitre is compressing or sBuashing the windpipe! Ultrasound scan A probe. the siAe of a small hand torch. is passed o er 42

41 the skin of the front of the neck and an image of the goitre is formed on a screen! As well as showing its siAe and e;tent it will also highlight any cysts or nodules that the specialist may not ha e noticed by e;amining the neck! +sotope scan This techniBue pro ides a different type of image which shows whether the nodules in the goitre are likely to be producing thyroid hormones. in which case the de elopment of an o eracti e thyroid is more likely in future years! +t is obtained by in@ecting a tiny amount of radioacti ity in the form of a radioacti e substance called technetium511m into a ein! About half an hour after the in@ection you lie under a sophisticated form of camera for a few minutes ,see page 04-! Fine needle aspiration This in ol es attaching a needle of the same siAe as that used for taking a blood sample to the end of a syringe. then. while you=re lying down. passing it without local anaesthetic through the skin of the neck into the enlarged thyroid gland! +f the nodule is ery small. the procedure may be carried out with the help of ultrasound to ensure that the needle is in the correct place! The discomfort is no more than that felt during straightforward blood tests! By pulling on the plunger and mo ing the needle up and down a tiny distance within the goitre. the doctor can obtain thyroid cells for analysis!

These are smeared on to a glass slide and. after processing in the pathology laboratory. are e;amined under a microscope! The appearance of the cells will help to determine whether the thyroid enlargement is the result of a malignant tumour! 87

#ine need'e %s,ir%tion

The doctor e;tracts cells from the thyroid gland using a syringe with a fine needle! 80 Fine needle aspiration. commonly known as F(A. is not often carried out in patients with a multinodular goitre unless the gland is ery much bigger on one side than the other. or the goitre is growing ery rapidly!

Tre%t)ent
+f your goitre is relati ely small. you probably won=t need any treatment! "our ?P will check thyroid hormone le els in your blood e ery one to two years as there is a possibility of the gland becoming o eracti e and causing hyperthyroidism at some stage during the ne;t 67 years or so! Although thyro;ine tablets are prescribed in certain parts of the world in an attempt to shrink the goitre. they are of little or no benefit and may cause hyperthyroidism! $urgery +f the goitre becomes so large that it looks really unattracti e or is compressing the windpipe. the most effecti e treatment is an operation to remo e most of the thyroid gland! (o treatment is necessary before surgery and you=ll be in hospital for about three days! The complications are the same as those for surgery for ?ra es= disease ,page 02-! "ou may ha e to take thyro;ine treatment afterwards as there may be insufficient thyroid tissue left to produce adeBuate amounts of hormones! )adioacti e iodine +n patients who aren=t fit enough for surgery or who don=t want to ha e an operation. it may be possible to reduce the siAe of the goitre by about 47 per cent by gi ing radioacti e iodine! A large dose is necessary. and you may ha e to be admitted to hospital for 6:E:2 hours! 86

The ,ossi9'e *h%n&e of % &oitre o1er % 'ifeti)e

The smooth so5called simple goitre of young adulthood changes to the multinodular goitre of middle age and the to;ic multinodular goitre of old age! The cause of the goitre is not known but. if whate er makes the thyroid gland grow in the first place continues to be present. the thyroid de elops lumps or nodules! These nodules make their own thyroid hormones and. as they increase in number and siAe o er many years. hyperthyroidism de elops! The windpipe ,trachea-. shown by the dotted lines. may be displaced and narrowed as the goitre enlarges!

89 +f so. you=ll be gi en a single room to a oid contaminating other patients and isitors with radioacti ity! +t may take se eral months for the goitre to shrink! +t is unlikely that the thyroid will become underacti e because the radioacti e iodine is mainly concentrated within the nodules and. as they become smaller. the thyroid tissue surrounding them that has been dormant and unaffected by the radiation wakes up and starts to produce thyroid hormones!

%se history
Fenny Morris was a single woman in her se enties who had been an accomplished actress! $he always wore a silk scarf around her neck. day and night. summer and winter! Friends and neighbours thought it was part of her slightly eccentric personality. but when she was admitted to hospital as an emergency with abdominal pain due to gallstones the scarf was remo ed to re eal a large goitre and a scar from a pre ious thyroid operation! Miss Morris e;plained that the operation had been carried out for a goitre when she was Buite young! +n her mid5forties the goitre appeared again but she was told further surgery was out of the Buestion because a second operation was technically more difficult and any damage to the nearby ner e supply to the oice bo; ,laryn;- would ruin her stage career! As time passed the goitre gradually grew and grew. and she took to wearing the scar es to a oid embarrassment! Blood tests in hospital showed her to ha e a slightly o eracti e thyroid gland and three months after treatment with radioacti e iodine her blood test came back normal! *Bually important. a year later. the siAe of the goitre had been reduced by at least a half. and she happily abandoned her scar esK 8:

Thyroid nod4'es
$ingle lumps or nodules in the thyroid are common. and can occur at any age! &omen are more likely to be affected than men!

