Hypothyroidism

Initially, hypothyroidism may not cause any symptoms. The symptoms often appear gradually and may not be noticeable in the earlier stages. There are various symptoms associated with hypothyroidism such as:

• Chronic fatigue
• Unexplained weight gain and difficulty losing weight
• Puffiness of the face
• Hoarseness of voice
• Disturbances in the menstrual cycle in women
• Fertility problems in women of child-bearing age
• Excessive hair fall; hair may become brittle, dry, and break easily
• Muscle and joint pains
• Elevated blood cholesterol levels
• Slower heartbeats
• Constipation
• Dry skin
• Impaired memory
• Depression
• Reduced tolerance to cold
• Thyroid gland enlargement (Goiter)

Hypothyroidism can also affect infants, young children, or teens, causing symptoms such as:

• Stunted growth
• Delayed onset of puberty
• Lethargy and sleepiness

Note: Infants may be born without a thyroid gland or with a poorly functioning gland, causing specific symptoms such as constipation, difficulty breathing, protruding tongue, and jaundice.

There are two hormones involved in hypothyroidism: thyroid stimulating hormone (TSH) and thyroxine. TSH is a hormone secreted by the pituitary gland in the brain, and its function is to stimulate the thyroid gland to produce thyroxine. Hypothyroidism is a hormonal disorder where the thyroid gland does not produce sufficient quantities of the thyroid hormone. It is clinically evaluated by the levels of TSH and free thyroxine concentrations. TSH levels are higher than the reference range, while thyroxine levels are below the reference range.

A. Clinical primary hypothyroidism

Primary hypothyroidism is caused by a problem with the thyroid gland itself. It occurs when the thyroid gland does not produce sufficient quantities of the thyroid hormone or thyroxine. Multiple causes may lead to the underproduction of the thyroid hormone, such as:

• Autoimmune disease: In this condition, the immune system produces antibodies that attack the thyroid gland. As a result, a large number of white blood cells, which are part of the immune system, damage the gland and cause insufficient production of thyroid hormones. The most common forms are Hashimoto’s thyroiditis (chronic lymphocytic thyroiditis) and atrophic thyroiditis.
• Iodine deficiency: Iodine is an essential mineral required by the thyroid gland to produce thyroxine. A deficiency of iodine in the diet leads to the underproduction of the thyroid hormone.
• Pregnancy: During or post-pregnancy, inflammation of the thyroid gland may occur, affecting the production of thyroid hormone. This condition is known as postpartum thyroiditis. However, most women with postpartum thyroiditis regain normal thyroid function.
• Surgical removal of the thyroid gland: In some cases, individuals with hyperthyroidism, thyroid nodules, small thyroid cancers, large goiters, or Graves’ disease may require surgical removal of part or all of their thyroid gland. If the entire thyroid is removed, it can lead to hypothyroidism as no thyroid hormones are produced. If only part of the gland is removed, it may still produce enough thyroid hormones for proper body functioning.
• Medications: Certain medications, such as antipsychotic drugs like lithium, antiarrhythmic drugs like amiodarone, and interleukins & anti-cancer medicines, can affect thyroid hormone production. Medications used to treat hyperthyroidism can cause paradoxical hypothyroidism.
• Radiation therapy: Ionizing radiation is commonly prescribed for individuals with hyperthyroidism or cancers of the head or neck, such as lymphoma or leukemia. However, exposure to ionizing radiation during treatment for certain cancers or hyperthyroidism can damage the thyroid gland, leading to hypothyroidism.

B. Central hypothyroidism

Central hypothyroidism is defined as hypothyroidism due to insufficient stimulation by TSH of an otherwise normal thyroid gland. It can be secondary hypothyroidism (pituitary) or tertiary hypothyroidism (hypothalamus) in origin. Rarely, the hypothalamus under-secretes the thyrotropin-releasing hormone (TRH), which affects the secretion of TSH by the pituitary gland, causing hypothyroidism. This condition is also known as tertiary hypothyroidism.

C. Congenital hypothyroidism

Some babies are born with a thyroid gland that is not fully developed or does not function properly, resulting in hypothyroidism at birth.

