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					                      Thyroid Disorders: The Incurable Disease




                                       Elizabeth McCauley
                                           Dr. Klevickis
                                            ISAT 351
                                          April 18, 2000




Key Words: Radioactive Iodine, Hyperthyroidism, Hypothyroidism, Graves’ disease, Thyroid-Stimulating
           Immunoglobulins
                              Abbreviations List

PTU   Propylthiouracil

RAI   Radioactive Iodine

RDA Recommended Daily Allowance

T3    Triiodothyronine

T4    Thyroxine

TRH Thyrotropin-Releasing Hormone

TSH   Thyroid-Stimulating Hormone

TSI   Thyroid-Stimulating Immunoglobulins




                                                   1
                                          Abstract

         The thyroid, the largest of the endocrine glands, is located in the neck. It controls

both physical and mental growth. One way in which the thyroid gland does this is by

controlling metabolism, which directs the processes of growth, energy production, and

waste elimination. The thyroid gland also prevents the buildup of calcium in the blood

(The Nutritional Health of your Thyroid). To fulfill the many responsibilities of the

thyroid gland, it is imperative that the gland be neither overactive nor underactive.

Either can result in significant problems.

         An overactive thyroid, oftentimes also known as Graves’ disease, is a condition

where all of the body’s reactions and processes are accelerated, frequently to three times

what they normally should be. This can be detrimental to the body if left untreated, and,

unfortunately, it can go unnoticed for many months. An underactive thyroid causes all of

the body’s processes to slow down and, thus, has signs and symptoms opposite of those

for overactive thyroid disorders. Goiter problems, such as endemic goiter, also affect the

body’s processes and often result in an enlarged thyroid due to a lack of iodine in the

blood.

         A thyroid disorder often is an unpredictable disease that can occur at almost any

age, especially in women. Although several treatment options presently exist, there is no

cure.




                                                                                             2
                                                     Table of Contents


Introduction ......................................................................................................................... 4

Discussion ........................................................................................................................... 7

   Hyperthyroidism ............................................................................................................. 9

   Hypothyroidism ............................................................................................................ 12

   Additional Thyroid Disorders ....................................................................................... 16

Annotated Bibliography .................................................................................................... 18




                                                                                                                                      3
                       Thyroid Disorders: The Incurable Disease

Introduction

         The thyroid is a small, butterfly-shaped gland that wraps around the trachea just

below the Adam‟s apple. This gland consists of two hormone-secreting lateral lobes (on

either side of the larynx) at the base of the front of the neck. These hormones are known

as thyroxine. The main function of thyroxine is to regulate metabolism for the

production of heat and energy in the body tissues. It also has many other functions.

Thyroxine regulates the rate at which calories are burned, and, thus, may cause weight

loss or gain. It helps slow down or quicken the heartbeat and raise or lower body

temperature, influences the rate at which food moves through the digestive tract, the way

muscles contract, and the rate at which dying cells are replaced (Thyroid Problems).

         In order for thyroxine to be produced, there must be an adequate supply of iodine

in the blood (in fact, worldwide, the likeliest cause of thyroid disorders is a deficiency of

iodine). The thyroid gland takes iodine from the bloodstream in order to produce the

hormones triiodothyronine (T3) and thyroxine (T4), which help regulate tissue and organ

metabolism. Both hormones rely on stimulation by the pituitary, which produces thyroid-

stimulating hormone (TSH) in response to rising or falling T3 and T4 levels (Zamula,

1992).

         The figure below (Figure 1) illustrates exactly where the thyroid is located and

how it interacts with other glands in hormone production. In general, the way to discover

whether or not a person has a thyroid problem is to measure the levels of each of these

hormones. If irregularities are found, then, most likely, a thyroid problem also will be

located.




                                                                                                4
Figure 1: How the Thyroid Gland Works



The hypothalamus produces                     Pituitary
thyrotropin-releasing
hormone (TRH), which
                                                                                           Hypothalamus
stimulates the pituitary gland
to produce thyroid-                                                   TRH
stimulating hormone (TSH).
TSH stimulates the thyroid
gland to produce hormones
T3 and T4. When the
pituitary senses a decrease in                                       TSH      T4 + T3
T3 or T4, it produces
additional TSH to stimulate         Thyroid
the thyroid gland to produce
more hormone.

Diagram by Boots
Pharmaceuticals, Inc.
                                                           T2 + T3




         The next figure (Figure 2) is a chart showing many popular foods and the

micrograms of iodine corresponding to each. Several studies performed in the early

1900‟s found a link between the amount of iodine consumed and the occurrences of

goiter problems (goiter is another term for an enlarged thyroid gland). Although many

Americans consume more iodine than the Recommended Daily Allowance (RDA)

specifies, there exist many countries where it often is not possible to obtain the RDA, if at

all. This is most likely due to the uneven distribution of iodine in the environment. In

the United States and other developed countries however, once the concept of iodized salt

materialized, the occurrences of goiter problems became a thing of the past (Zamula,

1992).




