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home : columnists : columnists August 22, 2017

Thyroid problems common in family medicine setting

By Dr. John Roberts

I've received a request to write about thyroid gland problems. Thyroid problems are common in a family medicine setting. For those who don't know what the thyroid gland is or does, keep reading.

The thyroid is an endocrine gland found in the front part of the neck below and to the sides of the Adam's apple. Endocrine glands produce hormones and secrete them into the bloodstream. The hormones then travel around the body and trigger various biologic processes by interacting with cells in different tissues. Hormones are like molecular fingers that flip switches on cells to tell them to perform particular functions.

The primary job of the thyroid gland is to control metabolism (energy use) in our cells. It does this by producing two hormones, T4 (thyroxine) and T3 (triiodothyronin). Both of these hormones contain iodine which is why iodine is so important in our diets.

Our cells have hormone receptors on their cell membranes that act as sensors to constantly monitor body functions and tweak them to maintain "homeostasis," a balanced internal environment. Biochemical systems that maintain homeostasis are extremely elegant. Some work like a furnace thermostat that turns the furnace on or off based on the temperature in the room. Instead of using wires and electricity to communicate, the body uses the circulatory system and hormones as chemical messengers.

The hypothalamus, a part of the brain, is the main thermostat in our body that interacts with the thyroid. When it detects that the body is cold or requires more energy production, it will release the hormone TRH (Thyrotropin Releasing Hormone). This hormone travels to another endocrine gland just below the hypothalamus, the pituitary, stimulating it to secrete TSH (Thyroid Stimulating Hormone) into the bloodstream. The TSH then stimulates the thyroid gland to release T4 and T3.

Once the hypothalamus has turned on the thyroid "furnace" via TRH and TSH, how does it get shut off? The hypothalamus and pituitary also monitor the levels of T4 and T3 in the bloodstream via a feedback loop - when the hormones reach a certain level, they turn off the production of TRH and TSH.

Now that you know the physiology of the thyroid, hopefully it will make it easier to understand how things can get out of whack. There are two main problems that can develop with the thyroid. The first is hypothyroidism, a "low" thyroid state, where too little T3 and T4 are produced. The other is hyperthyroidism or a "high" state where too much hormone is released. Either one of these conditions can be very serious since homeostasis is knocked out of balance.

Hypothyroidism can result with an interruption of any step of this complex hormonal pathway. The hypothalamus may not detect the body is cold or in need of energy. It may not produce or release TRH to stimulate the pituitary to secrete TSH. The pituitary may not make or release TSH or the thyroid gland itself may not respond to the TSH or make T3 or T4 properly.

Common symptoms of hypothyroidism include: fatigue, weight gain, water retention, intolerance to cold, brittle hair and nails, dry skin, muscle cramps, joint aches, thyroid enlargement (goiter), low heart rate and constipation.

Hypothyroidism may result from a number of conditions involving destruction of the endocrine glands or their ability to make hormones. Hypothyroidism is confirmed by doing lab tests for hormone levels. The level of TSH in the blood is the most sensitive test. Levels will be high in the blood because the pituitary is sensing the low levels of thyroid hormone and is trying to stimulate the thyroid to make more T3 and T4. Depending on the situation, blood tests for T4 and T3 may also be checked.

Treatment of hypothyroidism usually involves taking synthetic thyroid hormone pills. Monitoring is performed by checking blood levels of thyroid hormones on a periodic basis and adjusting the dose accordingly.

Hyperthyroidism is caused by problems with excess thyroid hormone production or secretion. The most common cause, Hashimoto's thyroiditis, results from the person's immune system producing antibodies that mimic TSH and keep the thyroid constantly turned on. Other problems like thyroid growths can produce too much hormone.

Symptoms of hyperthyroidism include: weight loss, anxiety, tremor, intolerance to heat, rapid heartbeat or palpitations, thyroid enlargement, apathy or depression, and sometimes bulging eyeballs.

Like hypothyroidism, it is confirmed with lab testing. Usually the level of TSH is low since the pituitary sees plenty of thyroid hormone in the blood. Thyroid hormone levels are usually elevated. Additional testing may include ultrasound or nuclear imaging of the thyroid to look for growths or other abnormalities.

The treatment of hyperthyroidism varies based on the cause. It may require taking medication to suppress hormone production or taking radioactive iodine to destroy hyperactive thyroid tissue. Surgery is sometimes performed. Over-treating hyperthyroidism sometimes results in hypothyroidism and the need to take thyroid hormone pills.

Dr. John Roberts is a local physician. His column appears in Monday's edition of the Times, and he has a daily health tip on the front page. Dr. Roberts is one of the owners of Sagamore News Media, parent company of The Times.

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