Ruchi Mathur, MD, FRCP(C) is an Attending Physician with the Division of Endocrinology, Diabetes and Metabolism and Associate Director of Clinical Research, Recruitment and Phenotyping with the Center for Androgen Related Disorders, Department of Obstetrics and Gynecology at Cedars-Sinai Medical Center.
Dr. Shiel received a Bachelor of Science degree with honors from the University of Notre Dame. There he was involved in research in radiation biology and received the Huisking Scholarship. After graduating from St. Louis University School of Medicine, he completed his Internal Medicine residency and Rheumatology fellowship at the University of California, Irvine. He is board-certified in Internal Medicine and Rheumatology.
There are medications available to immediately treat the symptoms caused by
excessive thyroid hormones, such as a rapid heart rate. One of the main classes
of drugs used to treat these symptoms is the
beta-blockers [for example,
propranolol (Inderal),
atenolol (Tenormin),
metoprolol (Lopressor)].
These medications counteract the effect
of thyroid hormone to increase metabolism, but they do not
alter the levels of thyroid hormones in the blood. A doctor determines which patients
to treat based on a number of variables including the underlying cause
of hyperthyroidism, the age of the patient, the size of the thyroid gland,
and the presence of coexisting medical illnesses.
Antithyroid Drugs
There are two main antithyroid drugs available for use in the United States,
methimazole (Tapazole) and propylthiouracil (
PTU). These drugs accumulate in
the thyroid tissue and block production of thyroid hormones. PTU also blocks the conversion
of T4 hormone to the more metabolically active T3 hormone. The major risk
of
these medications is occasional suppression of production of white blood cells by
the bone marrow
(agranulocytosis). (White cells are needed to fight infection.) It is
impossible to tell if and when this side effect is going to occur, so regular determination
of white blood cells in the blood are not useful.
It is important for patients
to know that if they develop a fever, a sore throat, or any signs of infection
while taking methimazole or propylthiouracil, they should see a doctor immediately. While a
concern, the actual risk of developing agranulocytosis is less than 1%. In
general, patients should be seen by the doctor at monthly intervals while taking antithyroid
medication. The dose is adjusted to maintain the patient in as close to a normal
thyroid state as possible (euthyroid). Once the dosing is stable, patients
can be seen at three month intervals if long-term therapy is planned.
Usually, long-term antithyroid therapy is only used for patients with Graves'
disease, since this disease may actually go into remission under
treatment without requiring treatment with thyroid radiation or surgery.
If treated from one to two years, the data shows remission rates of 40%-70%. When the disease
is in remission, the gland is no longer overactive, and antithyroid medication is
not needed.
Recent studies also have shown that adding a pill of thyroid hormone
to the antithyroid medication actually results in higher remission rates. The rationale
for this may be that by providing an external source for thyroid hormone, higher
doses of antithyroid medications can be given, which may suppress the overactive
immune system in
persons with Graves' disease. This type of therapy remains controversial,
however. When long-term therapy is withdrawn, patients should continue to
be seen by the doctor every three months for the first year, since a relapse of
Graves' disease is most likely in this time period. If a patient does relapse,
antithyroid drug therapy can be restarted, or radioactive iodine or surgery may
be considered.
Radioactive Iodine
Radioactive iodine is given
orally (either by pill or liquid) on a one-time basis to ablate a hyperactive gland. The iodine given for ablative treatment is
different from the iodine used in a scan. (For treatment, the isotope iodine 131
is used, while for a routine scan, iodine 123 is used.) Radioactive iodine is given
after a routine iodine scan, and uptake of the iodine is determined to confirm hyperthyroidism.
The radioactive iodine is picked up by the active cells in the thyroid and
destroys them. Since iodine is only picked up by thyroid cells, the destruction is
local, and there are no widespread side effects with this therapy.
Radioactive iodine
ablation has been safely used for over 50 years, and the only major reasons
for not using it are pregnancy and breast-feeding. This form of
therapy is the treatment of choice for recurring Graves' disease, patients with
severe cardiac involvement, those with multinodular goiter or toxic adenomas,
and patients who cannot tolerate antithyroid drugs. Radioactive iodine must be
used with caution in patients with Graves' related eye disease since recent
studies have shown that the eye disease may worsen after therapy. If a woman
chooses to become pregnant after ablation, it is recommended she wait 8-12
months after treatment before conceiving.
In general, more than 80% of patients are cured with a
single dose of radioactive iodine. It takes between 8 to 12 weeks for the
thyroid to become normal after therapy. Permanent hypothyroidism is the
major complication of
this form of
treatment. While a temporary hypothyroid state may be seen up to six months after treatment with
radioactive iodine, if it persists longer than six months, thyroid replacement therapy
(with T4 or T3) usually is begun.
Surgery
Surgery to partially remove the thyroid gland (partial thyroidectomy)
was once a common form of treatment for hyperthyroidism. The goal is to remove
the thyroid tissue that was producing the excessive thyroid hormone. However, if
too much tissue is removed, an inadequate production of thyroid
hormone (hypothyroidism) may result. In this case, thyroid replacement
therapy is begun. The major complication of surgery is disruption of
the surrounding tissue, including the nerves supplying the vocal cords and the
four tiny glands in the neck that regulate calcium levels in the body (the
parathyroid glands). Accidental removal of these glands may result in low
calcium levels and require calcium replacement therapy.
