Hashimoto's Disease

Definition
Hashimoto's disease causes inflammation of the thyroid, a butterfly-shaped gland
located at the base of the neck, just below the Adam's apple. Although it weighs less
than an ounce, the thyroid gland has an enormous effect on the health. It's part of the
endocrine system, which is made up of several glands and tissues that produce
hormones. These chemical messengers coordinate many of the body's activities, from
digestion to metabolism to reproduction.

Hashimoto's disease is an autoimmune disorder in which the immune system

inappropriately attacks the thyroid gland, causing damage to the thyroid cells and
upsetting the balance of chemical reactions in the body. The inflammation caused by
Hashimoto's disease, also known as chronic lymphocytic thyroiditis, often leads to an
underactive thyroid gland (hypothyroidism). Hashimoto's disease is the most common
cause of hypothyroidism in the United States.

Doctors use blood tests of thyroid function to detect Hashimoto's disease. Treatment
of Hashimoto's disease with thyroid hormone replacement medication usually is
simple and effective.

Symptoms
Hashimoto's disease does not have unique signs and symptoms. The disease typically
progresses slowly over a number of years and causes chronic thyroid damage, leading
to a drop in thyroid hormone levels in your blood. The signs and symptoms, if any,
are those of an underactive thyroid gland (hypothyroidism).

The signs and symptoms of hypothyroidism vary widely, depending on the severity of
hormone deficiency. At first, you may barely notice any symptoms, such as fatigue
and sluggishness, or you may simply attribute them to getting older. But as the disease
progresses, you may develop more obvious signs and symptoms, including:

 Increased sensitivity to cold

 Constipation
 Pale, dry skin
 A puffy face
 Hoarse voice
 An elevated blood cholesterol level
 Unexplained weight gain — occurring infrequently and rarely more than 10 to
20 pounds, most of which is fluid
 Muscle aches, tenderness and stiffness, especially in your shoulders and hips
 Pain and stiffness in your joints and swelling in your knees or the small joints
in your hands and feet
 Muscle weakness, especially in your lower extremities
 Excessive or prolonged menstrual bleeding (menorrhagia)
 Depression
Without treatment, signs and symptoms gradually become more severe and your
thyroid gland may become enlarged (goiter). In addition, you may become more
forgetful, your thought processes may slow, or you may feel depressed.

Causes

Thyroid

Your thyroid gland produces two main hormones, thyroxine (T-4) and
triiodothyronine (T-3). They maintain the rate at which your body uses fats and
carbohydrates, help control your body temperature, influence your heart rate and help
regulate the production of protein.

The rate at which thyroxine and triiodothyronine are released is controlled by your
pituitary gland and your hypothalamus — an area at the base of your brain that acts as
a thermostat for your whole system. The hypothalamus signals your pituitary gland to
make a hormone called thyroid-stimulating hormone (TSH). Your pituitary gland
then releases TSH — the amount depends on how much thyroxine and
triiodothyronine are in your blood. Finally, your thyroid gland regulates its production
of hormones based on the amount of TSH it receives. Although this process usually
works well, the thyroid sometimes fails to produce enough hormones.

Your immune system's role

Normally, your immune system uses naturally occurring proteins (antibodies) and
white blood cells (lymphocytes) to help protect against viruses, bacteria and foreign
substances (antigens) that invade your body. Hashimoto's disease is an autoimmune
disorder in which your immune system creates antibodies that damage your thyroid
gland. The disease causes inflammation of your thyroid gland (thyroiditis), which
may impair the ability of your thyroid to produce hormones, leading to an underactive
thyroid gland (hypothyroidism). Then, your pituitary gland attempts to stimulate your
thyroid gland to produce more thyroid hormones, thus causing your thyroid gland to
enlarge (goiter).
Doctors don't know what causes your immune system to attack your thyroid gland.
Some scientists think a virus or bacterium might trigger the response, while others
believe a genetic flaw may be involved. Most likely, Hashimoto's disease results from
more than one factor. A combination of factors, including heredity, sex and age, may
determine your likelihood of developing the disorder. Hashimoto's disease is most
common in middle-aged women and tends to run in families.

When to seek medical advice

See your doctor if you're feeling tired for no apparent reason or have any other signs
and symptoms of hypothyroidism, such as dry skin, a pale, puffy face, constipation or
a hoarse voice.

You'll also need to see your doctor for periodic testing of your thyroid function if
you've had previous thyroid surgery, treatment with radioactive iodine or anti-thyroid
medications, or radiation therapy to your head, neck or upper chest.

If you have high blood cholesterol, talk to your doctor about whether hypothyroidism
may be a cause. And if you're receiving hormone therapy for hypothyroidism caused
by Hashimoto's disease, schedule follow-up visits as often as your doctor
recommends. Initially, it's important to make sure you're receiving the correct dose of
medicine. And over time, the dose you need to adequately replace your thyroid
function may change.

Tests and diagnosis

In general, your doctor may test for Hashimoto's disease if you're feeling increasingly
tired or sluggish, have dry skin, constipation and a hoarse voice, or have had previous
thyroid problems or goiter.

Diagnosis of Hashimoto's disease is based on your signs and symptoms and the results
of blood tests that measure levels of thyroid hormone and thyroid-stimulating
hormone (TSH). These may include:

 A hormone test. Blood tests can determine the amount of hormones produced
by your thyroid and pituitary glands. If your thyroid is underactive, the level
of thyroid hormone is low. At the same time, the level of TSH is elevated
because your pituitary gland tries to stimulate your thyroid gland to produce
more thyroid hormone.
 An antibody test. Because Hashimoto's disease is an autoimmune disorder,
the cause involves production of abnormal antibodies. A blood test may
confirm the presence of such antibodies.