A sin&'e thyroid nod4'e

The nodule aries in siAe from that of a pea to a golf ball or e en larger! Like a goitre. the nodule is usually disco ered by accident while you=re washing or looking in a mirror! Bleeding into the nodule may cause pain which alerts you to its presence! Alternati ely. the nodule may be disco ered during medical e;amination for some Buite unrelated problem. although neither you nor your family had noticed it before! Most women are aware of the significance of a lump in the breast. and so naturally suspect that a nodule in the thyroid may also mean cancer! This is why your ?P will probably want you to see a specialist! +n fact. the great ma@ority of single thyroid nodules are not cancers of the thyroid!

onfir)in& the di%&nosis

+f you ha e a single thyroid nodule. your blood test will show normal le els of T9. T: and T$%. which means you=re classified medically as <euthyroid=D the e;ception is the <to;ic adenoma= in which the thyroid blood tests will demonstrate an o eracti e thyroid gland! The thyroid specialist will wish to e;amine your neck carefully as about half of

all patients thought to ha e a single nodule are in fact found to ha e generalised nodular enlargement of the thyroid known as multinodular goitre! +n this case you can be assured that your condition is not serious! 84 Those people who need further in estigations may ha e an L5ray. ultrasound or radioisotope scan of their thyroid. but the single most important test is fine needle aspiration ,F(A- of the lump! The techniBue is simple. Buick and. if necessary. can be carried out two or three times as it doesn=t cause pain or undue discomfort! F(A is one of the most important ad ances in the care of people with thyroid disease! +n the past the ma@ority of those with a single thyroid nodule had to ha e surgery but many operations can now be a oided simply by e;amining a small sample of thyroid cells obtained by aspiration in the outpatient clinic! The outcome will be one of those indicated o erleaf! Benign ,non5cancerous- nodules may continue to enlarge o er many years and e entually may get so big that an operation is needed to remo e them for the sake of your appearance! +f you can=t help worrying about the possibility that the lump is harbouring a cancer. your specialist may well suggest operating to remo e the nodule so that it can be e;amined microscopically and resol e the Buestion once and for all! 88

83

-!. POINTS
/ +n this country. the cause of a goitre usually remains a mystery / "oung people with a simple diffuse goitre rarely need any treatment / "ou=ll probably be referred to a specialist to ha e a multinodular goitre in estigated. and you may ha e se eral tests / A small goitre may be left alone. but you=ll ha e regular blood tests done by your ?P as there=s a chance of de eloping hyperthyroidism later on / An operation or treatment with radioacti e iodine may be necessary if the goitre is causing problems / Thyro;ine tablets won=t help to shrink a goitre. although they are still prescribed in some other countries / Although people who de elop thyroid nodules often worry that the lump may be cancer. this rarely turns out to be the case / The simple and painless in estigation known as fine needle aspiration means that far fewer people now ha e to ha e surgery / +f you=re concerned about your appearance or can=t stop worrying about the possibility of cancer. you can ha e an operation to remo e the nodule 82

Thyroid cancer
$h%t is *%n*er(
A lump of human tissue the siAe of a sugar cube may contain a thousand million cells! These are the minute building blocks from which our bodies are made. isible only down the microscope! +t is Buite amaAing that the billions of cells in a human body normally function in perfect harmony. e ery cell knowing its place and doing the @ob that it was designed to do! Most cells ha e a finite lifespanH millions of new ones are produced e ery day to replace those lost through old age or wear and tear! (ew cells are produced when e;isting cells di ide into two! *;cept in children. who are growing. there is normally a perfect balance between the numbers of the cells that are dying and those that are di iding! (ormally e;actly the right amounts of new cells are produced to replace those that are being lost! The control mechanisms in ol ed are e;ceedingly comple;! Loss of control can lead to an e;cess of cells. resulting in a tumour! %owe er. it is important to realise that only a ery small minority of tumours are cancerous! Most tumours are localised accumulations of normal or fairly normal cells and are benign! A wart is a common e;ample! 81

+o3 % t4)o4r for)s

A cancerous tumour begins as a single cell! +f it is not destroyed by the body=s immune system. it will double into two cells. which in turn di ide into four and so on! The de elopment of a cancer ,malignant tumour- in ol es a change in the Buality of the cells as well as an increase in BuantityH they change in both appearance and beha iour! They become more aggressi e. destructi e and independent of normal cells! They acBuire the ability to infiltrate and in ade the surrounding tissues! +n some instances the cells may also in ade lymphatic and blood essels and thus spread away from the <primary= growth to other places! +n time these cells may cause the de elopment of secondary growths. known as <metastases=. in the lymph glands and other organs such as lungs. li er and bones! Malignant tumours of the thyroid gland are rare! For e;ample. a specialist may see 47 to 077 patients with hyperthyroidism caused by ?ra es= disease for e ery one with thyroid cancer! The types of cancer that doctors see most freBuently areH ; Papillary cancer which usually affects children and young women! ; Follicular cancer which is unusual before the age of 97! These terms describe the appearance of the tumour under the microscope! +n papillary cancer. the tumour 37

+o3 *%n*er s,re%ds

'ancerous tumours can spread to distant sites in the body by a process called metastasis! +n metastasis the cancerous cell separates from a malignant

tumour and tra els to a new location in the blood or lymph! 30 contains papillae or fronds. whereas in follicular cancer. although the appearance is distinctly abnormal. there are still structures that resemble the normal follicles of the thyroid! Both cancers can occur at any age. howe er! Pro ided that diagnosis and treatment are at an early stage. the person may well li e out a normal lifespanD in other words. you=re still more likely to die of a stroke or a heart attack in old age!

onfir)in& the di%&nosis

Most patients isit their ?P with a lump in the neck or because of rapid growth of a goitre that they= e had for many years! The diagnosis of thyroid cancer is made at a hospital isit by fine needle aspiration or following surgery! #ccasionally. the patient consults his or her doctor because of enlarged lymph nodes in the neck which may at first be thought to be caused by %odgkin=s disease! %owe er. a biopsy shows that the patient actually has papillary cancer which has spread from the thyroid gland ia the lymphatic system to the nearby lymph nodes!