                                                                                           5
Figure 2: Some Iodine-Rich Foods

             Food                                 Serving Size                     Micrograms of Iodine

cod or haddock, cooked                           3 1/2 oz (100 g)                              175
chocolate milkshake (fast food)                 1 average (283 g)                              158
homemade meatloaf                                3 1/2 oz (100 g)                              123
lima beans, immature, boiled                      1/2 cup (91 g)                               104
chocolate ice cream                               1 cup (133 g)                                 94
corn grits, cooked                               1/2 cup (121 g)                                86
low-fat chocolate milk                            1 cup (250 g)                                 83
navy beans, boiled                                1/2 cup (91 g)                                78
low-fat yogurt                                    1 cup (227 g)                                 73
low-fat milk                                      1 cup (244 g)                                 66
skim milk                                         1 cup (246 g)                                 64
whole milk                                        1 cup (244 g)                                 61



     Iodine deficiency is no longer a problem in the United States, with virtually all Americans getting
     enough of the substance in their diets. The Recommended Daily Allowance (RDA) for iodine for
     adolescents and adults is 150 micrograms a day(1000 micrograms = 1 milligram) and 200
     micrograms for pregnant women. Most Americans consume more than the RDA, but are usually
     unaffected by excess iodine unless they have an underlying thyroid disease.


     Source: FDA’s Total Diet Study, 1982-1984


        A healthy thyroid gland releases just the right amount of hormone (thyroxine) to

meet the body‟s metabolic needs. However, if the gland becomes diseased, it may

produce too much thyroxine resulting in hyperthyroidism, or too little resulting in

hypothyroidism.

        An over-stimulated thyroid gland, also known as hyperthyroidism, speeds up the

body‟s metabolic processes. “Hyperthyroidism affects approximately 1 million

Americans and is more common in women, particularly those 30-40 years old”

(American Association of Clinical Endocrinologists Releases Clinical Guidelines for

Thyroid Disease, 1995). The most common type of hyperthyroidism is Graves‟ disease,

also known as diffuse toxic goiter, which will be the focus of the hyperthyroidism

section. Graves‟ disease is named after Robert Graves, the physician who first described


                                                                                                           6
this form of hyperthyroidism. Graves‟ disease occurs when the immune system triggers

formation of “thyroid-stimulating immunoglobulins (TSIs) that bind with TSH receptors

to abnormally stimulate thyroid function” (The Highs and Lows of Autoimmune Thyroid,

1998). In a sense, Graves‟ disease represents a basic defect in the immune system where

the body is trying to fight itself. Hypothyroidism, on the other hand, occurs when the

body produces antibodies that destroy an essential enzyme needed to produce T3 and T4

(The Highs and Lows of Autoimmune Thyroid, 1998). The most common type of

hypothyroidism is Hashimoto‟s thyroiditis, which is easily treatable with medicine.

       In addition to the above disorders, there also exist other thyroid problems such as

endemic goiter and thyroid disease resulting from pregnancy; however, these are not as

serious as hyperthyroidism or hypothyroidism because neither is permanent.


Discussion

       Thyroid diseases are unpredictable disorders in the sense that when they occur

and why are practically unknown. Researchers have noticed that thyroid disease seems to

run in families, but are not sure why.

       The figure below (Figure 3) visually shows the pattern of thyroid disorders

throughout my family as far back as is documented or known. Note how there is a

distinct pattern of thyroid disorders, especially hypothyroidism, on my mother‟s side of

the pedigree. As for myself, marked by the arrow at the bottom of the pedigree, I am the

only family member to have been diagnosed with Graves‟ disease. This is not entirely

unusual, however, because the genes for an autoimmune disease are passed to each

generation. What is unusual is that my family tends only to have autoimmune diseases of

the thyroid. Also unusual is that one of my uncles, the only male affected by thyroid



                                                                                             7
disease, has Hashimotos‟s disease. This is the most common form of hypothyroidism,

yet it affects women fifty-times more than men (Autoimmune Disease in Women, 1999).

Figure 3: Pedigree of My Family Members With Thyroid Disease


I.
                                  1                  2
                                                     1
                                   1




II.

                     1       2         3         4       5    6           7             8
                     1        1
                                       1         1       1




III.
                     1                 2     3                        4       5                6




IV.

                             1                   2                3



       This pedigree illustrates, to the best of my knowledge, the occurrence of thyroid disease
       throughout my family. The pedigree begins in the top left hand corner of the page (I) with
       my great-grandparents on my mother’s side, R.C. and Kate Vaden. They had 5 children,
       Robert, Margaret, Kathryn, Dolly and Charles. Dolly, (II, 5), had a small goiter on her
       thyroid and had her entire thyroid removed as a result. The other black circle, (II, 3),
       belongs to Kathryn, my grandmother, who has a small benign tumor on her thyroid.
       Kathryn married Kavanaugh Sparrow. They had two children, my mother Pamela and my
       uncle Kavey. Kavey, the only affected male I found (III, 2), has Hashimoto’s Thyrodoxia
       and was diagnosed several years ago. My mother, on the other hand (III, 3), was recently
       diagnosed with hypothyroidism. My mother married my father, John, whose family has
       only a minor occurrence of thyroid disease. As can be seen on the pedigree, only his sister,
       my aunt Jane (III, 6), has had a known thyroid problem. She had temporary
       hypothyroidism while in college, but now is fine. Thus, the pedigree leads down to my
       sister Kathryn and me, the last black circle with the arrow (IV, 3). I was diagnosed with
       hyperthyroidism in August 1999. To my family’s knowledge, I am the only known person in
       our family history with hyperthyroidism. It is important to note, however, that the
       occurrences of thyroid disease in my family shown on the pedigree are the only ones
       known. There may have been more infected family members in the past, but this
       information either was never discovered by doctors or documented by family members.




                                                                                                   8
     As for what triggers the disease, some specialists believe that stress can play a role

in initiating a thyroid disease, as well as a person‟s immune system, smoking, and sex

hormones. Thyroid diseases, therefore, can occur at any age, although the thyroid gland

typically weakens as humans grow older. Many experts feel its degeneration is partly

due to nutritional deficiencies, such as a lack of iodine. (The Nutritional Health of your

Thyroid). Although a weakened thyroid can cause hypothyroidism in older generations,

younger generations can still be affected by the thyroid disease known as

hyperthyroidism.