In the past, doctors were unable to detect underactive thyroid (hypothyroidism), the
main indicator of Hashimoto's disease, until signs and symptoms were fairly
advanced. But by using the sensitive TSH test, doctors are able to diagnose thyroid
disorders much earlier, often before you experience any signs and symptoms. Because
the TSH test is the best screening test, your doctor will likely check TSH first and
follow with a thyroid hormone test if needed. TSH tests also play an important role in
managing hypothyroidism. These tests also help your doctor determine the right
dosage of medication, both initially and over time.

Complications

Enlarged thyroid

Left untreated, an underactive thyroid gland (hypothyroidism) caused by Hashimoto's

disease can lead to a number of health problems:

 Goiter. Constant stimulation of your thyroid to release more hormones may cause the gland
to become enlarged, a condition known as goiter. Hypothyroidism is one of the most
common causes of goiter. Although generally not uncomfortable, a large goiter can affect
your appearance and may interfere with swallowing or breathing.
 Heart problems. Hashimoto's disease also may be associated with an increased risk of heart
disease, primarily because high levels of low-density lipoprotein (LDL) cholesterol — the
"bad" cholesterol — can occur in people with an underactive thyroid gland
(hypothyroidism). Hypothyroidism caused by Hashimoto's disease also can lead to an
enlarged heart and, in rare cases, heart failure.
 Mental health issues. Depression may occur early in Hashimoto's disease and may become
more severe over time. Hashimoto's disease can also cause sexual desire (libido) to decrease
in both men and women and can lead to slowed mental functioning.
 Myxedema. This rare, life-threatening condition can develop due to long-term
hypothyroidism as a result of untreated Hashimoto's disease. Its signs and symptoms
include intense cold intolerance and drowsiness followed by profound lethargy and
unconsciousness. A myxedema coma may be triggered by sedatives, infection or other stress
on your body. Myxedema requires immediate emergency medical treatment.
 Birth defects. Babies born to women with untreated Hashimoto's disease may have a higher
risk of birth defects than may babies born to healthy mothers. Doctors have long known
that these children are more prone to intellectual and developmental problems. There may
be a link between hypothyroid pregnancies and birth defects, such as cleft palate. A
connection also exists between hypothyroid pregnancies and heart, brain and kidney
problems in infants. However, if any of these conditions are diagnosed within the first few
months of a baby's life, chances of normal development are excellent.

Treatments and drugs

Treatment for Hashimoto's disease may include observation and use of medications. If
there's no evidence of hormone deficiency and your thyroid is functioning normally,
your doctor may suggest a wait-and-see approach.
Synthetic hormones
If Hashimoto's disease causes thyroid hormone deficiency, you may need replacement
therapy with thyroid hormone. This usually involves daily use of the synthetic thyroid
hormone levothyroxine (Levothroid, Levoxyl, Synthroid). Synthetic levothyroxine is
identical to thyroxine, the natural version of this hormone made by your thyroid
gland. The oral medication restores adequate hormone levels, returning your body to
its normal functioning.

Soon after starting treatment, you'll notice that you're feeling less fatigued. The
medication also gradually lowers cholesterol levels elevated by the disease and may
reverse any weight gain. Treatment with levothyroxine is usually lifelong, but because
the dosage you need may change, your doctor is likely to check your TSH level every
six to 12 months.

Monitoring the dosage

To determine the right dosage of levothyroxine initially, your doctor generally checks
your level of TSH after a month or two. Excessive amounts of the hormone can
accelerate bone loss, which may make osteoporosis worse or add to your risk of this
disease. Overtreatment with levothyroxine also can cause heart rhythm disorders
(arrhythmias).

If you have coronary artery disease or severe hypothyroidism, your doctor may start
treatment with a smaller amount of medication and gradually increase the dosage.
Progressive hormone replacement allows your heart to adjust to the increase in
metabolism.

Levothyroxine causes virtually no side effects when used in the appropriate dose and
is relatively inexpensive. If you change brands, let your doctor know to ensure you're
still receiving the right dosage. Also, don't skip doses or stop taking the drug because
you're feeling better. If you do, signs and symptoms will gradually return.

Effects of other substances

Certain medications, supplements and even some foods may affect your ability to
absorb levothyroxine. Talk to your doctor if you eat large amounts of soy products or
a high-fiber diet, or if you take any of the following:

 Iron supplements including multivitamins that contain iron

 Cholestyramine (Questran), a medication used to lower blood cholesterol
levels
 Aluminum hydroxide, which is found in some antacids
 Sodium polystyrene sulfonate (Kayexalate), used to prevent high blood
potassium levels
 Sucralfate, an ulcer medication
 Calcium supplements

Alternative medicine
Most doctors recommend levothyroxine, the synthetic form thyroxine (T-4).
However, natural extracts are available that contain thyroid hormone derived from the
thyroid glands of pigs. These products — Armour Thyroid, for example — contain
both levothyroxine and triiodothyronine (T-3).

Doctors have a number of concerns about natural thyroid hormone extracts such as
Armour Thyroid, including:

 The balance of T-4 and T-3 in animals isn't the same as in humans.
 The exact amount of T-4 and T-3 in each batch of a natural extract product can
vary, leading to unpredictable levels of these hormones in your blood.
 There's no scientific evidence that natural extracts of thyroid hormone offer
any advantage over synthetic versions.