Tre%t)ent S4r&ery
Both papillary and follicular cancers are usually treated by remo ing as much of the thyroid gland as possible ,total thyroidectomy-! Any enlarged lymph nodes in the neck containing thyroid cancer are also remo ed at this stage! (o special treatment is reBuired before the operation and you can usually go home after two days! As a result of the e;tent of the surgery. damage to the 36

Mi*ros*o,i* 1ie3 of the thyroid &'%nd

The follicles seen here in cross5section are best considered as slightly out5of5 shape golf balls! The dimples in the surface correspond to the follicle cells that make thyroid hormones and release them into the capillaries. which lie close by! The colloid. where reser es of thyroid hormone are stored. is like the semi5 liBuid filling of old5fashioned golf balls! There are many thousands of follicles in a thyroid gland! The superimposed needle tip shows that. during fine needle aspiration. a ery small sample of cells from two or three follicles is obtained. which may not necessarily gi e the whole picture! 39 parathyroid glands is more common than in other thyroid surgery! The low le el of calcium in the blood that results is easily treated by taking a itamin D deri ati e. known as alfacalcidol ,#ne5alpha-. in a dose of one to two micrograms each day by mouth!

R%dio%*ti1e iodine
+t is not possible to remo e e ery last part of the thyroid gland by means of surgery! For this reason. most patients with papillary or follicular cancer will be

gi en a large dose of radioacti e iodine ,iodine5090- to kill any remaining cells! The radioacti e iodine is gi en as a liBuid or a capsule in hospital! "ou will ha e to stay in hospital for 6:E:2 hours. in a single room. separated from the other patients! The radioacti e iodine is usually gi en three to four weeks after your operation and before thyro;ine tablets ha e been started. as it is most effecti e when the patient is hypothyroid and T$% le els in the blood are high! +f for some reason there is a delay. and you ha e already started taking thyro;ine to pre ent you from becoming hypothyroid after remo al of your thyroid gland. you will be taken off the treatment some four weeks before being gi en the radioacti e iodine! Towards the end of the period without thyro;ine you may feel tired but will come to no harm! The thyro;ine can be re5started in full dosage :2 hours after your treatment and you will feel your normal self after another 07 to 0: days!

Thyro:ine
Doctors belie e that the rate of growth of papillary and 3: follicular cancers of the thyroid may be increased by the hormone T$%! An important part of the treatment. therefore. is to make sure that you take enough thyro;ine to ensure that the le el of T$% in your blood becomes undetectable! Patients with thyroid cancer need a slightly greater dose of thyro;ine than those with hypothyroidism! A dose of 047 to 677 micrograms daily is usually sufficient to switch off T$% secretion by the pituitary gland!

#o''o3<4,
Papillary and follicular cancers. like the normal thyroid gland. make a substance called thyroglobulin! The thyroid gland can secrete this substance only in the presence of T$%. but this is not the case with thyroid cancer! $o. if there is no T$% detectable in the bloodstream because it has been suppressed by treatment with thyro;ine. any thyroglobulin in the blood must be coming from recurrent cancer in the neck or from cancer that has spread to other parts of the body ,secondaries or metastases-! Thyroglobulin is known as a <tumour marker=! +f a patient who is taking appropriate amounts of thyro;ine has a raised le el of thyroglobulin. the specialist may wish to arrange other tests such as an ultrasound of the neck ,see page 41-. or a 'T scan of the chest to identify the site of the recurrent tumour or its metastases! $canning of the whole body using radioacti e iodine may also be helpful! The scan is usually performed 6:E:2 hours after a dose of iodine5090 by mouth. four weeks after the patient has stopped taking thyro;ine or after T$% in@ections! Any tumour that is found may be treated with a large dose of radioacti e iodine in hospital! 34

'omputed tomography ,'T- fires L5rays through the body at

different angles! The L5rays are picked up by recei ers and the information analysed by a computer to create an anatomical picture!

Thyrogen
This is the name gi en to recombinant human T$%. a protein identical to T$% in the pituitary gland and blood. but which has been made in the laboratory! +t has recently become a ailable in the UC! Thyrogen ,thyrotropin alfa- can be gi en as an intramuscular in@ection on each of two successi e days before treatment with radioacti e iodine! By increasing the T$% concentrations in the blood in this way. you will not need to stop your thyro;ine tablets for four weeks and will not suffer any of the symptoms of an underacti e thyroid gland! About a year after your treatment by surgery and radioacti e iodine. your specialist may wish to measure the tumour marker. thyroglobulin. before and after two Thyrogen in@ections so that he or she can find out 38

&hole body scan using radioacti e iodine and a gamma camera! whether your thyroid cancer has been cured. or whether any other treatment may be needed!

