Hashimoto Thyroiditis

Hashimoto’s Thyroiditis

Thyroiditis is, like all other –itises, an inflammatory condition. It is regulated by your immune system and is a genetically inherited disease. This is not something that could have been prevented. Your immune system looks at your thyroid as foreign and has made specific attack soldiers to kill off the thyroid. These antibodies are called thyroid peroxidase antibodies.

This condition is similar to rheumatoid arthritis attacking the joints or psoriasis attacking the skin. The thyroid is essentially in charge of your metabolism but has many other control mechanisms for your body. When the thyroid is under attack with thyroiditis, two problems occur. The first is that the thyroid does not work properly.

No one functions well under attack. Thyroid function is tested by a hormone called TSH– which stands for thyroid stimulating hormone. The brain sends a signal (TSH) to the thyroid to tell it to either rev up and make more hormone or to calm down because there is enough. The thyroid makes thyroid hormone for the body that circulates around. The brain then gets a signal that there is either too much or not enough hormone. It then, via the TSH, tells the thyroid what to do. If there is too much thyroid hormone, there is no need to make more. The TSH then is low as there is no need to prod the thyroid into production. If there is not enough hormone, the TSH elevates as the brain tells the thyroid to get into gear and make hormone. Although at a glance, it may seem confusing that a low TSH means overactive thyroid, and a high TSH means under active thyroid, if you think in terms of stimulation, it makes sense. Symptoms of hypothyroidism are a mile long. Generally, most people complain of extreme fatigue. Being tired is tough to quantify. If I asked all of my patients if they are tired, most say yes. This fatigue is different, though. It does not get better with rest. I have heard it described as like being pregnant in the first trimester.

I have heard people say everything from feeling run down to absolutely not being able to get out of bed in the morning. The other complaints are of weight gain (probably from lower metabolism and inactivity because of fatigue), dry skin, hair falling out more than usual, thinning of eyebrows and eyelashes, irregular periods, swelling of the face and hands, and changes in bowel movements. The other thing that I have noticed (your company excepted of course) is that these patients go crazy. They describe a “brain fog” or difficulty with multiple step activities or directions. There are problems with short term memory and recall. Tempers get shorter. At first, I thought these patients were just depressed because they were tired and up a pants size, but the mental impairment is real and separate from reaction to symptoms. The other problem that occurs with the thyroid is that it becomes stiff and hard with the inflammation. Many patients are told that they have goiter (thyroid nodules or benign growths) because their doctors feel something in the neck. I think of it this way– if you had a scab on your hand and every day you picked at the scab, there would soon be an irritated lump of scar tissue. The thyroid does the same thing.

There are easy to recognize changes on ultrasound that occur with the inflammation. The thyroid occupies a valuable bit of real estate in the neck. It sits on top of the trachea and voice nerves. The esophagus runs behind it on the left side. The carotid arteries are the lateral borders. When the normally soft and squishy thyroid gland becomes hard, the neighbors get affected. Some patients note difficulty swallowing, feeling pills and food hang in the throat, occasional choking, chronic cough, frequent clearing of the throat, a deeper and raspier voice that is not able to project, and loss of upper registers of the singing voice. This of course does not happen overnight and most people attribute the symptoms of allergies, reflux disease, sleep apnea, getting older, etc. You have noticed that I have not mentioned anything very rosy at this point. So, what do we do? The first issue is to address the hypothyroidism. This is usually done with synthetic human thyroid hormone called Synthroid or with a drug called Armour. I personally believe that once the TSH elevates, the thyroiditis has likely been present for years and the battle has finally tipped in favor of the antibodies. The key is to balance good labs with symptom control.

Over time, more and more of the thyroid will be destroyed and your dosage needs will increase. There are a bazillion doses of Synthroid (25, 50, 75, 100, 112, 125, 137, 150, 175, 200, 300) and, as I mentioned before, the target is for a TSH of around 1. The flip side about starting extra thyroid hormone is that sometimes, we overdo it and make patients hyperthyroid. The main symptom of this is heart palpitations. It is my preference to give thyroiditis patients as much medication as they can tolerate. It is not like taking pain medication where it is bad the more you take. You should take however much you need. Without a thyroid in surgical patients, it is weight based. Essentially, you take your weight in kilograms and multiply by 1.6. This is the dose you would need with zero contribution from your own thyroid.

Regarding the structural changes of the thyroid, when symptoms become bothersome, surgery becomes an option. I usually operate on patients who do have some combination of problems swallowing, breathing, or voice. There are also some people who never do well with medical management and surgery allows their body to just be on medication, rather than on medication and varying doses of their own thyroid hormone. I often describe thyroiditis as having a roller coaster for a gland, or a tug of war battle that constantly cycles back and forth. The problems with surgery is that it leaves a small inch scar and does have some risks of low calcium levels (more on that some other time) or of potential injury to voice nerves. That being said, most all of the surgical patients do very well. They are thrilled that the pressure symptoms are gone and feel that it is easier to regulate their symptoms of fluctuating hypo and hyperthyroidism.

It is important to make sure that your doctor will listen to you and be flexible in tailoring your treatment to how you are feeling. There are “religions” associated with the proper way to treat thyroid problems– so try to keep an open mind. You will have this issue for life and only you know how you are feeling. It will not magically get better or go away on its own. Making changes in thyroid world is like watching paint dry really slowly. It didn’t get a problem overnight and solutions do not happen overnight either. It is a process that happens gradually. I am here to help.


With regards,

Carolyn Garner MD