Hyperthyroidism

       Hyperthyroidism is an over-functioning of the thyroid gland, which can be

thought of as the body being in overdrive. This overdrive mode causes the thyroid to

produce too much thyroid hormone. Such an increase in the thyroid hormone level

causes the bodily functions controlled by the thyroid to speed up, such as heart rate,

blood pressure (sometimes), and metabolism. But how exactly does this work?

       The feedback mechanism which involves the hypothalamus, pituitary and thyroid

glands, for some reason not exactly known, becomes faulty. This, in turn, causes an

overproduction of TRH, TSH, or sometimes the thyroid gland itself “declares

independence and begins to produce thyroxine in large quantities, regardless of the

instructions it receives from the pituitary” (Hyperthyroidism, 1999). In Graves‟ disease

and most other forms of hyperthyroidism, the thyroid gland produces too much thyroid

hormone on its own and overrides the normal pituitary gland control mechanism. The

pituitary senses that the level of thyroid hormone is excessive and compensates for this

by releasing less TSH (Diagnosing Graves‟ disease, 1999). Graves‟ disease also is a

glandular autoimmune disease which affects the thyroid gland in women seven times as


                                                                                              9
often as in men. An autoimmune disease means that a person‟s tissues, molecules, or

cells are mistaken as foreign and are attacked by that person‟s own immune system

(Graves‟ Disease).

       As a result of the changing levels of thyroid hormone in the body, there exists a

relatively easy way to diagnose a case of hyperthyroidism. This is with a blood test. The

blood test measures both T3 and T4 levels along with the level of TSH. If the T4 level is

high, it confirms the presence of hyperthyroidism. However, an elevated T4 level may

not necessarily prove the presence of an overactive thyroid. This is because thyroid

hormones are carried in the blood mainly in a form that attaches to certain blood proteins

and, therefore, allows only a small amount of the thyroid hormone to be free and active.

Factors such as pregnancy or birth control pills may increase the total amount of thyroid

hormone bound to protein and, thus, may give a false impression of hyperthyroidism

(Diagnosing Graves‟ disease, 1999). As a result, many endocrinologists also check the

T3 level in the blood. Prior to a blood test, a semi-accurate way of determining if

someone has hyperthyroidism, or especially Graves‟ disease, is by observing the person‟s

physical appearance and noting how many signs of the disease the person displays. Some

of the signs and symptoms include flushed skin, rapid pulse rate, increased temperature,

easy irritability, hair loss, tendency to lose weight, a slight tremor in the hands, and

palpitations. In addition to these, I also had a slight protrusion of my eyes, a definite

increase in appetite due to the increase in my metabolism, and a swelling of my thyroid

gland itself when I was diagnosed with Graves‟ disease in August of 1999. The increase

in metabolism is due in part to the activity in one‟s cells which are burning so much fuel

that normal supplies cannot keep up with the demand. The body uses its muscle and fat




                                                                                            10
for energy by means of a process called gluconeogenesis (Hyperthyroidism, 1998). Since

Graves‟ disease is an autoimmune disease, a person‟s immune system mistakenly attacks

the thyroid gland in addition to the tissue behind the eyes and the skin of the lower legs,

causing both to thicken. One out of every 20 patients with Graves‟ disease exhibits some

type of eye involvement, as I did, and oftentimes the seriousness of this sign is not

realized.

       Protrusion of the eyes, which is caused by an enlargement in the muscles of the

eyelids, gives the impression that the eyes are “bulging” or are larger because the muscles

of the eyelids pull back the eyelid and thus expose more of the eye. In addition to eye-

protrusion, there are other eye problems such as inflammation, double vision, or blurred

vision. Smoking tends to worsen the eye problems associated with Graves‟ disease. If

any of these problems are not discovered and treated, they could become permanent (The

Facts About Hyperthyroidism).

       As for the treatment of hyperthyroidism, there are usually three options from

which to choose – surgery, antithyroid drugs, and radiation with radioactive iodine.

Surgery, now the least-used option, consists of removing most of the thyroid gland in

hopes that it will be suppressed enough to function normally. Oftentimes either too little

or too much of the thyroid is removed or nerve damage results. If too little is removed,

the person will remain hyperthyroid, and if too much is removed, the person can become

hypothyroid and must take replacement pills everyday. When this procedure is done

correctly, it is 90-95% effective. Antithyroid drugs, which is the treatment I am using,

are only about 20-30% effective and consist of taking numerous pills each day (The Facts

About Hyperthyroidism). First, I was given a beta-blocker (Atenolol), which was needed




                                                                                           11
to slow down my heart rate. I took one pill a day for about 3-4 months and the problem

was corrected. I am still taking propylthiouracil (PTU) pills, seven a day, to fully combat

the hyperthyroidism. The main downside of taking these pills is that they reduce the

immune system. In my case, my blood must be taken once a month to monitor my

hormone levels as well as my white blood cell count. So far, this type of treatment has

been successful for me, but if the reductions in hormone levels stop, a permanent

solution, such as Radioactive Iodine (RAI), will need to be considered. RAI is the most

widely recommended treatment method because is causes very little radiation exposure to

the rest of the body and is quite successful. It is given orally and quickly goes to the

thyroid, because of the thyroid‟s need for iodine. Although this method is successful, it

should not be used for women who are pregnant or thinking of becoming so. Oftentimes

RAI can suppress too much of the thyroid, resulting in hypothyroidism and the need to

take supplements each day. Each treatment method should be discussed with one‟s

endocrinologist so that the best treatment method for the individual is chosen. It is

important to note that people who are diagnosed with hyperthyroidism will require

medical monitoring and follow-up for the rest of their lives.

