A 42-year-old cosmetologist in Houston">
Maybe Your Problem Is Your Thyroid
A 42-year-old cosmetologist in Houston, Texas, describes herself as a Type-A personality, someone constantly on the go. "I've always had a lot of energy," she says. So when she started to feel a bit run down, she blamed her busy lifestyle. After all, she asks, "Who doesn't feel fatigued?"
Over the next year, though, her dismissiveness turned to concern as she noticed other changes: a 15-pound weight gain; dry, scaly skin; and mental impairment she calls "brain fog." "When you walk into a room and can't remember what you were there for, we all do that sometimes, but when you get to where you're doing it several times a day," she says, "there's a problem.
She became dogged by clumsiness, too, dropping and breaking glasses when she did dishes. Her coordination and reflexes just didn't seem the same, and it was starting to get depressing. "I thought, 'I'm just losing my mind,' " she recalls. Eventually her fatigue overtook her. "It was like having a really bad case of the flu, but having it every day."
Few of us would know what to make of this strange mix of symptoms. But, familiar with her father's thyroid problems, she began wondering whether her thyroid could be involved. So she visited an endocrinologist -- an internist who specializes in hormonal disorders. Her choice proved to be a good one. The doctor immediately recognized her symptoms (as well as the goiter in her neck) and simple blood tests confirmed it: Coates had an underactive thyroid gland, or hypothyroidism.
Many people whose motors seem to slow down or who start to gain weight, especially in their 50s or beyond, blame advancing age, when the real cause is underactive thyroid. New research suggests this condition, especially in its mild form, may be twice as common as previously thought -- accounting for hundreds of thousands of cases of hard-to-diagnose but highly treatable symptoms, as well as a dangerous complication: high cholesterol.
What Happens in Hypothyroidism?
Your thyroid, a butterfly-shaped gland in the lower part of your neck, secretes thyroid hormones. These help regulate a myriad of processes throughout your body, including your heart rate and breathing, digestion, rate of calorie use, body temperature, brain function, muscle repair and red blood cell production.
To maintain the right level of thyroid hormones, your thyroid is linked in a feedback system with your pituitary gland. When your body gets low on thyroid hormones, your pituitary sends out thyroid secreting hormone, or TSH. As its name implies, TSH triggers your thyroid to secrete its hormones, thyroxine and triiodothyronine. Once you secrete enough of these, they signal your pituitary to shut off the TSH faucet until your thyroid hormone levels drop again.
Underactive thyroid, or hypothyroidism, occurs when your thyroid is damaged by disease or injury and can't secrete as much of its hormones as your body needs -- and as your pituitary is "asking for" -- in the form of TSH. The most common causes of underactive thyroid are autoimmine thyroiditis, in which your immune system creates antibodies that attack your thyroid, causing inflammation and scarring; prior surgery to your thyroid; or radiation to your head or neck. Pregnancy, which changes your metabolism, can set off hypothyroidism, too. So can some medications, including amiodarone, lithium, and interferon.
A Difficult Diagnosis
Researchers who screened more than 25,000 Coloradans during health fairs in their state found that nearly 10 percent had mild or overt hypothyroidism -- yet 90 percent of the affected group was not taking thyroid medication. Previous studies put the rate of hypothyroidism at about 5 percent for the general population. It's more common in older women.
"If the Colorado experience can be generalized," wrote the authors of the study, published in February, "there may be in excess of 13 million cases of undetected thyroid gland failure nationwide." One reason: The symptoms can be elusive. They tend to come on gradually, may remain subtle for years and can easily be attributed to other conditions, including the natural aging process and menopause. You might not think much of it if you felt more sluggish, tired more easily, developed drier skin and thinner hair and didn't tolerate cold temperatures as well as you grew older. But these are common symptoms of underactive thyroid. So are constipation, weight gain, vague aches and pains, and mental changes, including depression, confusion, dull memory and trouble concentrating. None of these, though, is specific to hypothyroidism.
