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

Dr.Ida Scudder

Only those who can see the Invisible
Can achieve the Impossible”
             -Dr.Ida Scudder

Dr. Ida Sophia Scudder was a third-generation American medical missionary who came to serve people in India. The first and second generation of the Scudder family served as medical missionaries in India and Ida as a young girl wanted to spend a lavish lifestyle in America. Her parents were working as medical missionaries in India and once Ida happened to visit India to meet her parents. That night there came a man knocking her door and he pleaded to operate his wife who is going to give birth. Ida said him that she is not a doctor but her father who is a doctor can help him. But the man refused saying that no men is allowed to operate his wife. She was shocked by his answer. Then came another man for the same reason and he refused saying the same. She felt very bad in her heart for the women of this nation. Then came the third man and refused because the doctor is a male. Later on Ida heard that the three women died. She felt so bad and she decided to finish her studies and come and serve the Indian women for the rest of her life. That was her life-changing experience and she dedicated the rest of her life for the plight of Indian women and the fight against bubonic plague, cholera and leprosy. She started a tiny medical dispensary for women at Vellore, Tamil Nadu. She knew that it is impractical to go on alone, so she opened The Mary Taber Schell Hospital in 1902. For the betterment of the South Indian women she decided to open a medical school for girls only. There were 151 applications on the first year in 1918. In 1928 ground was broken for the “Hillsite” medical school campus on 200 acres at Bagayam, Vellore. That year Mahatma Gandhi visited the medical school. She travelled to America numerous times to raise funds for the college and hospital, raising a total in the millions. In 1945 the college was opened or both men and women. In 2003, the Vellore Christian Medical Center was the largest Christian hospital in the world, with 2000 beds and its medical school is now one of the premier medical colleges in India. CMC Vellore has brought many significant achievements to India by starting the first nursing college in 1946 and by performing the first reconstructive surgery for leprosy in the world (1948). CMC Vellore performed the first successful open heart surgery in 1961, performing the first kidney transplant in India (1971), performing first bone marrow transplantation in 1986 and the first successful incompatible kidney transplant in India in 2009. Dr. Scudder won Elizabeth Blackwell Citation from the New York Eye and Ear Infirmary as one of 1952’s five outstanding women doctors. Dr. Ida Sofia Scudder died on May 23, 1960 aged 89 in her Hilltop bungalow in Kodaikanal, Tamil Nadu.