Articles

Thyroid Health

By Rita H. Boone, R.Ph., J.D.

Over thirteen million Americans are diagnosed with thyroid disease or disorder. The thyroid gland is a butterfly-shaped gland located at the base of your neck, just below your larynx or voice box. The lobes of the gland fit on either side of your trachea or windpipe.

As we all know, talk show host Oprah Winfrey has struggled with weight loss issues for many years. Suddenly, she gained 20 pounds earlier this year and took a leave from her show citing extreme exhaustion. After a battery of medical tests, she returned to her show in October and announced to her viewers that she had been diagnosed with hypothyroidism.

It is estimated that one in eight women will develop a thyroid disorder at some time in her life. However, the diagnosis of thyroid disease in women is often overlooked as its symptoms may mimic other disorders such as post-partum fatigue and depression. While these may be natural symptoms of childbirth, they may also be due to thyroid disease which has a high incidence following childbirth. Misdiagnosis can lead to delayed treatment and, in some cases, erroneous treatment.

Thyroid hormone, stored in the thyroid gland, consists of two hormones: levothyroxine (T4) and liothyronine or triiodothyronine (T3). The production of these hormones is controlled by another hormone, thyroid stimulating hormone (TSH). T3 is formed from the breakdown of T4 in the peripheral tissues. T3 is the more active form and plays the primary role in regulating metabolism in the body.

TSH is produced by the pituitary gland located in the brain. The pituitary gland is a tiny structure called the "master gland" because it produces hormones that control other glands and body functions including human growth. The pituitary gland consists of an anterior portion and a posterior portion. The anterior portion secretes, among other things, hormones that influence thyroid function.

Through the hormones it produces, the thyroid gland regulates metabolic rate, blood pressure, tissue growth and development, skeletal and nervous system development and plays an important role in the development of the reproductive system. It is most often referred to as the body’s "metabolic" hormone. Metabolism is defined as the broad range of biochemical processes that occur in any living organism; but most specifically, the breakdown of food and its transformation into energy.

The thyroid gland also produces calcitonin. Calcitonin is a hormone that lowers the levels of calcium and phosphate in the blood and promotes formation of bone. Calcitonin is also called thyrocalcitonin. It is used to treat hypercalcium by decreasing calcium blood levels and to treat osteoporosis by increasing bone density and decreasing fracture risk.

Thyroid disorders can range from mild, glandular enlargements that need no treatment to life-threatening cancer. However, the most common thyroid problems involve abnormal production of thyroid hormones. The gland can release too little thyroid hormone. This is a condition known as hypothyroidism. Symptoms of hypothyroidism include fatigue, depression, low body temperature, weight gain, dry skin, puffy face, hair loss, constipation, hoarseness/husky voice, irregular or heavy menstruation and infertility.

The gland can release too much thyroid hormone. This is a condition know as hyperthyroidism. Symptoms of hyperthyroidism include nervousness, irritability, weight loss, fast/irregular heartbeat, heat intolerance, sleep disturbances, trembling hands, shorter or scantier menstrual flow, and exopththalmos (bulging eyes).

Both hypothyroidism and hyperthyroidism can result in an enlarged thyroid gland. This is known most commonly as a goiter.

Manifestations of thyroid disorders range from the easily treated to those requiring multiple medical interventions. Graves’ disease is the leading cause of hyperthyroidism. It is an autoimmune disease (the immune system attacks the body’s healthy tissues instead of fighting off bacteria and abnormal tissue masses). The body produces antibodies that stimulate enlargement of the thyroid gland and tremendously increase thyroid production. Another name for Graves’ disease is diffuse toxic goiter. It is treatable and is rarely fatal.

Hashimoto’s thyroiditis is the leading cause of hypothyroidism. It too is an autoimmune disease. However, the immune system produces antibodies that attack the thyroid gland, causing damage that greatly reduces production of thyroid hormone.

Thyroid nodules are generally benign clumps of thyroid cells that simply do not function like normal thyroid tissue. Some nodules are cysts. A percentage, around 10%, of nodules is cancerous. Therefore, assessment and differentiation of nodules is important in the overall health care of patients.