O4t'oo5
This depends upon the siAe of the tumour and whether it has spread at the time of diagnosis! +f treated correctly. a young woman with a small papillary cancer of the thyroid is likely to ha e a normal life e;pectancy. despite the cancer ha ing spread to the lymph nodes in the neck! * en patients with follicular cancer that has spread to the bones or lungs may sur i e for many years with a good Buality of life! 33

%se history
$usan Fones was 02 when she fell hea ily while skating. striking the side of her neck against the ice5rink barrier! As the pain and bruising settled she noticed a pea5siAed lump in her neck! To begin with her doctor thought that it must be related to the accident. although it mo ed when she swallowed. suggesting that it lay within the thyroid gland rather than in the skin or muscle! &hen it hadn=t disappeared after si; weeks. he referred $usan to a thyroid specialist at the local teaching hospital! The consultant e;amined $usan=s neck carefully and found that. in addition to the single small thyroid nodule. there were three enlarged lymph nodes on the right side of her neck! %e proceeded to take a tiny sample from the thyroid nodule and from one of the lymph nodes. sucking out cells with a syringe and needle! The test took only a few minutes. causing $usan no discomfort and with no need e en for a local anaesthetic! The ne;t day $usan and her mother were told that the sample showed that the lump in $usan=s neck was a type of cancer of the thyroid. known as papillary carcinoma. and that it had spread to the nearby lymph nodes! The only treatment was an operation and two weeks later $usan was admitted to hospital where almost all of her thyroid gland was remo ed. together with the enlarged lymph nodes!

'areful inspection of the remo ed gland by the pathologists showed no other signs of thyroid cancer apart from the original swelling! After the operation. $usan was treated with radioacti e iodine to ensure that any remaining thyroid cells had been destroyed! $usan has been cured and simply needs to take thyro;ine tablets for the rest of her life and see the 32 specialist e ery year for a blood test! The skating accident was a blessing in disguise as it brought to light a thyroid cancer which was at a ery early stage! The fact that it had spread to the lymph nodes in the neck was of no conseBuence!

R%rer *%n*ers
These include the followingH ; Medullary cancer of the thyroid which can occur on its own or may run in families in association with abnormalities of other endocrine glands or of the skeleton! ; Lymphoma of the thyroid which usually affects elderly people and may be accompanied by e idence of disease in other parts of the body! ; Anaplastic cancer which also affects elderly people! The future prospects for people with these types of cancer is less good than for those with papillary or follicular cancer! Treatment is more difficult and may include chemotherapy and radiotherapy! 31

-!. POINTS
/ )emember that thyroid cancer is rare / The two types that doctors see most often E papillary and follicular cancers E can normally be treated successfully if they are caught early enough / An operation is necessary to remo e as much of the thyroid gland as possible and any abnormal lymph nodes in the neck. followed by treatment with radioacti e iodine to destroy any remaining cells / After surgery. patients will need to take thyro;ine in slightly higher doses than normal / A blood test will probably be done after treatment to make sure that there is no trace of cancer remaining and to check that it hasn=t spread / There are a few ery rare cancers which mainly affect elderly people in whom treatment may be more difficult 27

Thyroid blood tests

Me%s4rin& thyroid hor)one 'e1e's
+ncreasingly. patients wish to know about the actual le els of thyroid hormones and T$% in the blood! The normal or reference ranges for the commonly measured hormones are shown in the bo; on page 29!

These ranges will ary slightly from laboratory to laboratory. depending upon the normal population used for the calculations. and upon the type of chemical analysis used for the measurement of the hormones! The thyroid hormones. triiodothyronine or T 9 and thyro;ine or T:. are almost e;clusi ely bound to a protein in the bloodstream and. as such. are inacti e! Less than one per cent of these hormones are unbound or free and able to control the metabolism of the body! Measurement of total T9 ,TT9- and T: ,TT:- includes both bound and free fractions. whereas measurement of free T: ,fT:- and T9 ,fT9- e;cludes the much larger bound fraction! +n most circumstances. measurement of free and total thyroid hormones pro ides the same information about whether the thyroid is working normally or in an o er5 or underacti e fashion! $ome hospital laboratories offer the measurement of total thyroid hormones and others of free thyroid hormones. but rarely both! 20

Ty,i*%' res4'ts in hy,erthyroidis) %nd hy,othyroidis) +y,erthyroid

?enerally speaking. the more se ere the symptoms of o er5 or underacti ity of the thyroid gland. the more abnormal the results of the thyroid blood tests! +n most patients with hyperthyroidismH ; TT: would be about 017 nmol/l ; TT9 : nmol/l ; fT: :7 pmol/l ; fT9 06 pmol/l Much higher alues may be recorded. howe er. with fT: in e;cess of 077 pmol/l! +n older patients in whom hyperthyroidism may be no less serious with heart complications. such as an irregular heartbeat caused by atrial fibrillation. the le els of thyroid hormones may be only marginally ele ated! +n all patients with hyper5thyroidism. with ery rare e;ceptions. the T$% le el in the blood is so low that it cannot be detected!

+y,othyroid
By the time that patients with hypothyroidism present with typical symptoms. fT: and TT: le els are ery low and often less than 4 pmol/l and 67 nmol/l respecti ely. and associated with a raised T$% le el in the blood of more than 97 mU/l! )arely. hypothyroidism is the result of disease of the pituitary gland and not of the thyroid gland itself. in which case the low fT: or TT: is combined with a normal or low le el of T$%! +n mild or subclinical hypothyroidism ,see page :7-. fT: and TT: lie in the lower part of the normal range. 26

for e;ample 00 pmol/l or 84 nmol/l. and are usually associated with a T$% le el in the blood of between 4 and 07 mU/l!

Le els of T9 are not usually measured in patients with suspected hypothyroidism! 29

=4d&in& the *orre*t dose of thyro:ine

"our ?P or thyroid specialist will usually prescribe a dose of thyro;ine that raises the fT: and TT: to the upper part of the normal range and reduces the T$% le el in the blood to the lower part of the normal range! Typical results would be a fT: of 6: pmol/l or TT: of 0:7 nmol/l. and a T$% of 7!6 mU/l! +n some patients. a sense of well5being is achie ed only when fT : or TT: is raised. for e;ample 97 pmol/l or 037 nmol/l. and T$% low or undetectable! +n this circumstance. it is essential that the T 9 le el in the blood is uneBui ocally normal in order to a oid hyperthyroidism! Failure to take thyro;ine regularly is ery ob ious from blood test results!

