hypothyroidism

hypothyroidism, a deficiency in hormone production by the thyroid gland.

Causes of hypothyroidism

Hypothyroidism usually results from a disorder of the thyroid gland, in which case it is described as primary hypothyroidism. Congenital primary hypothyroidism is caused by lack of or abnormal development of the thyroid in utero and inherited defects in the synthesis of thyroid hormone. A major cause of acquired primary hypothyroidism is chronic autoimmune thyroiditis (inflammation of the thyroid). This condition has two forms: Hashimoto thyroiditis (Hashimoto disease), which is characterized by goitre (enlargement of the thyroid), and atrophic thyroiditis, which is characterized by shrinkage of the thyroid gland. There also exists a form of hypothyroidism known as central hypothyroidism, in which there is a deficiency of thyrotropin (thyroid-stimulating hormone; TSH), the hormone of the anterior pituitary gland that controls the thyroid. Central hypothyroidism may be caused by pituitary disease or deficiency of thyrotropin-releasing hormone, the hypothalamic hormone that maintains thyrotropin secretion.

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Hypothyroidism also may be caused by treatments for hyperthyroidism, such as radioiodine therapy or surgery. In addition, treatment for certain cancers, such as surgery for thyroid cancer and external-beam radiation therapy directed to the neck in order to treat patients with tumours of the lymph nodes of the neck (Hodgkin disease) or of the larynx, may also cause hypothyroidism. Other causes include infiltrative diseases of the thyroid, severe iodine deficiency (iodine is an essential constituent of thyroid hormone and is available only from the diet), and certain drugs (e.g., lithium carbonate, iodine, and iodine-containing drugs).

Clinical manifestations of hypothyroidism

Like other thyroid diseases, hypothyroidism is more common in women than men. The onset is usually gradual, taking several years for notable symptoms and signs to develop. However, it may be abrupt, taking only a few months to develop. Abrupt onset of hypothyroidism occurs most commonly after radioiodine treatment for hyperthyroidism. In some cases, hypothyroidism is very mild and is difficult to recognize because it causes few symptoms. In these patients, the condition may be attributed to aging. In other cases, hypothyroidism can be very severe, especially if it is allowed to progress untreated for months or years.

The clinical manifestations of hypothyroidism are characterized by slowing of most body functions. Neuromuscular symptoms include slowing of thought, speech, and action; lethargy and fatigue; sleepiness; muscle aches and weakness; and slow reflexes. Other common symptoms are dry skin and hair, decreased perspiration, puffy eyes, cold intolerance, deepening of the voice, decreased appetite but a tendency to gain weight, constipation, and irregular menstrual periods and increased menstrual blood flow in women. Cardiac contractility and heart rate decrease as a result of hypothyroidism. In later stages of thyroid deficiency, fluid may accumulate around the heart, causing a condition known as pericardial effusion. Hypothyroidism also raises serum cholesterol concentrations. In very young children hypothyroidism causes intellectual disability, and in children of all ages it causes growth retardation. In rare cases, hypothyroidism is life-threatening; this is called myxedema coma. The term myxedema refers to thickening of the skin and other organs due to the accumulation of glycosaminoglycans (large carbohydrates and proteins) associated with low serum thyroid hormone concentrations. Myxedema coma is characterized by nonresponsiveness, low body temperature (hypothermia), and respiratory depression. This condition is commonly precipitated by intake of sedating drugs, cold exposure, or infection and occurs most often in elderly women.

Cretinism

Hypothyroidism in infants, though treatable, can occasionally lead to severe intellectual disability and growth retardation leading to dwarfism. Normal fetal development requires both maternally and fetally produced thyroid hormone. In the first 12 weeks of gestation the fetus is dependent on maternal thyroid hormone. At about 12 weeks the fetal thyroid gland begins to function, although some maternal thyroid hormone crosses the placenta to reach the fetal circulation. The most-severe impairment of fetal mental and skeletal development, known as cretinism, occurs when both mother and fetus have thyroid deficiency. This tends to occur more often in regions of the world where severe iodine deficiency is a problem. Cretinism also occurs in infants who have little or no thyroid tissue, especially if the hypothyroidism is not recognized very soon after birth. The ability to prevent cretinism by prompt treatment has led to routine screening for hypothyroidism in newborns.

Diagnosis and treatment of hypothyroidism

The diagnosis of hypothyroidism is confirmed by measuring serum thyroxine (the thyroid hormone produced in greatest quantity) and thyrotropin. Measurements of free serum hormone detect hormones that are not bound to proteins in the blood and therefore circulate freely through the body. Measurements of total serum hormone detect hormones that are bound to protein in the blood and hormones that are free. These measurements are significant because free thyroid hormones are metabolically active, whereas hormones bound to proteins are not. In hypothyroidism the usual findings are low serum total and free thyroxine concentrations and high serum thyrotropin concentrations. An exception is that serum thyrotropin concentrations are normal or low in patients with hypothyroidism caused by hypothalamic or pituitary disease. Some patients have high serum thyrotropin concentrations but normal serum concentrations of thyroxine and triiodothyronine (the thyroid hormone normally produced in the lowest quantity). This is known as subclinical hypothyroidism, and these patients have few or no symptoms and signs of hypothyroidism.

Patients with hypothyroidism should be treated with thyroxine in doses sufficient to raise serum thyroxine concentrations and lower serum thyrotropin concentrations. This treatment normalizes serum thyroxine and thyrotropin concentrations and is usually sufficient to reverse the symptoms and signs of hypothyroidism in patients of all ages. In newborn infants, treatment with thyroxine is initiated based on measurements of thyrotropin and thyroxine in blood that is obtained from the infant a few days after birth; prompt treatment results in normal development.