Hypothyroidism

       Hypothyroidism is a condition in which the amount of thyroid hormone in the

body is below normal or, in other words, is the opposite of hyperthyroidism. Like

hyperthyroidism, however, the exact cause of this disease is unknown. It can occur

spontaneously or can result from over-treatment of hyperthyroidism.

In general, since hypothyroidism is the opposite of hyperthyroidism, the signs and

symptoms of the diseases often are opposites of each other. Signs and symptoms of




                                                                                           12
hypothyroidism include a feeling of being run down, cold, tired, demonstrating weight

gain, dry hair, a puffy face, and a failure of memory.

       The figure below, Figure 4, is a diagram of the signs and symptoms for both

hyperthyroidism and hypothyroidism. Note how the symptoms of one disease directly

oppose the symptoms of the other disease in several instances. Many also can be pushed

aside as normal signs of aging and stress.

Figure 4: Signs and Symptoms of Thyroid Disease

   Hypothyroidism                                                             Hyperthyroidism
   Tiredness
                                                                               Nervousness
   Depression
                                                                               Irritability
   Forgetfulness
                                                                               Difficulty sleeping
    Loss of lateral
                                                                               Bulging eyes
    eyebrow hair
                                                                               Unblinking
                                                                               stare
    Puffy face and                                                              Goiter
    eyes
                                                                                Rapid
    Dry, coarse hair                                                            heartbeat
                                                                                Increased sweating
    Goiter
                                                                                Heat intolerance
    Slow heartbeat
                                                                                Unexplained
    Dry skin                                                                    weight loss
                                                                                Scant menstrual
    Cold intolerance
                                                                                periods
                                                                               Frequent bowel
    Weight gain
                                                                               movements
    Heavy
                                                                               Warm, moist palms
    menstrual
    periods
                                                                               Fine tremor of
    Constipation                                                               fingers
                       The above figure illustrates both the signs and symptoms of thyroid
                       disease. On the left side of the picture hypothyroidism is recognized,
    Brittle nails      while on the right side, hyperthyroidism is described. Notice how a
                       woman is used for the diagram because Thyroid Disease is 3 times
                       more likely to occur in women than men.

                       Diagram redrawn from Boots Pharmaceuticals, Inc.
                                                                                                     13
       The explanation for many of the symptoms of hypothyroidism stems from the

lack of thyroid hormone circulating in the body. For instance, when an inadequate

amount of thyroid hormone reaches the heart cells, the heart does not pump efficiently

enough to meet the body‟s needs. Also, if the liver does not have the proper amount of

thyroid hormone, cholesterol cannot be cleared, thus, arteries may clog and heart

problems may result. Too little thyroid hormone affects the way smooth muscles

contract, making the movement of blood more difficult. Last but not least, the rapid

growth of cells is stunted leaving nails, skin, and hair brittle and dry (Hypothyroidism

and Your Health, 1995).

       When diagnosing hypothyroidism, a blood test is performed, which tests for TSH

and T4 levels. The TSH test is quite useful because the pituitary gland, which makes

TSH, acts as a “thermostat” for the body and provides insights as to what the thyroid is

producing. The pituitary gland is so sensitive that it completely stops making TSH when

the thyroid gland is only slightly overactive. For example, when my TSH level was

tested before my hyperthyroidism diagnosis, my level was around 0.025, which is quite

close to 0 (meaning no TSH would be produced), while normal is between 0.5-5.5. As

for T4 levels, normal is about 5-12 micrograms per deciliter. While a person with

hypothyroidism would have levels below these numbers, a person with hyperthyroidism

would have levels above. In my situation, with hyperthyroidism, my first measured T4

level was around 18.7 (although now, with treatment, my level is down to around 6).

Regarding T3 levels, normal is approximately 75-180 nanograms per deciliter. Since this

hormone does not play as large of a role in the diagnosis of hypothyroidism as the T4

level does, it normally is not tested (Testing and Diagnosis, 1998).




                                                                                           14
        Once the blood has been tested, a T4 in the low to normal range, along with a high

TSH, confirms a diagnosis of thyroid failure (Hypothyroidism: The Underactive

Thyroid, 1999). New research also suggests that those persons who believe they are

hypothyroid have a thyrotropin releasing hormone (TRH) blood test performed.

                  The physician measures the patient‟s TSH level, gives an
                  injection of TRH, then draws blood 25 minutes later and re-
                  measures the TSH. If the first TSH level is normal and the
                  second TSH level is high, it tells the doctor that the patient‟s
                  thyroid is underactive (HELP! My TSH is “Normal” But I
                  Think I‟m Hypothyroid, 1997).

        The treatment for hypothyroidism is similar to that for hyperthyroidism, although

there only is one choice – taking pills. The most common pill is levothyroxine sodium,

which is a pure synthetic T4 and thus replaces the T4 that the thyroid fails to secrete. Most

often, a patient is given very small doses and for several weeks the dose is slowly

increased until the proper working dosage is discovered (The Facts About

Hypothyroidism). Although this medicine may take several weeks to fully begin

working, some patients notice a difference during the first week or two of medication.

Just like Graves‟ disease, hypothyroidism is a permanent disorder. The pills must be

taken for life.