!ffe*t of i''ness on thyroid 9'ood tests

+llness. whether sudden such as pneumonia or a heart attack. or of long duration. such as rheumatoid arthritis or depression. may affect the results of thyroid blood tests and gi e the impression of hyper5 or hypothyroidism! +t is possible that. after referral to a specialist and after further in estigations. no underlying thyroid disease will be found! T+.ROID B6OOD T!STS S+O>6D NOT B! INT!RPR!T!D IN ISO6ATION AND ORR! T M!DI A6 AR! $I66 A6SO D!P!ND ON AR!#>6 ASS!SSM!NT O# S.MPTOMS AND 6INI A6 !?AMINATION@ 2:

-!. POINTS
/ The normal ranges for thyroid blood tests will ary from laboratory to laboratory / ?enerally. the more se ere the symptoms the more abnormal the results of the thyroid blood test / Thyroid blood tests should not be interpreted in isolation 24

<%ypothyroidism= with normal blood tests

$ome patients are con inced that their symptoms of tiredness. weight gain and feeling low are the result of an underacti e thyroid gland. e en though le els of the hormones thyro;ine ,T:- and thyroid5stimulating hormone ,T$%- are normal! This mistaken belief has not been helped by numerous articles in newspapers and magaAines and inaccurate information on the internet! Unfortunately. a few doctors are prepared to diagnose hypothyroidism and treat patients with thyroid hormones. e en though blood tests are normal or with no blood testing at all! These doctors do not usually ha e any training in thyroid disease and

most stand to gain financially from their acti ities! The following answers to Buestions freBuently asked by patients who feel that they would benefit from thyroid hormone treatment may help to con ince you that it is not possible to ha e an underacti e thyroid gland if the blood le els of T: and T$% are normal! 28

AB4t I h%1e the sy),to)s of %n 4nder%*ti1e thyroid @ @ @2

The trouble is that the symptoms of an underacti e thyroid gland are what we call non5specific! +n other words. similar complaints are also made by patients with other problems! For e;ample. many middle5aged women gain weight and this may lead to tiredness. as may the menopause itself. or there may be stress at home and at work! Most of us feel down from time to time and prolonged fatigue might easily result from a recent iral infection! +f thyroid blood tests are normal. it makes no sense to insist that the thyroid can still be underacti e. rather than consider other diagnoses. changes in lifestyle. or confrontation of the difficulties at home or in the office!

A+o3 do yo4 5no3 3h%t 'e1e' of thyro:ine is nor)%' for )e(2

+n the author=s hospital the normal or reference range for free thyro;ine ,fT :- in the blood is 07E64 picomoles per litre ,pmol/l-. although this will ary slightly from laboratory to laboratory! +f your free T: is measured at 0: pmol/l. you might reasonably ask whether it should not be 67 pmol/l and. if so. whether T : should be gi en to relie e your symptoms! The answer lies in the measurement of the pituitary hormone. T$%! By chance. the le el of T: in the blood remains the same from day to day. month to month. and year to year in a healthy person! Any fall in the le el is sensed by the pituitary gland. which increases its output of T$% in an attempt to stimulate the thyroid to produce more T: and return its le el to its normal position! +f a normal free T: of 67 pmol/l fell to a alue of 0: pmol/l. which is still within the reference range. the 23 concentration of T$% in the blood would become abnormally high E an indication for considering treatment with thyro;ine! +f a free T : of 0: pmol/l is accompanied by a normal T$% concentration. this means that your free T : concentration is right for you and has been at that le el irtually from the day you were born! Doctors will. howe er. be suspicious of the combination of a low normal free T : of. say. 07 pmol/l and a high normal T$% of perhaps 9!6 milliunits per litre ,mU/l- ,normal is up to 9!4 mU/l-. which may indicate that you ha e underlying autoimmune thyroid disease. especially if thyroid antibodies are present in your blood! Most doctors would treat you with thyro;ine. not anticipating any dramatic response. but in order to pre ent the onset of more se ere hypothyroidism in future years!

A$hy do so)e ,%tients 3ith nor)%' 9'ood tests fee' )4*h 9etter 3hen t%5in& thyroid hor)ones(2
About 67 per cent of people gi en a dummy medicine. known as a placebo. belie ing it to be a real medicine. will feel better no matter what the illness is! This <placebo effect= may last for se eral weeks or e en months before wearing

off! +f you belie e that you might ha e an underacti e thyroid gland despite normal blood tests. any impro ement in well5being while taking thyro;ine would be the result of your relationship with a <sympathetic= doctor who prescribes what you want! &hen similar patients were gi en either placebo or thyro;ine for se eral weeks. not knowing which they were taking. they were unable to tell the difference! +n other words. thyro;ine was of no more benefit than a dummy tablet in patients who. because of symptoms 22 such as tiredness and weight gain. thought that they had an underacti e thyroid gland. although blood tests were normal!

