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THYROID AND MENOPAUSE

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					THYROID AND MENOPAUSE
DR. NISHIT F. SHAH M.D. ( Med ). D.M. ( Endo) CONSULTANT ENDOCRINOLOGIST P .D. HINDUJA NATIONAL HOSPITAL MAHIM, MUMBAI 400 016

THYROTROPES AND GONADOTROPES
Pulse concordance

TSH -- LH -- FSH -- Alpha subunit Men Postmenopausal women Hypothyroids [ Not euthyroid young women ]
JCEM 1990; 71:425-32

THYROIDISMS

AND

GONADOTROPINS

FSH IN POSTMENOPAUSAL HYPOTHYROIDS – 43% THYROTOXICS – 52% INHIBIN B  cycling women (Normal postmenopausal – 72%)
Horm Metab Res. 2003; 35: 498-501

THYROTOXICS Basal LH higher Treatment increases FSH/LH ratio
Br J Obstet Gynaec. 1977;84:254-7

THYROIDISMS

AND

EARLY MENOPAUSE

HYPOTHYROIDISM CAUSING EARLY MENOPAUSE Lay websites : www.thyroid-info.com, www.womentowomen.com, www.thyroidtalk.com

RADIOABLATION: I131 therapy for thyroid cancer Earlier menopause [ Median 49.5 v/s 51 years]
JCEM 2001; 86: 3512-5

AUTOIMMUNITY : Premature Ovarian Failure Autoimmune oophritis
Fert Steril. 2005; 83:1327-32

MENOPAUSE AND THYROID
SURGICAL MENOPAUSE TSH to TRH : normalized with estrogens.
Gynecol Endocrinol. 1993;7:279-83

CLIMATERIC SYNDROME 10% TSH TO TRH,  FT3,  FT4 Pituitary resistance to T4, T3 Normalized with L-T3 therapy.
Acta Endocrinol. 1986; 111: 204-8

ESTROGEN EXPOSURE Early Menarche Late Menopause Hysterectomy (Hyperestrogenic state) Hashimoto’s Clin Endocrinol. 1990; 32:301-6 Thyrotoxicosis Minerva Chir. 1975;30:992-6

AGE OR MENOPAUSE
The Colorado Thyroid Disease Prevalence Study
Arch Intern Med 2000; 160: 526-34

AGE
HYPOTHYROIDISM Overall 4 to 10% Elderly 7 to 26%
70% of all hypothyroids >50 years at diagnosis

HYPERTHYROIDISM : Subclinical Overall 4% Elderly 6% More in iodine deficiency areas

MENOPAUSE
HEALTHY WOMEN STUDY TSH and antibody status (21% v/s 26%) did not differ by menopause status or HRT
Ann Epidemiol.1995;5:229-33

SWAN: Study of Women’s Health Across the Nation TSH >5.0 in 6.2% TSH < 0.5 IN 3.2% No association with indicators of menopausal transition
Clin Endocrinol. 2000; 58 : 340-7

MENOPAUSE CLINIC
1. Overt hypothyroid 2.6% Subclinical hypothyroid 8.6% Subclinical hyperthyroid 1.4%
Clin Invest Med. 1995; 18: 11-8

2. Overt thyroidisms 2.4% Subclinical 23% 17% Hypothyroid 6% Hyperthyroid
Climacteric 2002; 5 : 162

SCREENING FOR HYPOTHYROIDISM AT A MENOPAUSE CLINIC (in Thailand)
Int J Gynaecol Obstet 2002;77: 39-40

n =1261  pre-, peri and post- menopausal TSH, FT4 HYPOTHYROIDISM 29.8% Overt 0.6% Subclinical 4.2% Secondary or tertiary 25%
HYPERTHYROIDISM Thyrotoxic 0.3% Subclinical 1.3%

HINDUJA HEALTH CHECK- UP: TSH
TSH < 0.3 TSH > 5.0

N ALL Jan1998-Dec1999
SELECT Jan-Dec 2006

n 382

% 2.6

n 1162

% 7.9

14715

MALES 20-30
31- 40 41- 50 51+

312 21
62 110 119

13 1
3 4 5

4 5
5 4 4

39 6
7 10 16

12 29
11 9 13

FEMALES 20-30
31-40 41-50 51+

819 57
138 296 328

52 4
3 14 31

6 7
2 8 9

130 7
25 38 60

16 12
18 13 18

SCREEN: ALL OR SELECT ?
ALL : [ Vanderpump MP, Turnbridge WM Thyroid 2002; 12: 839-47]
HYPERTHYROIDISM ( V/S PERIMENOPAUSE) Nervousness, Sweating, Palpitation, Insomnia, Weight loss, Diarrhea, Alopecia, Fractures.

