Hyperthyroidism Awareness

It is important to remember that hyperthyroidism can occur at any age. While most may present with a rather typical constellation of symptoms, many may present with exacerbation of pre-existing conditions which may make the diagnosis initially elusive. Worsening anxiety, insomnia, fatigue, panic attacks, palpitations, hypertension or diarrhea may not initially signal that the thyroid is involved. Clinicians must have a low threshold to check thyroid function early to rule out a component of hyperthyroidism.

Once a suppressed thyrotropin (TSH) has been detected, further investigation with serum triiodothyronine (T3) and free thyroxine (free T4) can help delineate overt from subclinical disease. A thorough history of past thyroid disease, as well as current medications and supplements, can help detect any pre-existing diagnoses or exogenous sources of thyroid hormone or over supplementation with iodine. More commonly, hyperthyroidism is due to either Graves diseasetoxic multinodular goiter or toxic adenoma. Distinction between these can usually be made with the assistance of a thyroid uptake scan, TSH receptor antibody measurement, and thyroid ultrasound. An additional physical exam finding of exophthalmos can further support the diagnosis of Graves’ disease. Understanding the etiology can help guide patient expectations. A small percentage of patients with Graves’ Disease may undergo spontaneous remission after 1 to 2 years, which may prompt patients to wait before considering a definitive treatment option.

With confirmation of the diagnosis of hyperthyroidism, focus is on hormonal control with an antithyroid medication (ATM, most commonly Methimazole in the United States). This may be augmented with beta-blockade, steroids, cholestyramine or SSKI for those who are difficult to control.

Many patients may need further consideration for definitive management with either radioactive iodine ablation (RAI) or thyroidectomy. Your local resources may also influence these options, but it is critical to understand that all three treatments (ATM, RAI and thyroidectomy) are possible options. Certain patient factors and priorities may alter the preferred definitive treatment. Smaller gland size, easy to control hormones, and lack of eye symptoms are factors that may favor continued ATM management. A large goiter with compressive symptoms, difficult to control hormones requiring high dose medications/ multiple modalities, pregnancy, severe eye disease, multiple nodules within the thyroid with or without thyroid cancer, or desire for rapid and reliable hormone control may favor thyroidectomy. RAI is a good option for patients with a smaller gland size, and a desire to pursue definitive management but avoid surgery.

There are also relative contraindications for treatment options. ATMs may have serious side effects, like agranulocytosis or liver failure, which prevent further use, or may cause skin eruptions making long term use intolerable. Additionally, high dose requirements or fluctuating doses may make long term use of ATMs not reliable. Women who are pregnant, wanting to become pregnant in the next 6 months to 1 year, breast feeding or have small children in the home will want to avoid RAI. Patients with severe eye involvement, have a large goiter with compressive symptoms, or are smokers should also avoid RAI. Thyroidectomy will be a poor option for patients with multiple previous neck operations on or around the thyroid due to internal scarring, or who are high risk for general anesthesia. Additionally, if they have a history of previous gastric bypass surgery, they are higher risk for major complications from hypocalcemia/hypoparathyroidism after thyroidectomy.

To help the patient navigate these decisions, it is important to allow them the opportunity to discuss each treatment option with respective physician experts – medical management with endocrinology, RAI with endocrinology and potentially nuclear medicine as well, and thyroidectomy with the thyroid surgeon.

In summary, patients with hyperthyroidism require medical control, as well as a clear understanding of the etiology of their hyperthyroidism. Patients with Graves disease, toxic multinodular goiter and toxic adenoma have more than one treatment option, and it is important for patients to be educated and engaged in treatment decisions.

For Further Reference:
American Thyroid Association Guidelines for Diagnosis and Management of Hyperthyroidism and other causes of Thyrotoxicosis| by the American Thyroid Association

‘Fear No More the Heat o’ the Sun’ by William Shakespeare.

Will you believe if someone says death can bring happiness and peace? Even the words ‘death’, ’happiness’ and ‘peace’ seem to not fit together. But when we read the extract “Fear No More the Heat o’ the Sun”, we probe into what death really is. Is it only capable of giving sadness and heartbreaks?

Starting with, this poem is an extract from Shakespeare’s play ‘Cymbeline’. It is sung by two characters Guiderius and Arviragus to the dead in the play. The characters take turns to sing the stanzas and lines of the poem.

The first stanza addresses the dead and it tells the dead not to dread the summer’s heat and winter’s harshness. The dead are set free from all the worldly responsibilities that weigh down the living. The dead needn’t worry about making ends and other materialistic needs. Only death treats all humans equally. Be it the children of high born stations or the ones who work as chimney sweepers, all return to ashes on their death. 

“Golden lads and girls all must,

As chimney-sweepers, come to dust.”

The dead needn’t fear the anger of the crown (a ruler by differing from him/her) and are free from the clutches of the tyrant. The dead needn’t worry about opposing and are free from all restraints. They needn’t worry about having proper clothes to wear and a proper meal to eat. And to them everything looks equal, be it big or small. All men powerful, intelligent, strong and valiant will meet the same end – they all return to dust. As the dead cannot bring anything along with them that can distinguish them from others, all are treated the same.

“The sceptre, learning, physic, must

All follow this, and come to dust.”

The dead needn’t fear ‘the lightning flash’ and ‘all-dreaded thunder stones’. They needn’t fear such natural elements and can rest in peace. When living are prone to be talked at by the society, the dead can sleep well without fearing to meet the society’s standards. They needn’t heed to the slanders and other harsh criticisms. The dead have completed all laughing and crying. They have nothing more to cry about and so they can rest well after their tiresome journey on the earth. Death doesn’t look at the age of the person it takes with it. Young or old all return to dust.

“All lovers young, all lovers must

Consign to thee, and come to dust.”

Now, the singers wish that no exorciser disturb the dead from their sleep and no sorcery to enchant them. The singers hope that ghosts will restrain themselves from approaching the dead and that no evil shall come near them. Nothing will dare to approach, for death has come and they pray that the grave should be known by all.

“Nothing ill come near thee!

Quiet consummation have;

And renowned be thy grave!”

When we die, we will be relieved of our burdens and worry. We experience a peace we have never experienced. Death comes with heartbreaks but also with relief. Hence, death may need not always be associated with negative feelings.

The repetition of the phrase, “and come to dust” in all the three stanzas, shows the temporal nature of human life. Everything that is material has no value on death. So, instead of running after material prospects, we should focus on eternal prospects. We can take nothing with us on our death but we can always leave something for the world. Thus, we should be kind and happy while living, and so we can leave happy memories for others on leaving.