A$h%t is the h%r) in t%5in& thyroid hor)ones if they )%5e )e fee' 9etter(2
There is no harm for most patients in taking a dose of thyro;ine of between 47 and 34 micrograms daily! Unfortunately as the <placebo effect= wears off you may be tempted to take higher and higher doses. which may produce the symptoms of an o eracti e thyroid gland! This is e en more likely to occur if you are taking a combination of thyro;ine and triiodo5thyronine. such as animal thyroid e;tract ,for e;ample. Armour thyroid-! Although. in the short term. you may be delighted with any weight loss and apparent increase in energy. in the long term this self5induced hyperthyroidism will lead to osteoporosis and possible fracture and to an irregular heartbeat ,atrial fibrillation-. heart failure. stroke and e en death!

AI 5no3 of so)e ,%tients 3ho %re t%5in& thyroid hor)ones %nd steroids 9e*%4se of sy),to)s 'i5e )ine2
Addison=s disease occurs when the adrenal glands. which sit on top of the kidneys. fail to produce enough cortisol ,hydrocortisone-! This occurs from time to time in patients with real hypothyroidism caused by autoimmune disease! There can. howe er. be no @ustification whatsoe er for doctors prescribing steroids along with thyroid hormones for patients with symptoms of an underacti e thyroid gland. but in whom thyroid blood tests ha e either not been taken or are normal! +ndeed. to prescribe steroids in the 21

belief that the adrenal glands are not working properly without adeBuate testing beforehand is medical malpractice! -!. POINTS
/Measurements of T:and T$% are reliable and when taken together allow the doctor to decide when hypothyroidism is present and when it is not present / +t is not possible to ha e an underacti e thyroid gland with uneBui ocally normal le els of T: and T$% in the blood / Thyroid hormone treatment should ne er be started without confirmatory blood tests 17

>uestions and answers

Do + ha e to change my dietG

"ou may ha e heard that iodine has something to do with the thyroid gland! +ndeed iodine is an integral part of the thyro;ine ,T :- and triiodothyronine ,T9molecules! A lack of iodine in the diet may cause a goitre or e en hypothyroidism! This is commonly found in people who li e in mountainous areas far from the sea such as the %imalayas. but the diet in the UC contains adeBuate amounts of iodine and you don=t need to take supplements! For the disbelie ers iodised salt is a ailable in some supermarkets! *;cessi e iodine intake. howe er. may unmask underlying thyroid disease and cause both hyperthyroidism and hypothyroidism! +s smoking harmfulG The eye disease that accompanies ?ra es= disease is more common and more se ere among patients who smoke! Patients with hyperthyroidism caused by ?ra es= disease should stop smoking! 10 &as stress responsible for making my thyroid gland o eracti eG Although it is difficult to pro e. most thyroid specialists are impressed by how often ma@or life e ents. such as di orce or death of a close relati e. appear to ha e taken place a few months before the onset of hyperthyroidism caused by ?ra es= disease! There is now e idence that stress can affect the immune system which is abnormal in ?ra es= disease! $o the answer is probably <yes= but there are other important factors such as heredity! &ill my new baby ha e thyroid troubleG The children of mothers with ?ra es= disease or a pre ious history of ?ra es= disease may be born with an o eracti e thyroid gland! This is known as neonatal thyroto;icosis and lasts for only a few weeks! The obstetrician and the paediatrician will be looking out for this rare complication which is readily treated! #ccasionally mothers with hypothyroidism gi e birth to a child with an underacti e thyroid gland! Again this is usually short5li ed and will be detected by the routine blood testing of all babies a few days after birth! &ill my children be affectedG (ot necessarily! +n fact. the risk is relati ely small. although it is greater than that for children who ha e no family history of autoimmune disease! (or is it always the same disease that runs in families! For e;ample. a mother may ha e ?ra es= disease. while her daughter de elops type 0 diabetes mellitus! 16 'ould my thyroid condition e;plain why + did badly in my e;amsG +t is likely to be hyperthyroidism that affects people who are the right age to be taking e;ams! +f it is not adeBuately treated. a reduced ability to concentrate will certainly lead to a substandard performance and the specialist will be happy to write to the rele ant headteacher or college tutor to e;plain the problem! 'ould thyroid disease ha e caused my an;iety/depressionG The answer is almost certainly <no=. although hyperthyroidism and hypothyroidism will make underlying psychiatric illness worse! Unfortunately. e en when a person with hyperthyroidism is successfully treated so that their o eracti e thyroid is brought under control. their psychiatric symptoms don=t

disappear altogether. although they may impro e! &ill my ?ra es= disease recurG +f your hyperthyroidism has been effecti ely treated with iodine5090. it will ne er return! +f the hyperthyroidism has settled after a single course of carbimaAole there is a 97 to 47 per cent chance of recurrence. usually within one to two years of stopping the drug! )ecurrent hyperthyroidism after surgery is usually apparent within a few weeks but may occur as long as :7 years after apparently successful surgery! Does it matter if + forget to take my medicationG The occasional missed tablet is not the end of the world! +ndeed symptoms of hypothyroidism caused by lack of thyro;ine are not usually felt for two to three weeks 19 after stopping the tablets so it would still be possible to en@oy a 35 to 075day holiday if you=d inad ertently left your medication at home! %owe er. this is not to be recommended! Also patients with hypothyroidism may ha e other autoimmune diseases such as diabetes mellitus! Failure to take thyro;ine regularly will affect the response to insulin and may lead to une;pected coma as a result of a low blood sugar! Again. missing the odd carbimaAole dose will not cause significant problems but symptoms of hyperthyroidism are likely to de elop if you don=t take the tablets for 6: to :2 hours. especially within a few weeks of starting treatment! + feel better when + am taking a higher dose of thyro;ine than recommended by my doctor! +s this safeG There is considerable debate about the correct dose of thyro;ine! The consensus is that enough should be gi en to ensure that le els of T : in the blood are at the upper limit of normal or slightly ele ated and those of T$% at the lower limit of normal. or in some patients undetectable! Although. by taking e;cessi e thyro;ine. a sense of well5being. increased energy and e en weight loss may be achie ed in the short term. there are long5term dangers to the heart and a possibility of increasing the rate of bone thinning and therefore encouraging the de elopment of osteoporosis! &ill tests in ol ing radioacti ity affect my fertilityG Definitely not! The amount of radioacti ity in ol ed is tiny E less than that in an L5ray E so you ha e absolutely no cause for concern! 1: 'an treatment for ?ra es= disease make me fatG (o. although you will probably put back any weight you lost before your condition was diagnosed and treated! %owe er. there=s no reason why you should end up weighing any more than you did before you started to de elop ?ra es= disease! My daughter was put on thyro;ine at birth because she was hypothyroid! &ill she ha e to take thyro;ine fore erG (ot necessarily! $he will be taken off thyro;ine and then gi en a blood test when she=s around a year old to see whether she still needs it! +s the time of day when + take my thyro;ine tablets importantG