        If the levothyroxine sodium alone does not help the patient to feel close to

“normal,” an addition of a T3 medicine may be used. It is interesting to note that in the

past, before levothyroxine sodium had been discovered, patients were given a pill made

from desiccated animal thyroid in hopes that an animal‟s thyroid would help their own

(Thyroid Problems: Too Little Hormone = Hypothyroidism, 1999). Prescriptions were

soon stopped for this because the dosage of each pill varied. An exact dosage for a patient

could not be determined. The animal thyroid also contained T3, which is not



                                                                                            15
recommended unless necessary. In addition to taking pills, which supply the needed T4,

soy products may need to be avoided because they contain isoflavones, which are the part

of the soy product that act as an anti-thyroid agent. Isoflavones, therefore, suppress

thyroid function and can worsen hypothyroidism. Children, fed with soy-formula, were

even three-times as likely to develop thyroid problems (Thyroid Disease: The Dangerous

Downside of Soy Products, 2000).

       On the positive side, once diagnosed with hypothyroidism, treatment can not only

restore the body‟s metabolism back to normal (and possibly result in weight loss), but

also can result in lower cholesterol levels and, thus, decreased heart disease risk.

Additional Thyroid Disorders

       In addition to the major thyroid disorders, hyperthyroidism and hypothyroidism,

there exist other disorders, such as goiters and thyroid problems during and after

pregnancy.

       Goiters are enlargements of the thyroid gland mainly associated with iodine

deficiency. They also result in swelling in the front part of the neck (where the thyroid is

located) (Diagnosis: Hypothyroidism! – Answers to Some Common Questions, 2000).

In almost all cases, treatment by medication or surgery will correct the problem and

reduce the thyroid gland to its normal size (Zamula, 1992). Prior to medication, however,

the treatment for goiters in the old west was to wrap a snake around the neck of the

patient and let it slither over the goiter to shrink it (Thyroid Fun Stuff, 1997).

       As for thyroid problems in relation to pregnancy, they are quite common because

thyroid diseases often occur in women around 20-30 years of age. In fact, if a case of

hypothyroidism is severe enough, it could reduce a woman‟s chances of becoming

pregnant. Once a woman is pregnant, the symptoms of hypothyroidism are similar to the


                                                                                          16
symptoms of pregnancy, such as tiredness and weight gain. Thus, the disease can be hard

to detect. On the positive side, the treatment for this disease does not have harmful side

effects for either the mother or the child. If a woman is diagnosed with hyperthyroidism

because of the changes in menstrual periods, she is more likely to have miscarriages. In

this case, it is imperative that the disease be identified. For hyperthyroidism, PTU is still

prescribed but must be monitored closely, because it can affect the baby‟s thyroid as well

as the mother‟s.

       As for thyroid problems after pregnancy, one of every twenty women develops a

thyroid problem within a few months after giving birth. This condition is known as

postpartum thyroiditis. It will cause hyperthyroidism for several weeks and then switch

to hypothyroidism for several more weeks. Generally, this condition goes away on its

own within 1-4 months. However, women who develop this condition once are more

likely to develop it in the future. One out of every four women who develops postpartum

thyroiditis will go on to develop a permanent thyroid disorder (Thyroid Problems and

Pregnancy, 1998).

       The thyroid is an essential gland which controls many of the processes within the

body. Thyroid disorders are diseases which affect those bodily processes and, thus, the

thyroid gland needs to be kept healthy. Although incurable, the disorders are easily

treatable with proper diagnosis.




                                                                                           17
                                    Annotated Bibliography


Ahmad, Saeed, Mark H. Brakke and James F. Marks. “Treatment guidelines for
     hyperthyroidism and hypothyroidism.” JAMA. v. 274 (Oct. 4, 1995) p. 1011-
     12.

      This article consists of letters written in response to an article published in JAMA in which
      guidelines for physicians on the care of patients with thyroid disorders are given. The first writer
      discusses the role of amiodarone in causing thyroid disorder. The second writer asks questions
      relating to cost saving and, screening for serum thyroid stimulating hormone (TSH) in women
      over 60 years of age. The third writer notes treatment of hypothyroidism diagnosed and treated in
      newborns.

“American Association of Clinical Endocrinologist Releases Clinical Guidelines for
      Thyroid Disease.” American Family Physician. v. 51 (Feb. 15, 1995) pp. 679-
      680.

      This article discusses clinical guidelines on the management of thyroid disease issued by the
      American Association of Clinical Endocrinologists. Approximately 6-7 million Americans suffer
      from hypothyroidism, and about one million suffer from hyperthyroidism. The guidelines
      discussed cover the signs and symptoms of both diseases and the difficulties encountered in their
      diagnosis. Advice on a system of care for these patients also is provided.

“Autoimmune Disease in Women – The Facts.” American Autoimmune: Related
      Diseases Associatoin, Inc. January 1999. http://www.aarda.org/women.html (7
      March 2000).

      This was a wonderful website which discussed several types of autoimmune diseases and the rate
      of occurrences in each. This also was useful because it was geared towards women and discussed
      how and some thoughts on why the occurrences of the diseases are more prevalent in women.
      Endocrine diseases are discussed as well as connective tissue diseases.

“Causes of Graves‟ Disease.” Graves‟ Disease: Causes. June 14, 1999.
      http://www.tsh.org/publications/pt2cause.html (27 Jan 2000).

      This article obviously discusses the causes, or what are believed to be some causes for the disease.
      It noted that Graves’ Disease clearly runs in families which was interesting to me because I had
      been told that it did not. Also discussed, based on the heredity factor, was the occurrence of
      thyroid disease in sets of identical twins. Briefly, the article said that either both will have the
      disease or both will not, but rarely does only one have it. Some specialists also believe that stress
      can play a role in starting the disease.

