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


Menstrual hygiene: A challenging development issue
The major reasons behind menstruation still being a taboo in the Indian society are illiteracy, poverty and lack of awareness.

The blood coming out from vagina normally occurs as part of a woman’s monthly cycle called menstruation or periods. Every month, our body prepares for pregnancy. The uterus, or womb, sheds its lining in case of no pregnancy . The menstrual blood is partly blood and partly tissue from inside the uterus. We can say that periods are the onset of puberty in girls. During this time a girl goes through several physical and psychological changes in her body. It is associated with bleeding along with stomach ache , nausea as well as mood swings.
After the onset of puberty , it brings various rules, restrictions, isolation and changed expectations in the girls life by the society. These changes in attitude towards girls such as restrictions on their self expressions, schooling, mobility and freedom has far reaching consequences on the mindset of women.
In the Indian society menstruation is still considered as a taboo. Till now, adolescent girls are not given proper information about menstruation. People create major hurdles in educating girls about menstrual hygiene.

Mothers also don’t talk with their daughters about this topic because they feel shy while expressing the terms. Another reason they don’t discuss this topic is because most of them lack scientific knowledge on puberty and menstruation.
Most of the people in India, especially the girls are illiterate. This is one of the reasons for which menstruation is still a relevant taboo in our Indian society. The other important reasons are poverty and lack of awareness about menstrual health and hygiene.
Very less number (less than 18 percent) of Indian women use sanitary pads.

According to the latest National Family and Health Survey 58 per cent of young Indian women (15-24 years) use a hygienic method of protection (mostly sanitary pads) which is a significant increase from the 12 percent using pads in 2010. This is a consequence of greater attention to menstrual hygiene management over the past few years in India. This not only prevails in the Indian society but is a global issue.

On a global level, at least 500 million women and girls lack adequate facilities for menstrual hygiene management. The lack in appropriate information on sanitation and hygiene facilities, especially in public places like schools, workplaces or health centres can pose a major obstacle to women and girls.

In many families women’s freedom is still in the hands of patriarchal discourse. With the evolution of these cultures, there has not been any significant change in people’s attitudes and mentality towards menstruation.

In some families menstruation is still denoted as an unclean or embarrassing thing. For them even mentioning menstruation in public or private places is embarrassing. Most girls feel embarrassed to go to a medical store to buy sanitary pads for them. There are also many girls who cannot afford to buy the Sanitary Napkins.

Most of the girls in financially unprivileged families drop out of school when they begin to menstruate. More than 77 percent of girls and women in India use an old cloth, which is often reused, ashes, newspapers, dried leaves and husk sand during periods.

During these periods women are not allowed to participate in day-to-day activities. They are not allowed to enter the house or carry in with their household chores. They are even restricted from entering the kitchens. They are restricted from entering the temple. They are not even allowed to any sacred places and also not allowed to perform any rituals. They are restricted from doing all these works because they think that a menstruating woman is impure and everything she touches turns impure or bad. They think after menstruation a woman must be purified before entering the house or other places.
While menstruating, a woman goes through several psychological trauma and mood swings . During this time they should be given proper care but instead they are treated poorly by the society.

To prevent the troubles faced by the menstruating women in our society, we must give them proper education about menstrual health and hygiene, provide financial support or distribute sanitary napkins to the unprivileged women so that they don’t have to suffer the ill fate.

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‘The Doll’s House’ as a Feminist play.

“I have been your doll-wife, just as at home I was papa’s doll-child; and here the children have been my dolls. I thought it great fun when you played with me, just as they thought it great fun when I played with them.”

“The Doll’s House” by Henrik Ibsen, a 19th century play, strongly stamps the rights of women into the minds of the readers. It explores what roles women are forced to play and how they lose themselves by doing so. Now, the ‘Doll’ in the title will make us think about what its role is and how it is connected to the play. A doll is made to look pretty, made to entertain others, and to be toyed by its owner. Similarly, women are also expected to look pretty, please men and are directed to play the roles given. This is how women were treated and are even now.

This play explores these intricacies in the lives of women. Nora is the doll in the play and her house the playhouse. Nora is also an embodiment of the entire women folk in general. The plot is set during Christmas, and so we can see Nora busy with her Christmas preparation in the first act. She is happy to hear of her husband’s promotion and also expects greater happiness because of it. She is visited by Mrs. Linde, who is an old friend of hers, and has come to seek her husband’s help in finding a job. Afterwards, she is also visited by Krogstad from whom she had leant money in the past. He blackmails her of revealing a forgery done by her in borrowing money. She has forged her father’s signature to get money. Krogstad tells her to get him a job in the bank from her husband. 

