The thyroid debate

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GOOD MEDICINE

Can't lose weight? Can't sleep? Feeling irritable? Low on energy? Your thyroid may be the culprit. It's a tiny gland with a great big job.

Twenty-seven million Americans have thyroid disease — and more than eight out of 10 of them are women, reports the American Thyroid Association.

The thyroid, a butterfly-shaped gland in the neck, regulates your metabolism. Sometimes it goes awry, resulting in hypothyroidism (when it's underactive) or the more serious hyperthyroidism (when it's overactive). Whether or not to test if the thyroid is really off kilter is the subject of debate in the medical community, stirred up by a recent report in the Journal of the American Medical Association.

Checking for early signs of thyroid disease is easy, accurate and cheap: All it takes is a simple blood test. Yet the screening guidelines are all over the map. The main reason is that there's limited science available to help guide doctors.

After reviewing data on mild thyroid disease, the JAMA study concluded that there's no evidence to justify widespread thyroid screening. The focus, it said, should be on people at high risk for the disease. And because large randomized controlled clinical trials have not been conducted to see if the effects of mild thyroid failure are serious, the panel felt that there was not enough evidence to justify treatment or recommend screening for everyone.

mixed reviews
The report has its critics, especially among endocrinologists who regularly diagnose and treat thyroid disorders. "The findings do not present a consensus from various endocrine organizations, which share a different view," says Hossein Gharib, M.D., professor of medicine at the Mayo Clinic College of Medicine, in Rochester, Minn. Gharib estimates that up to 5 percent of the patients who walk through the doors of the Mayo Clinic have thyroid problems that are found by doctors there.

Discovering thyroid disease early can spare a patient needless discomfort, say many physicians. Slightly low or high thyroid levels can worsen over time, so even a mild deviation from normal is to be taken seriously.

So how do you know if you should have your thyroid tested? And if your levels are just below or above normal, should you start medication or take a wait-and-see approach?

What remains paramount, concluded the panel, is "clinical judgment and patients' preferences."

"When a patient has symptoms, there is no controversy about checking for thyroid disease," says panelist Rhoda H. Cobin, M.D., F.A.C.E., clinical professor of medicine at Mount Sinai School of Medicine in New York City.

But not everyone who has a mild thyroid problem displays symptoms. The panel agreed that aggressive case-finding in people at high risk (those with family histories of the condition, or women over 50) is appropriate.

detective work
Determining whether complaints like high cholesterol, hoarseness or fatigue are related to a thyroid disorder or something else entirely often requires extensive medical detective work.

"Dry skin caused by thyroid disease, for instance, is indistinguishable from the dry skin you might get during the winter," says Donald Bergman, M.D., president of the American Association of Clinical Endocrinologists.

The first step to sorting all this out is a blood test that tells doctors if the pituitary gland, which drives the thyroid to produce hormones, is releasing abnormal amounts of thyroid-stimulating hormone. An enlarged thyroid, or goiter, is another red flag.

Next up is measuring the actual level of thyroid hormone. Even if that's below or above normal, the results may be inconclusive. The reading could be a fluke, caused by a temporary inflammation, so doctors typically recheck levels within a few weeks or months.

If test levels remain outside the normal range, then you clearly have mild thyroid disease. Your doctor will test for antibodies to find out if your immune system is attacking the gland. (Most thyroid disease is caused by one of two autoimmune disorders; see "Why Your Thyroid Acts Up" on page 48.) Knowing exactly what is causing your problem can help your physician plot the best course of action.

to treat or not to treat
Slightly abnormal thyroid levels can remain stable for years without causing symptoms. Nevertheless, in many people, mild thyroid disease will gradually progress. That's why some experts like to reduce potential risk by treating a patient as soon as an abnormality is detected. But Cobin notes that the lack of clinical trials leads to questions that make the issue of treatment controversial. Is the presence of mild failure itself associated with adverse health outcomes, and will treatment improve those outcomes?

Cobin says that the few small trials which evaluated symptomatic patients with very mild thyroid disease did not see much improvement in symptoms compared with subjects taking a placebo, but that physicians may want to use a "therapeutic trial" of medication to see if it helps a specific patient.

Bergman agrees to a point. "If someone has symptoms that are vague and has even minimal thyroid dysfunction, it's worth treating her to see if she feels better," he says. But someone who doesn't improve may not, in fact, be getting the right dose, he notes. "Sometimes a patient who starts medication will say, 'The fog has lifted,'" he says. Because this could be a placebo effect, Bergman monitors each patient and adjusts her dosage to make sure that her improvement is sustained long-term.

The review panel found that treating a person with mild thyroid disease didn't have a clear advantage over waiting until the dysfunction reached a more critical level. For someone who has no symptoms and isn't thrilled about popping pills, this may come as good news. Yet once a problem has been identified, it's vital to continue to get regular thyroid blood tests. For when thyroid-hormone levels creep outside the normal range or symptoms start to appear, medication is a must. "If someone has too much or too little thyroid hormone, there are going to be repercussions for every tissue and organ in the body," declares Cobin.