Wilson’s Syndrome is something we work with physicians to treat and to optimize patient health care quite a bit at Bellevue Pharmacy. Patient’s blood tests are normal, there is no pathology of the patient’s thyroid gland, but the symptoms of hypothyroidism are manifest. The cause appears to be a failure of T4 to convert to T3 adequately. Blood tests cannot determine whether T4 is being adequately converted to T3 because that occurs in the tissues of the body. A very specific "Wilson’s" treatment protocol using varying dosages of compounded thyroid hormone is used to alleviate the symptoms caused by this disorder. Treatment involves lowering the level of reverse T3 that blocks the enzyme that converts T4 to T3. Once reverse T3 is lowered, sufficient levels of active, endogenous T3 take over.

A variety of tests are used to evaluate thyroid disorders. Simple blood tests can measure TSH levels. However, an abnormal level of TSH should be followed up with a blood test for T3 and T4 levels to provide the clearest perspective of how the thyroid is functioning.

Diagnostic criteria for hypothyroidism include low or normal blood levels of thyroid hormone (TH) and high levels of TSH. A blood level of antithyroid antibodies should be obtained to rule out Hashimoto’s thyroiditis as the cause.

Hyperthyroidism manifests as a high blood level of TH and a low blood level of TSH. To rule out Graves’ disease, health care providers also check for thyroid stimulating antibodies and/or give a radioactive iodine uptake test.

Thyroid nodules are diagnosed using blood tests, fine needle aspiration biopsy, thyroid scan and/or ultrasound. The biopsy is usually used for larger nodules and is the best test for thyroid cancer. The thyroid scan (the patient swallows radioactive iodine or technetium) uses a special camera to record hot (usually benign, but overactive) or cold (inactive, and either benign or malignant) nodules. The ultrasound indicates whether a cyst is filled with fluid or is solid and is used to determine the size of nodules and their growth over time.

Treatment of thyroid disorders can consist of use of a variety of preparations. These include commercial and compounded preparations for situations in which titration of dosage is a significant factor in optimizing thyroid health. Treatment regimens may range from a single daily tablet to radical surgical intervention followed by high does radioactive drug therapy.

Hashimoto’s thyroiditis typically is treated with only a daily dose of prescription, synthetic T4 (levothyroxine sodium). The treatment typically lasts a lifetime, but the dose is titrated over time based upon symptoms and blood tests. Follow up with the healthcare provider is essential.

Hyperthyroidism, including Graves’ disease, may be treated with radioactive iodine, antithyroid drugs, and/or surgery. All of these treatment have the disadvantage of leaving some patients permanently hypothyroid. Propylthiouracil (PTU) and methimazole (Tapazole) are commonly prescribed antithyroid drugs. They work by interfering with uptake of iodine by the thyroid gland and by interfering with certain steps required for the gland to produce thyroid hormone.

Nodules, if benign and unobstructive, may need only monitoring. If a biopsy is inconclusive or identifies a malignancy, surgery is the option of choice. If surrounding lymph nodes are involved, they may be sacrificed as well. Follow up treatment with large doses of radioactive iodine for approximately six weeks typically eradicates any remaining cancerous tissue. Overall, the cure rate is high.

Thyroid optimization requires patient education about possible life long treatment and the need for follow up. Compliance must be emphasized as well. Replacement therapy can be either natural or synthetic. Dosing titration is often an issue. Middle-aged and young adults often require 0.075-0.1 mg/day. The elderly may start with a dose of 0.05 mg/day.

If T3/T4 supplementation is necessary, Armour thyroid products are available. However, custom compounding of T3, T4, and T3/T4 for doses that are unavailable commercially is a specialty of Bellevue Pharmacy.

In sum, thyroid health is a matter of concern for millions of Americans. While there are an abundance of commercially prepared products available for treatment of thyroid diseases/disorders, Bellevue Pharmacy specializes in offering tailor-made dosages as treatment options for patients with specialized needs to foster and enhance their quality of life, including mood, energy, and alertness.