Hyperthyroidism vs
hypothyroidism
Hyperthyroidism
• Primary hyperthyroidism
• Secondary hyperthyroidism (TSH-dependent or hCG-dependent)
Hyperthyroidism
• Causes: Graves’ disease, toxic multinodular goitre, solitary toxic
adenoma, thyroiditis, iodine-containing drugs eg amiodarone, ectopic
thyroid tissue (struma ovarii, metastatic thyroid cancer),
choriocarcinoma (hCG dependent), pituitary tumor (TSH dependent)
• Clinical features: Weight loss, fatigue, heat intolerance, palpitation,
angina, agitation, tremor, proximal myopathy, loose stool,
oligomenorrhea, infertility, goitre
Hyperthyroidism
• Graves disease – Presence of thyroid-stimulating antibodies
(autoantibodies) in blood, bind to TSH receptors in the thyroid,
activating adenylate cyclase and cAMP causing an overactive thyroid
• Laboratory diagnosis – High fT3 and fT4, low TSH
• With treatment – fT3 and fT4 decreases, slowly the TSH increases
• Management – antithyroid drugs, radioactive iodine, subtotal
thyroidectomy + beta blockers give symptomatic relief
Thyroid storm
• Lugol iodine blocks thyroid hormone secretion
• Antithyroid drugs suppresses thyroid hormone synthesis
• Start with high doses at first to achieve euthyroid, then go for
titration regimen with or without replacement regimen of fT4
• Radioactive iodine may be used unless a patient in pregnant
• Drugs for 18 months to 2 years to achieve remission
• Long term follow up to watch out for relapse or become hypothyroid
(even after 10 years)
• Signs of hypothyroid – Raised TSH, normal fT3 and fT4
Hyperthyroidism in pregnancy
• The IgG in hyperthyroidism crosses the placenta and causes
fetal/neonatal hyperthyroidism
• Neonatal hyperthyroidism is transient as the maternal antibody is
gradually cleared but still may require short term treatment
• 5% of pregnant women have transient hyperthyroidism (at 1-3
months) followed by transient hypothyroidism (at 4-6 months)
Hypothyroidism
• Primary hypothyroidism
• Secondary hypothyroidism – Decreased trophic stimulation in
hypopituitarism and hypothalamic disease
• Iodine deficiency may cause increased TSH secretion as a
compensatory mechanism
• Lithium can cause hypothyroidism as it inhibits fT3 and fT4 secretion
• Laboratory diagnosis – High TSH concentration, low fT4 concentration.
fT3 has no value in the diagnosis
Hypothyroidism
• Causes: Idiopathic atrophic hypothyroidism, Hashimoto thyroiditis,
postsurgery, radioactive iodine, antithyroid drugs, drugs (lithium,
amiodarone), congenital, secondary (pituitary or hypothalamic)
• Clinical features: lethargy, cold intolerance, constipation, weight gain,
dyslipidemia, bradycardia, hoarse voice, slow tendon reflex,
menorrhagia, infertility (rarely macrocytic, non-megaloblastic anemia,
dementia, psychosis)
• Growth failure in children
Hypothyroidism
• Treated with replacement therapy T4 (levothyroxine), start with 40
micrograms/day, increase at 4-6 week interval.
• Start with 25 micrograms/day in patients with heart disease due to
increased metabolic rate and increased oxygen needs
• T3 has more rapid onset of action may be needed for myxedema
coma
• With treatment – TSH normal (if TSH is increased, inadequate
replacement; if TSH is decreased, too much replacement with a risk of
AF and osteoporosis), fT4 is high normal (due to lack of fT3 synergistic
effect); Fall in TSH lags behind fT4 rise
Hypothyroidism
• If the symptoms of hypothyroidism still felt with treatment, patient
may need T3 replacement
• Non-adherent patients: High TSH but normal or high fT4
• Treatment of myxedema coma is T4 and T3, glucocorticoids. Also treat
the underlying cause such as infection, heart failure, electrolyte
imbalance
Subclinical hypothyroidism
• Laboratory diagnosis: High TSH, but normal fT4
• De novo or had a history of hypothyroidism, a compensated state
without any symptoms
• If there are symptoms OR if TSH > 10mIU/L OR pregnant, you treat it;
if asymptomatic, recommended to measure thyroid peroxisomal
autoantibodies
• 1/3rd may progress to full hypothyroidism
• Yearly TCA if positive for autoantibodies
Effect of drugs on thyroid function
• Hypothyroidism-causing: corticosteroids, dopaminergic drugs,
phenytoin, carbamazepine, amiodarone, lithium, antithyroids
• Hyperthyroidism-causing: tamoxifen, estrogen, heroin, methadone
(increases TBG)