“Diagnosing Graves‟ disease.” Graves‟ Disease: Diagnosing. June 14, 1999.
      http://www.tsh.org/publications/pt2dx.html (27 Jan 2000).

      This website offered a plethora of information about the two specific hormones produced by the
      thyroid. Also information was provided on exactly what autoantibodies are found in the blood
      that help diagnose Graves’ disease. Some additional background on TSH and what its purpose in
      the body is was also given.




                                                                                                        18
Franklyn, JA et al. “Incidence of Cancer and Mortality After Radioiodine Treatment for
       Hyperthyroidism.” Clinical Thyroidology. v. XII Issue 1, June 1999.

       I obtained this article through my endocrinologist. This article discusses radioiodine treatment
       specifically and the possible links between it and both cancer and mortality. As opposed to what I
       would have thought, a study done in the U.K. showed that an overall decrease in cancer incidence
       and mortality was shown in patients treated with radioiodine. Specifically, cancers of the
       pancreas, bladder, and bronchus. However, a link has been found between radioiodine treatments
       and a higher risk of thyroid cancer.

“Graves‟ Disease.” Mayo Clinic Health Education. January 2000.
      http://www.mayohealth.org/mayo/pted/htm/graves.htm (23 Jan 2000).

       This is a wonderful reference for information on Graves’ disease. This article discusses the
       thyroid in general as well as all the aspects of Graves’ disease. I did not realize that patients
       with Graves’ disease may have the skin over the shins appear red and swollen as well as the tops
       of the feet. How the disease affects the eyes also is discussed in great detail. I did not realize
       either how many different ways the eyes can be affected during thyroid disease, and specifically
       during Graves’ disease.

“Hyperthyroidism.” October 26, 1999. http://www.personal.u-
      net.com/~my4tune/hyper.html (19 Jan 2000).
       This article discusses the symptoms, treatment options, and possible causes of hyperthyroidism.
       Also included at the end of the article is a bibliography so further research can be conducted on
       your own. In summary, Graves’ disease is where the immune system is convinced that the thyroid
       is a foreign tissue and beings producing antibodies against it. The article goes into great detail
       about the workings of Glucose and ATP and when a person has this disease, where energy is
       derived from.

“Hyperthyroidism (Overactive Thyroid).” Health Information Library. January 1998.
      http://www.unitedhealth.org/library/HORM4701.htm (19 Jan 2000).

       This article briefly describes the symptoms and risks of treatment for hyperthyroidism. I did not
       realize that this disease causes the bones to lose calcium at an increased rate and thus, bones can
       become brittle due to osteoporosis. As for the treatment options, there exist drugs, radiation, or
       surgery. I did not realize either that surgery is the riskiest of the three because it can cause nerve
       damage, infection, and, ironically, hypothyroidism.

Hypothyroidism and Your Health. Knoll Pharmaceutical Company. Mount Olive: NJ,
      July 1995.

       This pamphlet discusses hypothyroidism and how it affects the different systems in the body such
       as the heart, liver and cell growth. I did not realize that hypothyroidism could cause flat, white
       patches on skin or that it affects the way arteries and veins contract, making the movement of
       blood more difficult. This pamphlet also discusses the importance of treatment, for without
       treatment, heart or kidney disease and mental illness can occur.




                                                                                                           19
“Hypothyroidism: The Underactive Thyroid.” Information on Hypothyroidism. June
      14, 1999. http://www.tsh.org/ptinfo/hypobroc.html (27 Jan 2000).

       This article, by the Thyroid Foundation of America, focuses on all aspects of hypothyroidism
       including symptoms, treatment, and follow-up. One startling fact is that one woman in ten over
       the age of 65 has evidence of the earliest stages of hypothyroidism. Hypothyroidism can occur
       spontaneously, or it can develop after treatment for hyperthyroidism. Once treatment begins the
       dosage may need to be increased during pregnancy and decreased as the patient ages. Another
       interesting fact is that thyroid hormone excess may also cause excessive calcium loss from your
       bones, thus making your risk for fractures increase.

Ladenson, Paul W., M.D. “Treatments for Graves‟ Disease: Letting the Thyroid Rest.”
      The New England Journal of Medicine. v. 324 no 14, April 4, 1991.

       This is an editorial that discusses the three current treatment methods for hyperthyroidism.
       Radioactive-iodine therapy and surgical thyroidectomy are both extremely effective and usually
       result in permanent cure. However, thyroid surgery is inconvenient, expensive, and must be done
       only by the most experienced doctors. Also, when research was done on a group of doctors who
       treated thyroid patients, the majority said that if the patient was young, anti-thyroid drugs would
       be sought first.

Lucas, K. Jean. “Hyperthyroidism.” Inside Health. January 1997.
       http://www.mydoctors.com/TLCPublicationsHyperthyroid.htm (27 Jan 2000).

       This article, by The Leland Clinic. P.C., addresses many common questions about
       Hyperthyroidism. Discussed in detail are medications and treatment options for patients with
       hyperthyroidism. One method of treatment, initially, is to take beta blockers – which is what I did.
       These reduce the heart rate to normal and reduce the tremors that are associated with the disease.
       Also given is advice for how to prevent the weight gain that will result from taking many of the
       medications. This was particularly interesting to me because I had an increase in my weight due
       to my medication.

McConnell, Edwina A. “Myths & Facts . . . About Thyroid Disease.” Nursing 96. v. 26
     (Apr. 1996) p. 17.