The scenario changes slightly for thyroid-related autoimmune disorders. "Evidence indicates that people with these kinds of disorders are likely to progress to overt hypothyroidism within two to 10 years," says Leonard Wartofsky, M.D., chairman of the department of medicine at Washington Hospital Center in Washington, D.C. If a patient doesn't want to go on drugs, Wartofsky repeats screening tests every six months and prescribes medication at the first hint that the disease has begun to progress.

no one has to suffer
Despite the disagreement about screening and treatment, no one has to suffer. Synthetic thyroid hormone can compensate for the body's shortfalls in those with hypothroidism, while another type of medicine can lower hormone levels in those with hyperthyroidism. Finding the correct dosage is a matter of careful monitoring and adjustment, preferably by an endocrinologist. If you start taking birth-control pills or hormone replacement, or if you develop thyroid problems during pregnancy (which is not uncommon), your dosage will also need some tinkering.

Ultimately, what to do about your problem is between you and your physician. So if your doctor doesn't have much experience handling thyroid disease, says Bergman, "you should be referred to someone who does."

you might have thyroid problems if ...
Hypothyroidism can cause weight gain, trouble losing weight, dry skin and hair, fatigue, hoarseness, muscle cramps, depression, high cholesterol, mild hypertension, and an inability to tolerate the cold. Hyperthyroidism, on the other hand, can affect bowel habits and cause weight loss, hand tremors, increased perspiration, irritability, trouble sleeping, weakness in the upper arms and thighs, cardiac arrhythmia, infertility and thinning bones. In pregnant women, abnormal thyroid levels can cause a rapid heart rate in the baby, low birth weight, premature birth, and even stillbirth.

the neck check
Perform a thyroid self-check at least once a year, suggests the American Association of Clinical Endocrinologists.

Standing before a mirror, tilt your chin slightly up.
Now sip some water. Your thyroid gland is just below your larynx and above your collarbone. See your doctor if you notice any bulges there as you swallow: You might have an enlarged thyroid, or goiter.
screening for thyroid problems
Here's a rundown of screening timetables, as recommended by prominent medical organizations:

THE U.S. PREVENTIVE SERVICES TASK FORCE No recommendations for or against routine screening.

THE AMERICAN COLLEGE OF PHYSICIANS Check women over 50 who have one or more symptoms for thyroid disease.

THE AMERICAN ACADEMY OF FAMILY PHYSICIANS No need to routinely screen people under 60 who don't have symptoms.

THE AMERICAN COLLEGE OF OBSTETRICIANS AND GYNECOLOGISTS Physicians should watch for post-partum thyroid problems.

AMERICAN THYROID ASSOCIATION Check everyone — especially women — starting at age 35 and every five years thereafter.

the herbal approach to thyroid symptoms
While no single herbal treatment has been proven to slow down an overactive thyroid or stimulate a sluggish one, these well-known herbal treatments combat some of the most common symptoms. The dose amounts can vary depending on your specific medical condition. Always consult your doctor before beginning an herbal regimen.

Legend for Chart:
A-symptom
B-herb
C-how to take it
D-how much
Hypothyroidism
A
B
C
D
weight gain
bladderwrack
dried herb
5-10 g (about 1 Tbsp), three times a day
mild depression
St, John's wort
standardized extract
175-900 mg, twice a day
dry skin and hair
black currant oil
standardized extract
500 me, twice a day
high cholesterol
garlic
standardized extract
400-1,200 mg, daily
fatigue
ginseng
standardized extract
100-200 mg, twice a day
muscle cramps
kava
standardized extract
100 mg, three times a day
hypertension
hawthorn
standardized extract
100-300 mg, three times a day
Legend for Chart:
A-symptom
B-herb
C-how to take it
D-how much
Hyperthyroidism
A
B
C
D
frequent bowel movements (diarrhea)
chamomile
dried herb (as a tea)
2-4 g (about 1 tsp), three, times a day
excessive perspiration
sage
dried herb (as a tea)
3 g (about 1 tsp), three times a day
irritability and nervousness
lemon balm
dried herb (as a tea)
1-4 g (about ½-1 tsp), three times a day
insomnia and hand tremors
valerian
standardized extract
500-1,000 mg, 30 to 60 minutes before bed
muscle weakness
astragalus
standardized extract
250-500 mg, three times a day
irregular heartbeat
hawthorn
standardized extract
100-300 mg, three times a day
infertility
chaste tree
tincture (added to water)
40 drops, once a day
thinning bones
horsetail
dried herb (as a tea)
6 g (2 tsp), three times a day
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By Catherine Winters

Why your thyroid acts up
Several things can cause your thyroid to go haywire, such as a genetic disposition, type 1 diabetes or, most commonly, an autoimmune condition. Graves' disease causes hyperthyroidism, while Hashimoto's disease is the primary cause of hypothyroidism. People with a family history of thyroid problems are likelier to get one of these conditions.

Regardless of the cause, women suffer the lion's share of thyroid problems, and older women are especially vulnerable. By age 60, up to 17 percent of women (compared with 9 percent of men) have an underactive thyroid. Pregnancy, too, can throw the thyroid out of whack. Women who carry the antibody for Hashimoto's or Graves' disease may develop symptoms for the first time during pregnancy.

After giving birth, women may develop an inflammation of the thyroid gland (thyroiditis) that briefly causes hyperthyroidism followed by hypothyroidism. While the condition often resolves on its own, medication may be needed to control symptoms until the thyroid returns to normal. In some cases, experiencing a thyroid problem during or just after pregnancy is a predictor of thyroid disease down the road.

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