HYPOTHYROIDISM ( V/S POSTMENOPAUSE) Slowness, Memory loss, Lack of concentration, Depression* Cold intolerance, Dry skin, Brittle nails, Aches, Cramps, Paraesthesia, Constipation Hypothyroidism magnifies menopausal symptoms. *Depression correlates with TPO-Ab, not biochemical thyroid dysfunction or
menopausal status
JCEM 1998;83:3194-7

SUBCLINICAL HYPOTHYROIDISM
SYMPTOMATIC RELIEF

CARDIOVASCULAR RISK Hypothyroidism- Strong indicator for arteriosclerosis and myocardial infarction in elderly women
Ann Intern Med. 2000;132: 270-8

Cardiac Function- Subtle impairment of myocardial contractility- diastolic dysfunction Cholesterol: Total, LDL, HDL Decrease in LDL by thyroxine therapy reduces cardiovascular risk by 9 to 31%
JCEM 2001; 86:4860-6

T-Abs associated with  Lp ( a ) in men and postmenopausal women
Eur J Endocrinol. 1997; 136:87-91

THYROXINE AND OSTEOPOROSIS
L- Thyroxine prevents the beneficial effect of HRT on BMD
Gynecol Endocrinol. 1999;13:196-201

NO OSTEOPOROSIS – Replacement therapy – Post Menopausal- slight  in QUS OSTEOPOROSIS – Replacement in ex-toxics, esp. post menopausal – Supressive therapy- cancer / benign goitre – Subclinical hyperthyroidism e.g. MNG. esp. post menopausal . Fractures.

OSTEOPOROSIS PREVENTION
Calcium supplementation: 1000 to 1500 mg/day. At least 4 hours after L-thyroxine. Vitamin D supplementation: 800 to 2000 units/day

Antiresorptive drugs HRT ( including ex- toxics) Anti thyroid agents rhTSH- Reversible inhibition of bone resorption

SUBCLINICAL HYPERTHYROIDISM
Osteoporosis
( Hyperthyroidism 2.5 times more in fracture patients)

Cardiac arrhythmia Thromboembolic complications Mortality from circulatory diseases  2 to 3 times

Struma Ovarii : Post menopausal
J Nucl Med. 1988;29:263-5

HYPOTHYROIDS ON ORAL HRT
CEE 0.625 mg +/- MPA 5 mg12/30
NORMAL BASAL TBG 20.3+3.5 12 Weeks 31.3+3.2 THYROXINE REPLACEMENT BASAL 12 Weeks

20.8+2.9 30.8+4.0

T4
FT4

8.0+0.9

10.4+1.5

1.3+1.0
1.5+0.3

10.9+2.3
1.2+0.3

TSH TSH > 7 in 7/18

1.1+0.6

3.2+3.1

Arafah BM. NEJM 2001; 344: 1743-1749

START/ STOPPAGE OF HRT: Reassess after 2 to 3 months

HYPOTHYROIDS ON OTHER HRT
TRANSDERMAL ET
No effect on TBG

RALOXIFENE
No effect on TBG Co- administration:  TSH
Thyroid 2001; 11:779-82

Reduced absorption of L- thyroxine
Pharmacotherapy 2006; 26:881-5

SOY SUPPLEMENTS Decreased absorption of L- thyroxine TPO activity Goitrogen in iodine deficiency  Binding of T4 to Transthyretin Soy isoflavones do not adversely effect thyroid function in healthy, iodine replete postmenopausal women
J Med Food 2003; 6: 309-16

THYROID NODULES AND CANCER
BENIGN NODULES Slow growth after menopause
J Endocrinol Invest. 2004; 27:31-6

THYROID CANCER Post Menopause OR 1.3 - natural OR 1.8 - artificial Early menarche, Late menopause Papillary Follicular [ Papillary have ER ]
Premenopausal thyroid cancer  Risk of developing breast cancer RR 1.42
Cancer 2001; 92:225-31

BREAST CANCER
IN POST MENOPAUSAL WOMEN
• Hypothyroidism OR 3.8 • Low normal T4 OR 2.3
Thyroid 2005; 15:1253-9

• Thyroid disease 58% (v/s 18%) Subclinical hyperthyroidism 31% ERss positive Hypothyroidism 8% TPO-Ab 19%

 TH/E2 ratio
Braz J Med Biol Res. 2005; 38:761-5

•  Tumour size, Vascular invasion, metastatic LNs
J Surg Oncol. 2004; 87:19-25

AN

L-THYROXINE A DAY KEEPS THE DOCTOR AWAY


				
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