The following risk factors are associated with hypothyroidism:

• Gender: Women are more likely to develop hypothyroidism than men.
• Age: Hypothyroidism is more common among individuals older than 60 years.
• Family history: The risk is higher if there is a family history of hypothyroidism or other thyroid-related disorders.
• Race: Individuals of White or Asian descent are more likely to develop this disorder.
• Medical conditions: Several health problems can increase the risk of hypothyroidism, including:
  • Type 1 or Type 2 diabetes
  • Multiple sclerosis
  • Rheumatoid arthritis
  • Sjogren’s syndrome
  • Lupus
  • Celiac disease
  • Addison's disease
  • Pernicious anemia
  • Vitiligo
  • Bipolar disorder
  • Down syndrome
  • Turner syndrome

The tests essential to confirm a diagnosis of hypothyroidism are:

A. Blood tests

Some of the common blood tests used to diagnose hypothyroidism include:

• Thyroid stimulating hormone (TSH): This is the most important and sensitive test for hypothyroidism. It measures how much of the thyroxine (T4) hormone the thyroid gland is being asked to make. An abnormally high TSH indicates that the thyroid gland is being asked to produce more T4 due to insufficient T4 in the blood, confirming hypothyroidism. TSH also assists the doctor in determining the appropriate dosage of medication, both initially and over time.
• Thyroxine total (T4): Most of the T4 in the blood is attached to a protein called thyroxine-binding globulin. The "bound" T4 cannot enter body cells. Only about 1%–2% of T4 in the blood is unattached ("free") and can enter cells. The free T4 and the free T4 index are simple blood tests that measure how much unattached T4 is present in the blood and available for cellular uptake. In hypothyroidism, thyroxine levels are lower than normal.
• Thyroxine Total (T3): The total T3 includes both bound and free forms circulating in the blood and can be affected by the amount of protein available in the blood to bind to them. The T3 hormone can be measured as free T3 or total T3. The triiodothyronine (T3) total test measures the total levels (both free and bound forms) of T3 hormone in the blood and is usually performed as part of the thyroid profile total test. Its levels may be normal or low in hypothyroidism.

Along with these three tests, supporting tests may be required to evaluate and monitor the condition, such as:

• Anti-thyroglobulin antibody
• Thyroxine binding globulin

Additionally, all newborn babies are routinely screened for thyroid hormone deficiency to rule out congenital hypothyroidism.

B. Imaging tests

The following imaging tests can be used to identify the cause of hypothyroidism:

• Thyroid scan: This test helps evaluate the size, shape, and position of the thyroid gland. It uses a small amount of radioactive iodine to diagnose the cause of hypothyroidism and check for thyroid nodules.
• Ultrasound: An ultrasound of the thyroid is used to examine thyroid nodules, which are solid or fluid-filled lumps that form within the thyroid gland. This imaging can also help the doctor assess whether the nodules are cancerous.
• Radioactive iodine uptake test: Also known as a thyroid uptake test, this measures how much radioactive iodine the thyroid absorbs from the blood after ingesting a small amount. It helps evaluate thyroid function and determine the cause of hypothyroidism.

There is no specific way to prevent hypothyroidism. The best way to prevent complications of the disease or having the symptoms impact your life significantly is to watch for signs of hypothyroidism. Those at higher risk for hypothyroidism should be more vigilant regarding their symptoms. If you experience any of the symptoms, it is advisable to consult your doctor. Hypothyroidism is quite manageable if diagnosed and treated early.

Hypothyroidism is treated by prescribing a synthetic version of the thyroxine hormone. The prescribed medicine must be taken every day in the morning or as directed by the physician. Certain medications, such as iron and calcium supplements or aluminum hydroxide found in some antacids, may interfere with the absorption of thyroxine.

The dosage may need to be adjusted based on close monitoring of TSH and thyroxine levels. The dosage of the thyroid medication is determined by the doctor, taking into account the following factors:

• Age
• Cause of hypothyroidism
• Other concomitant health conditions
• Any other medications being taken by the patient

For example, the elderly population is typically started on a lower dose, whereas a higher dose may be necessary if gastrointestinal diseases, such as celiac disease, hinder the absorption of the medication.