With the introduction of radioactive iodine therapy and
antithyroid drugs, surgery for hyperthyroidism is not as common as
it used to be. Surgery is appropriate for:
pregnant patients and children who have
major adverse reactions to antithyroid medications.
patients
with very large thyroid glands and in those who have symptoms stemming from compression of tissues
adjacent to the thyroid, such as difficulty swallowing,
hoarseness, and shortness of breath.
Night sweats are severe hot flashes that occur at night and result in a drenching sweat. In order to distinguish night sweats that arise from medical causes from those that occur because one's surroundings are too warm, doctors generally refer to true night sweats as severe hot flashes occurring at night that can drench sleepwear and sheets, which are not related to an overheated environment.
Hypothyroidism is any state in which thyroid hormone production is below normal. Normally, the
rate of thyroid hormone production is controlled by the brain at the pituitary.
Hypothyroidism is a very common condition and the symptoms of hypothyroidism are
often subtle.
Dizziness is a symptom that is often applies to a variety of sensations including lightheadedness and vertigo. Causes of dizziness include low blood pressure, heart problems, anemia, dehydration, and more. Treatment of dizziness depends on the cause.
There are four major types of thyroid cancer: papillary, follicular, medullary, and anaplastic thyroid cancer. Tumors on the thyroid are referred to as thyroid nodules. Symptoms of thyroid cancer include swollen lymph nodes, pain in the throat, difficulty swallowing, hoarseness, and a lump near the Adam's apple. Treatment usually involves chemotherapy, surgery, radioactive iodine, hormone treatment or external radiation and depends upon the type of thyroid cancer, the patient's age, the tumor size, and whether the cancer has metastasized.
Thyroid nodules are the most common endocrine problem in the United States. The term "thyroid nodule" refers to any abnormal growth that forms a lump in the thyroid gland. The vast majority of thyroid nodules are benign.
Vitiligo is a condition in which the skin turns white due to the loss of pigment from the melanocytes, cells that produce the pigment melanin that gives the skin color.
Premature ventricular contractions (PVCs) are premature heartbeats originating from the ventricles of the heart. PVCs are premature because they occur before the regular heartbeat. There are many causes of premature ventricular contractions to include: heart attack, high blood pressure, congestive heart failure, mitral valve prolapse, hypokalemia, hypoxia, medications, excess caffeine, drug abuse, and myocarditis.
There are many types of thyroid disease. Some occur due to the function of the thyroid itself such as hypothyroidism, hyperthyroidism, Hashimoto's thyroiditis, etc. Some causes of thyroid disease occur due to problems with the structure of the thyroid gland such as goiters, thyroid nodules, and thyroid cancer. Treatment of thyroid disease depends on the cause of the disease.
Insomnia is the perception or complaint of inadequate or poor-quality sleep because of difficulty falling asleep; waking up frequently during the night with difficulty returning to sleep; waking up too early in the morning; or unrefreshing sleep. Secondary insomnia is the most common type of insomnia. Treatment for insomnia include lifestyle changes, cognitive behavioral therapy, and medication.
Gynecomastia, an enlargement of the gland tissue in the male breast is the caused by an imbalance of hormones. Certain medical conditions may also lead to gynecomastia such as cirrhosis, malnutrition, disorders of the male sex organs, kidney failure, thyroid disorders, and medications. Gynecomastia is generally treated with medication, and if necessary surgery.
Dry skin (xeroderma) may be caused by external factors, like cold temperatures, low humidity, harsh soaps, and certain medications, or internal factors, such as thyroid disease, diabetes, psoriasis, or Sjogren's syndrome. Symptoms and signs of dry skin include itching and red, cracked or flaky skin. The main treatment for dry skin is frequent, daily lubrication of the skin.
Hypercalcemia is a condition in which calcium levels in the blood are elevated. Hypercalcemia is associated with other conditions such as hyperparathyroidism, lung cancer, breast cancer, kidney failure, and elevated levels of vitamin D. Symptoms of hypercalcemia include constipation, nausea, abdominal pain, kidney stones, to name a few. Treatment depends on the cause of hypercalcemia.
Graves' disease is an autoimmune disease that affects the thyroid. Some of the symptoms of Graves' disease include hand tremors, rapid heartbeat, trouble sleeping, enlarged thyroid, thinning of the skin or fine brittle hair. Causes of Graves' disease are thought to be multifactorial such as genes, gender, stress, and infection. Treatment for Graves' disease is generally medication.
Thyroiditis is the inflammation of the thyroid gland. The inflamed thyroid gland can release an excess of thyroid hormones into the blood stream, resulting in a temporary hyperthyroid state. Some forms of thyroiditis can be diagnosed based on tenderness and enlargement of the thyroid gland. A thyroid scan sometimes is used in making the diagnosis. Thyroiditis can also be diagnosed with a biopsy of the thyroid gland.
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