       This article discusses a number of common assumptions about thyroid disease which are untrue.
       For example, hyperthyroidism is not another name for Graves’ disease. Also, contrary to popular
       belief, treatment is not complicated; it involves a single dose of radioactive iodine therapy given
       orally. Remember however, that this is just one method of treatment. Discussed as well is how
       hypothyroidism does and can affect children. .

Rogers, Douglas G. “Thyroid disease in children.” American Family Physician. v. 50
       (Aug. 1994) pp. 344-50.

       This article discusses thyroid diseases found in children such as congenital hypothyroidism,
       acquired hypothyroidism, Graves’ disease, and thyroid nodules. In children surgical excision is
       still required to definitively determine whether a nodule is malignant. Also discussed is the fact
       that newborn screening programs detect about one infant with congenital hypothyroidism for
       every 4000 live births. However, up to five false-positive screenings may occur for every one
       confirmed case of congenital hypothyroidism. It is known as well that if a mother has an
       untreated thyroid disease she can possibly pass it on to her fetus.




                                                                                                        20
Rose, Verna L. “Screening Guidelines for Thyroid Disease.” American Family
       Physician. v. 59 no 2 (Jan. 15, 1999) p. 478.

      The American College of Physicians-American Society of Internal Medicine (ACP-ASIM) has
      issued updated screening guidelines for thyroid disease. These guidelines note that 1 in 71 women
      over 50 years of age has unsuspected thyroid disease that will respond to treatment. This article
      suggests that all women over 50 should be screened for thyroid disease.

Shomon, Mary. “Diagnosis: Hypothyroidism! – Answers to Some Common Questions.”
     Thyroid Disease. January 2000.
     http://thyroid.about.com/health/thyroid/library/weekly/aa072197.htm (27 Jan
     2000).

      This article addresses concerns from those diagnosed with hypothyroidism such as side effects of
      medicines, long term health risks, and disappearance of symptoms. Answers to questions include
      the fact that side effects of thyroid hormone replacement drugs are pretty rare, though they may
      take as long as 10-16 weeks before the symptoms are gone. Also written is the key issue or focus
      of treatment which is to speed up the metabolism which may include not only taking medicine, but
      also may include eating less calories and increased exercise so as to not gain weight either.

Shomon, Mary. “Frequently Asked Questions on Hyperthyroidism: Part 1 of a 3–Part
     Series.” Thyroid Disease. February 23, 1998.
     http://thyroid.about.com/health/thyroid/library/weekly/aa022398.htm (27 Jan
     2000).

      This article answers some important questions and concerns about hyperthyroidism such as
      “What causes hyperthyroidism?” and “What does it mean that hyperthyroidism is an autoimmune
      disorder?” Also discussed is the origin of the name Graves’ Disease. The disease is named after
      Robert Graves, the physician who first described this form of hyperthyroidism. In Graves’
      Disease, antibodies are produced that attack some of the proteins on the surface of thyroid cells.
      The article even discusses how the habit of smoking can increase the symptoms of Graves’
      Disease.

Shomon, Mary. “HELP! My TSH is „Normal‟ but I Think I‟m Hypothyroid.” Thyroid
     Disease. January 2000.
     http://thyroid.about.com/health/thyroid/library/weekly/aa111097.htm (27 Jan
     2000).

      This article focuses on TSH levels and what is normal and what is not. Shomon discusses how
      various labs and doctors have different standards as to what is a normal level and what is not and
      thus, some people find that even if they are in the normal range, they do not feel good. Once
      treatment has begun it is imperative that if you switch doctors, you must inform your new doctor
      of your previous doctor’s range and where you fit in, just in case the new doctor uses a different
      scale. Hypothyroid symptoms also are discussed along with TSH and TRH testing procedures and
      who should get which.




                                                                                                     21
Shomon, Mary. “The High Cholesterol/Thyroid Connection: „Undiagnosed Thyroid
     Disease May Be the Reason for Your High Cholesterol.‟” Thyroid Disease.
     January 2000.
     http://thyroid.about.com/health/thyroid/library/weekly/aa011800a.htm (27 Jan
     2000).

       This article discusses the connection between cholesterol levels and thyroid disease. Specifically,
       the link between hypothyroidism and elevated cholesterol levels. Both can be helped through
       medication, but one must be diagnosed with hypothyroidism before treatment. The article also
       talks about cholesterol in general. In summary, thyroid testing and subsequent treatment for
       hypothyroidism can restore the body’s metabolism to normal and result in lower cholesterol levels
       and decreased heart disease risk.

Shomon, Mary. “Thyroid Disease: The Dangerous Downside of Soy Products.”
     Thyroid Disease. January 2000.
     http://thyroid.about.com/health/thyroid/library/weekly/aa083099.htm (27 Jan
     2000).

       This article discusses the composition of soy milk and milk products and why it can cause
       hypothyroidism to occur in children. This is particularly interesting to me because as a baby I
       was raised on soy milk and milk products. Soy milk and products have isoflavones which act as
       anti-thyroid agents. The grain millet also contains high levels of flavonoids, and is commonly
       known as problematic for thyroid function. One study, discussed in this article, found that thyroid
       problems were almost triple in those soy formula fed children compared to their siblings and
       healthy unrelated children.

“Testing and Diagnosis.” Graves‟ Disease. January 2000.
       http://drkoop.com/conditions/graves_disease/page_74_369.asp (27 Jan 2000).

       This website detailed the functions of the hormones produced by the thyroid. Specifically, it
       detailed the relationships between the pituitary and both T3 and T4 hormones. It also gave the
       normal ranges for both types of thyroid hormones. Information on TSH was provided along with
       how various types of hyperthyroidism can be diagnosed as well.