The primary risks associated with thyroxine arise from taking too little or too much of the medication. If too little is taken, hypothyroidism will persist. Conversely, if too much is taken, symptoms of hyperthyroidism—an overactive thyroid gland—may develop. The most common symptoms of excessive thyroid hormone include:

• Fatigue
• Inability to sleep
• Increased appetite
• Nervousness
• Intolerance to heat
• Shortness of breath
• Racing heart

Patients experiencing hyperthyroidism symptoms during thyroxine replacement therapy should have their TSH levels tested. If TSH is low, indicating an excess of thyroid hormone, the dosage needs to be reduced.

If you have hypothyroidism, you will be prescribed a synthetic version of the thyroid hormone to combat the deficiency. Here are a few tips to help you take the medicines and improve your symptoms.

It is important to take the tablet daily, preferably first thing in the morning, for as long as advised by your doctor.

You can take the tablet with water and on an empty stomach.

Maintain a gap of at least 4 hours between the thyroid medicine and other medicines such as calcium or iron supplements.

To keep track of your pills, you may store them in an airtight labeled box with labels for each day of the week. This will help you monitor your doses and ensure you have not missed any.

Diet Tips

• Taking a balanced diet that fulfills the body’s requirements of iodine may help hypothyroidism caused by iodine deficiency. Consume iodine-fortified table salt as it is a good way to include iodine in your diet. Shellfish, lean proteins, and whole grains are good sources of iodine.
• In the case of Hashimoto’s disease or other types of autoimmune thyroid diseases, patients may be sensitive to the side effects of iodine. Eating foods with large amounts of iodine may actually cause or worsen hypothyroidism. Taking iodine supplements might also have the same effect. Hence, it is important to consult a doctor about which foods to limit or avoid and whether one can take iodine supplements or other medications that might contain iodine.
• Eat a low-fat diet and include foods rich in calcium and Vitamin D such as milk and milk products, as well as oily fish. Add leaner proteins such as chicken breast or fish.
• Avoid certain vegetables like cabbage, broccoli, or cauliflower as these are known to interfere with the functioning of the thyroid gland.
• Limit soy food products like tofu, vegan cheese, soy milk, soybeans, and soy sauce. Soy is known to hinder the absorption of thyroid hormone. Hence, avoid eating or drinking soy-based foods for at least four hours before and after taking the medication.
• Like soy, fiber can also interfere with hormone absorption. Since fiber is vital for the body, do not avoid it completely. Instead, avoid taking the medication within several hours of eating high-fiber foods.

Incorporating a few diet-related changes can help you manage your condition better and lead a healthy life. Here are a few diet tips for people with hypothyroidism that can help control the condition.

Exercise and Yoga

Daily exercise and yoga can help boost the body’s metabolic rate and ease the symptoms of hypothyroidism. Regular exercise may also help battle complications of hypothyroidism, including obesity and heart-related issues. You can engage in light exercise programs to boost your metabolism and help with the symptoms of hypothyroidism.

Some yoga asanas that are helpful for thyroid issues are:

• Sarvangasana
• Halasana
• Setubandhasana
• Sirsasana

Note: Please perform these asanas under expert supervision only.

Akshar, founder and chairman of Akshar Yoga, suggests some yoga asanas for hypothyroidism with their benefits and steps to perform the asanas.

Hypothyroidism can cause many health complications such as:

• Goiter: Constant stimulation of the thyroid gland to produce more hormones may cause the gland to swell and become larger. This is known as goiter. It appears as a cosmetic deformity in the neck and may also cause trouble while breathing or swallowing.
• Obesity: Even with a reduced appetite, people with hypothyroidism tend to gain weight and find it difficult to lose weight due to a slower basal metabolic rate, which predisposes them to obesity.
• Cardiac problems: Hypothyroidism is associated with an increased risk of heart diseases or heart failure. It elevates the levels of low-density lipoprotein (LDL), which is detrimental to heart health.
• Infertility: In women, hypothyroidism can interfere with the normal cycle of egg production or the ovulation process, causing challenges when trying to conceive. In men, an underactive thyroid is known to cause abnormal sperm morphology and erectile dysfunction.
• Peripheral neuropathy: Long-term hypothyroidism can damage the peripheral nerves that carry information from the brain and spinal cord to the rest of the body, causing pain, tingling, or numbness in the extremities.
• Myxedema: This is a rare and serious complication that occurs when thyroid levels in the body are extremely low. The patient may become lethargic, drowsy, and in severe cases may slip into a life-threatening coma known as myxedema coma.
• Balance problems: Hypothyroidism can also present with balance problems, especially in older women.
• Joint pain: Low levels of thyroid hormone can cause joint and muscle pain, as well as tendonitis, which is the inflammation of a tendon, the thick fibrous cords that attach muscle to bone.
• Mental health issues: Hypothyroidism can lead to slow mental functioning, memory lapses, and concentration difficulties. Depression may also occur and can become more severe over time.
• Birth defects: Women with untreated thyroid disease are more likely to give birth to babies with a higher risk of birth defects. These children are also likely to experience intellectual and developmental problems. Infants with congenital hypothyroidism, if not treated promptly, are at risk of both physical and mental developmental issues.

• Ayurveda: Ayurvedic preparations of triphala, guggulu, and punarnavadi have been found to be helpful in treating hypothyroidism.
• Homeopathy: Homeopathic preparations, such as calcarea carbonica, are effective in the treatment of hypothyroidism.

A diagnosis of hypothyroidism may often be a cause of anxiety for the patient as it comes with multiple health symptoms. Patients often struggle with obesity and have poor energy levels. They may experience heart problems such as increased cholesterol levels and heart failure. Women of reproductive age may also face difficulties in conceiving a child due to hypothyroidism. Additionally, hypothyroidism is known to cause chronic depression, all of which may affect patients' quality of life. Fortunately, hypothyroidism is generally manageable with inexpensive medications. If your thyroid hormone levels are low, a simple treatment along with the following tips could greatly improve your quality of life.

• Lose weight: If you have low thyroid levels, you may have a decreased metabolic rate and a higher body mass index (BMI), which can put you at risk of obesity. If you are overweight, you may need more thyroid hormone to carry out regular functions. A low-calorie diet can help you lose weight, and in extreme cases, weight loss surgery can also be an option. Talk to your doctor about available options to lose weight and how it can improve your thyroid function and disease control.
• Eat a balanced diet: A healthy diet can help manage certain symptoms of hypothyroidism such as lethargy, fatigue, and tiredness. Eating well also lowers your risk of developing other health complications due to an impaired thyroid gland. Include foods rich in selenium, omega-3 fatty acids, calcium, magnesium, and vitamins E and B6. Increase your intake of fresh fruits and vegetables, whole grains, and lean meats while avoiding processed foods. It may be time to reconsider what goes on your plate.
• Exercise regularly: As hypothyroidism can make you feel tired and low on energy, it is important to stay physically active. This can improve your metabolism and overall health, aiding in weight loss and helping you manage your condition. Start slowly with morning and evening walks or playing a sport. Swimming or cycling are also great options. Consider yoga, which involves stretching and twisting of the muscles, stimulating the thyroid gland and helping maintain a healthy metabolism.
• Take medications regularly: Strictly follow your doctor’s advice about taking medications on time. Take your medicines daily at almost the same time to ensure consistent hormone levels in the blood throughout the day. The best time to take thyroid medications is early in the morning, but avoid taking them with tea or coffee; maintain a gap of at least 30 minutes between food and the medication. It may be wise to set reminders to avoid skipping doses.
• Manage stress: Stress leads to numerous hormonal changes in the body, increasing the resistance of thyroid receptor cells to thyroid hormones and weakening immunity. Therefore, managing stress is crucial for those with hypothyroidism. Measures to de-stress may include indulging in hobbies, meditation, joining a dance or art class, gardening, planning a mini-vacation, or spending time with friends and family.

Pregnancy and hypothyroidism: Hypothyroidism is very common during pregnancy and can pose significant risks to both mother and baby. The mother may be at increased risk of miscarriages, hypertension, anemia, and muscle pain, while the baby may face cognitive and developmental impairments. Women with hypothyroidism require an increased dosage of thyroid medication during pregnancy and must consult their doctor as soon as pregnancy is confirmed. Routine monitoring tests for TSH and thyroxine levels are essential to optimize treatment dosages.