"The litany of symptoms a patient may present with can lead a physician in so many different directions," says Kelly Hale, founder and president of the American Foundation of Thyroid Patients. To complicate matters, if you have mild hypothyroidism you may have subtler or fewer symptoms or no symptoms at all. But this doesn't necessarily mean your condition is insignificant. Subtle symptoms can affect your quality of life. Even without symptoms, you may already have the high total cholesterol and high LDL ("bad") cholesterol that often accompany underactive thyroid. This increases your risk for heart disease and stroke. You may also be at risk for progressing to overt hypothyroidism, which means more severe symptoms and even higher cholesterol. For those reasons, many physicians advocate routine thyroid screenings to detect abnormalities. The American College of Physicians advised in a 1998 position paper that all women over 50 should be screened. The American Thyroid Association goes further, suggesting both men and women over 35 have the tests. Opponents say hypothyroidism is so uncommon before age 50 that routine screenings in younger people aren't warranted. In fact, the U.S. Preventive Services Task Force, which publishes the nation's bible on who should be screened, when, and for what, does not recommend hypothyroidism screenings at all. Instead, it reminds doctors to suspect hypothyroidism whenever symptoms appear in high-risk patients, namely older women. Some experts advise that anyone with high cholesterol be screened for hypothyroidism, whatever their age. Thyroid problems are the second most common contributor, after diet, to high cholesterol levels, according to the American Association of Clinical Endocrinologists. "Patients who have been diagnosed with high cholesterol should ask their physician about having their thyroid checked," says AACE president Dr. Richard Dickey. "If they have an underlying thyroid condition in addition to their high cholesterol, the cholesterol problem will be difficult to control until normal levels of thyroid hormone are restored."
Regardless of guidelines for screening people without symptoms, "if you are experiencing nonspecific symptoms, especially if you have a family history of thyroid disease, consider that your symptoms might be attributable to mild hypothyroidism," advises Dr. Paul Ladenson, a professor in the Division of Endocrinology and Metabolism at The Johns Hopkins School of Medicine, and secretary of the American Thyroid Association. Definitely pay attention, he says, if you notice a new symptom, it lasts more than two weeks and it occurs along with other symptoms that may point to thyroid problems. When this is the case, and there's no other clear explanation, it's worth asking your doctor about thyroid tests.
Getting the Right Treatment
Treatment standards are also a matter of debate. A daily dose of the inexpensive drug levothyroxine, a thyroid hormone replacement, can offset overt hypothyroidism. But, as with screening guidelines, doctors aren't in complete agreement about whether to treat mild cases or simply keep an eye on them. The scientific evidence to date doesn't make a clear case for or against. Still, general guidelines are emerging. Three factors, says Ladenson, may tip the balance in favor of treating a patient: Having symptoms, having potentially reversible high cholesterol or having a sign of high risk for progression to overt hypothyroidism. You're at higher risk for progression if you are older than 50, your thyroid stimulating hormone level is well above normal (10 mIU/L or more), or you test positive for thyroid antibodies, which indicates that your immune system is attacking your thyroid.
Patients who are stabilized on levothyroxine should get their thyroid function retested every six to 12 months. Close monitoring is important because aging, pregnancy, weight gain or loss and use of other drugs or dietary supplements can change your dosage needs. The Colorado study found that 40 percent of people taking thyroid medication were not receiving the right dose, even though 92 percent had seen a health-care provider in the past year. "Unfortunately," says Ladenson, "the most common reason is that people are not taking their medicine faithfully."
Ellen Brightly, an information specialist for the Thyroid Foundation of America, explains one reason why: "A person can have a thyroid problem and feel fine, and say 'Why should I take medicine?' " But when patients stop medication, symptoms virtually always come back. Even slight underdosing can cause symptoms and any cholesterol problem to return. Overtreatment can lead to problems of its own, such as nervousness, palpitations and chest pain, and can contribute to osteoporosis. So patients should take their medication as directed, and visit their doctor for an exam and follow-up tests at least once a year, or any time they suspect the dosage may need to be adjusted. "It takes some patience to get the right dosage," says Coates. "But the payoffs are worth it. Within a month's a time," she says, "you can tell a profound difference. You have more energy, your mood improves, things really improve all around. It's kind of like a sunflower opening -- it gets bigger and bigger, and then it opens up. It blossoms."
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