(o. but most people find it=s better to take them at the same time each day E that way you=re less likely to forget! +t does not matter when you take them in relation to meals! 14

?lossary
This glossary e;plains the meaning of the most freBuently used clinical and related terms connected with the diagnosis and treatment of thyroid disorders! %&r%n4'o*ytosis: a rare blood disorder characterised by a se ere reduction in the number of white blood cells in the circulating blood! This will lea e the sufferer susceptible to a ariety of bacterial infections causing symptoms such as sore throat. mouth ulcers and high fe er! %nti9odies: these are produced by the body=s immune system as a defence mechanism against <foreign= protein contained. for e;ample. in bacteria! Antibodies are not normally formed against proteins that are part of the body! %4toi))4ne dise%se: antibodies are inappropriately produced which are directed against parts of the body! For e;ample. in most patients with hypothyroidism. antibodies are formed that participate in the destruction of the thyroid gland. whereas in ?ra es= disease antibodies directed against the surface of the 18 thyroid cell stimulate it to o erproduce thyroid hormones! *%r9i)%Bo'e: the drug most commonly used in the UC in the treatment of hyperthyroidism! +t acts by interfering with the e;cessi e production of thyroid hormones! de C4er1%in2s thyroiditis: a form of iral thyroiditis that can occur following a iral infection of the thyroid! e4thyroid: a term for normal thyroid function! e:o,hth%')os: prominence of the eyes most commonly found in patients with hyperthyroidism caused by ?ra es= disease! The e;ophthalmos may affect one or both eyes. may be apparent before the o eracti e thyroid gland de elops and may appear for the first time after successful treatment of the hyperthyroidism! fine need'e %s,ir%tion 7#NA8: a test that in ol es passing a small needle into the thyroid gland and sucking out ,aspirating- a small sample of tissue for e;amination under the microscope! This techniBue often a oids the need for surgery in patients with certain types of goitre! &enes: part of a body cell that contains the biological information of characteristics that parents pass to their children during reproduction! They control the growth and de elopment of cells! &oitre: an enlarged thyroid gland! 13 0r%1es2 dise%se: the name gi en to the most common form of hyperthyroidism! Patients often ha e e;ophthalmos. a goitre and sometimes raised red patches on the legs known as pretibial my;oedema!

+%shi)oto2s thyroiditis: the name gi en to a particular kind of goitre caused by autoimmune disease! Although the thyroid gland is enlarged. there is often e idence of hypothyroidism! hor)ones: chemical messengers that alter the acti ity of specific target cells! They are produced in specific glands or organs and transported to their site of action in the bloodstream! hy,erthyroidis): condition resulting from an o eracti e thyroid gland! hy,othyroidis): condition resulting from an underacti e thyroid gland! )y:oede)%: this means the same as hypothyroidism. but is often used to describe patients in whom the thyroid underacti ity is se ere and of long standing! ,ost,%rt4) thyroiditis: a transient disturbance in the balance of the thyroid gland which can occur in the first year after childbirth! There are usually no symptoms. but there may be symptoms of hyper5thyroidism or hypothyroidism! Treatment is not usually necessary! ,ro,r%no'o' 7Inder%'8: a drug belonging to the group known as beta blockers which alle iate some of the 12 symptoms. for e;ample tremor in patients with an o eracti e thyroid gland! #ther members of the group include nadolol ,'orgard- and sotalol ,$otacor-! ,ro,tosis: another word for e;ophthalmos! ,ro,y'thio4r%*i': this drug has a similar action to carbimaAole! +t is used if patients de elop side effects to carbimaAole and is prescribed to patients who are breast5feeding when hyperthyroid! r%dio%*ti1e iodine 7iodine<1318: an isotope of iodine which is used in the in estigation and treatment of hyperthyroidism! tet%ny: this results from a low le el of calcium in the blood with tingling in the hands. feet and around the mouth. and painful spasm of the muscles of the hands and feet! thyro&'o94'in: a protein secreted by the thyroid gland! +ts measurement is an important part of the follow5up of patients who ha e been treated for thyroid cancer! +t is known as a <tumour marker= because its presence in certain situations may indicate that the cancer has returned to other parts of the body! thyroto:i*osis: another term for hyperthyroidism! thyrotro,hin 7thyroid<sti)4'%tin& hor)one" TS+8: a hormone secreted by the pituitary gland and responsible for controlling the output of thyroid hormones by the thyroid gland! +n hypothyroidism caused by disease of the thyroid gland. T$% 11 concentrations are ele ated in the blood and in hyperthyroidism T$% concentrations are low! thyro:ine 7T48: a hormone secreted. along with triiodothyronine. by the thyroid gland! +t has to be con erted in the body to triiodothyronine before it is acti e! Thyro;ine is a ailable in tablet form for the treatment of hypothyroidism! triiodothyronine 7T38: a hormone which. along with thyro;ine. is secreted by the thyroid gland! +t is responsible for controlling the metabolism of the body!