“The Facts About Hyperthyroidism.”
      http://www.jmedpharma.com/html/hyperthyroidism.html (19 Jan 2000).

       This online article is a great reference by Jones Pharma Incorporated, which details the many
       aspects of hyperthyroidism. This article also mentions that Graves’ disease tends to run in
       families, but no one yet understands what triggers the disease to occur. As for the diagnosis
       section, a low blood TSH level strongly suggests that a patient is hyperthyroid. At the end of this
       article there are listed more organizations and references to check out for more information,
       which were helpful since questions arise during my research .

The Facts About Hypothyroidism. Jones Medical Industries, INC. St. Louis, MO.

       This pamphlet details the signs and symptoms of hypothyroidism as well as diagnosis and
       treatment options. Also given is a list of the various thyroid function tests and some general
       information about the thyroid gland itself. Places to call for more information are given on the
       back cover. Although this pamphlet is small, it gives a great summary of hypothyroidism.




                                                                                                          22
“The Nutritional Health of your Thyroid.”
      http://www.galxymall.com/retail/healthpartner/thyroid/graves.htm (19 Jan 2000).

       This website offered information on what exactly the thyroid does and theories as to why thyroid
       diseases occur. Some experts believe that the degeneration of the thyroid is due to nutritional
       deficiencies while others believe it is just due to age and stress factors. Suggestions also were
       made as to how a person’s diet should be changed in order to help combat the effects of a thyroid
       disorder.

“Thyroid Fun Stuff.” Thyroid Home Page. January 1997.
      http://www.thyroid.com/fun.htm (27 Jan 2000).

       This article discusses some famous people who had both hyper and hypo thyroid disease such as
       both George and Barbara Bush, who have hyperthyroidism, as well as their dog Millie. This
       article also includes humorous stories written by not famous people about their experiences with
       thyroid disease. One story talks about how in the old west the method of treatment for goiter
       diseases was to wrap a snake around the person’s neck and let the snake move over the goiter
       until it disappeared!

“Thyroid Problems.” Thyroid Problems. http://www.med-
      help.com/ThyroidProblems.html (19 Jan 2000).

       This website described the functions of the thyroid in general and discussed the hormones
       released by the thyroid and their importance to the functioning of certain bodily processes. Goiter
       problems also were discussed. Signs and symptoms of both hypothyroidism and hyperthyroidism
       were discussed as well. Treatment options for both disorders were briefly described along with
       parathyroid disorders.

“Thyroid Problems and Pregnancy.” The Kelly G. Ripken Program. January 1998.
      http://thyroid-ripken.med.jhu.edu/info-pregnancy.html (19 Jan 2000).

       This website in general is a great one for information on thyroid disease because Kelly Ripken
       herself suffers from hyperthyroidism. This article however discusses the connection between
       thyroid disease, pregnancy and treatment. Often it also is not unusual for a woman to develop a
       thyroid problem shortly after having a baby. This is termed postpartum thyroiditis and usually
       goes away after about 4 months. Once this occurs, the person is more susceptible for it to occur
       after each child thereafter.

“Thyroid Problems: Too Little Hormone = Hypothyroidism.” Thyroid Problems.
      January 1999. http://www.healthtouch.com/level1/leaflets/tfa/tfa010.htm (23 Jan
      2000).

       This article, by the Thyroid Foundation of America, discusses the basic facts of hypothyroidism,
       symptoms, and treatment options. The article also says that between 8 and 9 million Americans
       have hypothyroid problems. It mentions the connection between being a member of a family with
       a history of thyroid disorders and hypothyroidism as well. As for treatment options, doctors now
       are trying to steer people away from using desiccated animal thyroid which is a generic medicine
       often given to patients in the past because the amount of medication in each pill varied and thus
       determining the specific dosage was difficult.




                                                                                                          23
 “Treatments of Graves‟ Disease: Beta-Blockers and other treatments.” Graves‟
       Disease: Beta-Blocking Medications. June 14, 1999.
       http://www.tsh.org/publications/pt2txbeta.html (27 Jan 2000).

      This article, as given by the title, discusses in particular beta-blockers as well as iodine
      treatments. I did not realize that beta-blockers could make asthma worse which is important to
      me because I have mild asthma and have taken beta-blockers initially when I was first diagnosed.
      Also mentioned was how diabetics should be told that when taking beta-blockers, these drugs can
      obscure the warning signs of low blood sugar.

Walpert, Naomi. “The Highs and Lows of Autoimmune Thyroid Disease.” Nursing 98.
      v. 28 no 12 (Dec. 1998) pp. 58-60.

      This article discusses autoimmune thyroid disease. Tissue and organ metabolism is regulated by 2
      iodine containing hormones produced by the thyroid gland. Thus, malfunctions in the thyroid
      gland can have serious implications for a patient’s metabolism. Two examples that illustrate the
      diagnosis of both hyper and hypo thyroidism are described. Sidebars examine the interpretation
      of thyroid function tests and eye problems linked to autoimmunity

Zamula, Evelyn. “Many Treatments Available: Thyroid Disorders Often Unsuspected.”
      FDA Consumer. v. 26 (Dec. 1992) pp. 34-9.

      This article discusses how the thyroid gland can become enlarged if a person lacks sufficient
      dietary iodine. The gland takes dietary iodine from the bloodstream and uses it to make iodine
      containing- hormones called thyroxine and triiodothyronine. These hormones regulate the rate at
      which calories are burned, help slow or quicken the heartbeat, raise or lower body temperature,
      and influence the rate at which food moves through the digestive tract. The article also discusses
      the symptoms, causes, and treatment of hypothyroidism and hyperthyroidism.




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