Through the series of dialogues in the first act, we see how her husband, Torvald pets her and objectifies her. Instead of calling by her name, he uses ‘little squirrel’, ‘little lark’, ‘little skylark’ and so. By using such words, he objectifies her and diminishes her being. The adjective ‘little’ shows how he considers her lower than him and how he always treats her like a child. In fact, everyone in the play treats her like a child. 

When Nora reveals to her friend, Mrs. Linde, that she has borrowed a huge sum to save her husband’s life, Mrs. Linde is shocked by it. 


Couldn’t I? Why not?


No, a wife cannot borrow without her husband’s consent.”

This shows that women of that period weren’t allowed to concern themselves with financial matters. We can even see that for a woman to borrow money, she needs a consent of a man and his sign. This is why Nora forged her father’s signature to borrow money. Nora also adds that she wouldn’t let her husband know about it because it would hurt his pride. Torvald never considers Nora as his equal and seems that being helped by women would make him look weak. This is a conventional thought which needs to be broken.

“A man who has such strong opinions about these things! And besides, how painful and humiliating it would be for Torvald, with his manly independence, to know that he owed me anything! “

In the second act, things speed up and we see Nora anxiously awaiting what would happen after the revelation. She mentally prepares herself to face the consequences and strongly believes her husband will take the blame all upon himself. This will be proved wrong later.


Your squirrel would run about and do all her tricks if you would be nice, and do what she wants.


Speak plainly.


Your skylark would chirp about in every room, with her song rising and falling –


Well, my skylark does that anyhow.

These lines show how Nora is always expected to please her husband. Torvad also likes to show off her to others and is proud of ‘owning’ her. A woman is a human and an individual and no mere object to own or show off. Thus the playwright brings out the toxic habit of objectification.

It is also seen that Nora never has an identity of her own. She is referred to as the daughter of her father and wife of Torvald. The society seems to repress her individuality by adding surnames to her. The play progresses to show how Nora sets out to find herself and her identity as an individual.


There, you see it was quite right of me not to let you stay there any longer.


Everything you do is quite right, Torvald.

It can also be seen that Nora is never to have her own thoughts and to do what she likes. Her freedom as an individual is thus constrained by her husband. Her husband controls her, her actions, thoughts and directs her on what she has to do. And when the truth of her debt and forgery is revealed, he blames her and throws her under the bus. He is more worried about how his reputation in the society will be tarnished on the revelation of her actions. He is self-conceited and doesn’t bother to listen to Nora.


[walking about the room]. What a horrible awakening! All these eight years—she who was my joy and pride—a hypocrite, a liar—worse, worse—a criminal! The unutterable ugliness of it all!—For shame! For shame! [NORA is silent and looks steadily at him. He stops in front of her.] I ought to have suspected that something of the sort would happen. I ought to have foreseen it. …. Now you have destroyed all my happiness. You have ruined all my future. It is horrible to think of!

This is an awakening to Nora. Nora borrowed money in order to save her husband, but her husband completely ignores that fact. And when Krogstad sends a mail to them telling that he won’t reveal anything to the world, her husband immediately changes his colours and tells her that he had ‘forgiven’ her.

All these makes Nora realize what kind of life she was leading. She has an honest talk with her husband for the first time in eight years since they have married. She tells him that he had never considered her as an individual with feelings but a merely pleasing doll

“You have never loved me. You have only thought it pleasant to be in love with me.”

She says that she was a mere doll passed down from her father to him. She was never to have her opinions with her father and so the same with her husband too. All her life she was treated like a doll and now she has also become to treat her own children like that. Here I quote the lines told in the beginning again. 

She breaks up her marriage and sets herself free from everything that restrains her from being an individual. Before everything, she owes a duty to herself which she had not been concerned about before. She is going to educate herself and find herself.


Before all else, you are a wife and a mother.


I don’t believe that any longer. I believe that before all else I am a reasonable human being, just as you are—or, at all events, that I must try and become one.

The realization that she had never lived her life as an individual and that she had always been objectified transforms her. She slams the door of her house and sets out.

“I was your little skylark, your doll, which you would in future treat with doubly gentle care, because it was so brittle and fragile. [Getting up.] Torvald—it was then it dawned upon me that for eight years I had been living here with a strange man, and had borne him three children—. Oh, I can’t bear to think of it! I could tear myself into little bits!”

Every woman like Nora should liberate themselves from their constraints. The entire play takes place inside the house and it shows how Nora and women are confined to four walls. Nora finally escapes her confinement and liberates into the real world. 

[The sound of a door shutting is heard from below.]

Thus this play motivates every woman to find her way out of the door and slam it. This is a realistic play even applicable for the 21st century.

Read the full play at https://www.gutenberg.org/files/2542/2542-h/2542-h.htm