Although a ailable in tablet form. it is not usually prescribed for patients with hypothyroidism because it does not pro ide such good control as thyro;ine! 077

Useful addresses
Benefits !nD4iry 6ine
TelH 7277 226677 MinicomH 7277 6:9944 &ebsiteH www!dwp!go !uk (! +relandH 7277 66783: ?o ernment agency gi ing information and ad ice on sickness and disability benefits for people with disabilities and their carers!

British Thyroid #o4nd%tion

P# Bo; 13. 'lifford &etherby. &est "orkshire L$69 8LD Tel/fa;H 70:69 371373 or 70:69 371::2 &ebsiteH www!btf5thyroid!org Pro ides support and information to sufferers of thyroid disorders. promotes a greater awareness of these disorders among the general public and medical profession. helps set up regional support groups and raises funds for research! 070

N%tion%' Instit4te for +e%'th %nd

Mid'ity Place. 30 %igh %olborn London &'0J 8(A TelH 767 3783 4277 Fa;H 767 3783 4270 *mailH niceMnice!nhs!uk &ebsiteH www!nice!org!uk

'ini*%' !:*e''en*e 7NI !8

Pro ides national guidance on the promotion of good health and the pre ention and treatment of ill5health! Patient information leaflets are a ailable for each piece of guidance issued!

Prodi&y $e9site
$owerby 'entre for %ealth +nformatics at (ewcastle ,$'%+(-. Bede %ouse. All $aints Business 'entre (ewcastle upon Tyne (*0 6*$ TelH 7010 6:9 8077 Fa;H 7010 6:9 8070 *mailH prodigy5enBuiriesMschin!co!uk &ebsiteH www!prodigy!nhs!uk/P+L$/inde;self!asp A website mainly for ?Ps gi ing information for patients listed by disease plus named self5help organisations!

Thyroid !ye Dise%se

P# Bo; 614:. 'olne &iltshire $(00 2&) TelH 72:: 277 2099

h%rit%9'e Tr4st

*mailH tedctMtedct!co!uk &ebsiteH www!tedct!co!uk 076 #ffers information. care and support to those affected by thyroid eye disease ia UC5wide support groups and telephone helplines! )aises awareness of the condition among the medical profession and general public. and fund raises for research!

The internet %s % so4r*e of f4rther infor)%tion

After reading this book. you may feel that you would like further information on the sub@ect! The internet is of course an e;cellent place to look and there are many websites with useful information about medical disorders. related charities and support groups! +t should always be remembered. howe er. that the internet is unregulated and anyone is free to set up a website and add information to it! Many websites offer impartial ad ice and information that has been compiled and checked by Bualified medical professionals! $ome. on the other hand. are run by commercial organisations with the purpose of promoting their own products! #thers still are run by pressure groups. some of which will pro ide carefully assessed and accurate information whereas others may be suggesting medications or treatments that are not supported by the medical and scientific community! Unless you know the address of the website you want to isit E for e;ample. www!familydoctor!co!uk E you may find the following guidelines useful when searching the internet for information!

Se%r*h en&ines %nd other se%r*h%9'e sites

?oogle ,www!google!co!uk- is the most popular search engine used in the UC. followed by "ahooK ,httpH//uk!yahoo!com- and M$( ,www!msn!co!uk-! Also popular 079 are the search engines pro ided by +nternet $er ice Pro iders such as Tiscali and other sites such as the BB' site ,www!bbc!co!uk-! +n addition to the search engines that inde; the whole web. there are also medical sites with search facilities. which act almost like mini5search engines. but co er only medical topics or e en a particular area of medicine! Again. it is wise to look at who is responsible for compiling the information offered to ensure that it is impartial and medically accurate! The (%$ Direct site ,www!nhsdirect!nhs!uk- is an e;ample of a searchable medical site! Links to many British medical charities can be found at the Association of Medical )esearch 'harities= website ,www!amrc!org!uk- and at 'harity 'hoice ,www!charitychoice!co!uk-!

Se%r*h ,hr%ses
Be specific when entering a search phrase! $earching for information on <cancer= will return results for many different types of cancer as well as on cancer in general! "ou may e en find sites offering astrological information! More useful results will be returned by using search phrases such as <lung cancer= and <treatments for lung cancer=! Both ?oogle and "ahooK offer an ad anced search option that includes the ability to search for the e;act phraseD enclosing the search phrase in Buotes. that is. <treatments for lung cancer=. will

ha e the same effect! Limiting a search to an e;act phrase reduces the number of results returned but it is best to refine a search to an e;act match only if you are not getting useful results with a normal search! Adding <UC= to your search term will bring up mainly British sites. so a good phrase might be <lung cancer= UC ,don=t include UC within the Buotes-! 07: Always remember the internet is international and unregulated! +t holds a wealth of aluable information but indi idual sites may be biased. out of date or @ust plain wrong! Family Doctor Publications accepts no responsibility for the content of links published in this series! 074

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