Today we are going to jump right into the examination and testing of the thyroid. This is the second part of a series of articles covering the basics of the thyroid gland. For part one, covering how the thyroid works, click HERE!
How to diagnose Hashimoto’s?
The physical examination of the thyroid gland includes palpation of the tissues. Additionally, some clinicians may inspect the thyroid gland visually. In the sitting position your clinician will place your head in a slight hyperextended position and will shine a light across the front of your neck. Then you will be instructed to swallow. The clinician will monitor for any abnormal enlargement, masses, contour and asymmetry when you swallow. The physical examination of the neck is done to check for any abnormal masses and presence of any prominent pulsation. The following are some findings observed in the physical examination of a patient with Hashimoto’s disease:
- Enlargement of the thyroid gland, which is present in the neck, is a common finding of Hashimoto’s disease. As TSH secretion is increased in hypothyroidism the gland will work harder and harder to produce hormones and therefore grow .
- Hashimoto’s disease is the result of an autoimmune disorder of thyroid gland and therefore, it has a fine nodular texture. Furthermore, uninodular or multinodular lesions can also be present in Hashimoto’s disease .
- This autoimmune goiter is usually painless, swelling and tenderness may be present with acute inflammation or attack.
Apart from the above mentioned signs, the following hypothyroidism related symptoms may also be observed during physical examination of Hashimoto’s disease :
- Delayed response of deep tendon reflexes
- Low resting/basal body temperature
- Dry skin
- Puffy face
- Hertog’s Sign (lateral thinning of the eye brow)
“Hashimoto’s disease associated with hypothyroidism and if left untreated it can cause hyperlipidemia, which is detected by increased levels of low-density lipid (LDL)”
The diagnosis of Hashimoto’s disease depends on the findings of circulating antibodies to thyroid antigens (mainly, thyroperoxidase (anti-TPO) and thyroglobulin (anti-TG)) along with proper clinical features demonstrated on physical examination . The following blood tests are conducted to detect Hashimoto’s disease.
If you want my quick guide to interpreting your thyroid labs, ideal reference ranges and understanding your condition then sign up below!
The initial procedure followed to diagnose Hashimoto’s disease is to check the TSH level. The measurement of the TSH level in blood is important, as it indicates the communication between the brain and the thyroid. In theory, this marker also represents thyroid gland activity. An elevated level of TSH has been considered as a hallmark of hypothyroidism . Despite this, my clinical experience suggests that you can have a normal TSH, and still have both the symptoms of hypothyroidism, and circulating anti-bodies. That is why a simple TSH test is not enough, and a full thyroid panel should be completed.
The amount of T4 in the blood helps to determine the T3 potential, and also offers suggestions about issues with hormone conversion. The usual findings of hypothyroidism include a decreased level of T4 in the blood . The ratio between T3 and T4 is especially important if you are on synthroid, as many people do not properly convert this T4 containing medication into the active T3.
The amount of T3 in the blood is often proportional to symptoms. It should be measured regularly.
Antithyroid antibody test
The anti-thyroid antibody test is performed to determine the presence of thyroid autoantibodies. Thyroid autoantibodies are mainly of two types: anti-TG antibodies and anti-thyroperoxidase (TPO) antibodies. These erroneously attack the thyroid tissues and destroy thyroid follicular cells .
- Anti-TG antibodies attack thyroglobulin (a protein in the thyroid)
- Anti-thyroperoxidase antibodies (anti-TPO) are the biomarker of autoimmune thyroid diseaseand are present in almost all patients with Hashimoto’s thyroiditis . TPO antibodies attack thyroperoxidase, an enzyme present in thyroid cells that assist in the conversion of T4 to T3. The presence of TPO autoantibodies in the blood provides the evidence of the previous attack on the thyroid tissue by the body’s immune system .
Complications of Untreated Hashimoto’s Disease
Untreated Hashimoto’s can cause a number of chronic complications, which include:
Untreated Hashimoto’s leads to chronic hypothyroidism and the enlargement of the thyroid, AKA a goiter. Large sized goiters affect the appearance of the individual, along with possible breathing and swallowing difficulty.
Hashimoto’s disease associated with hypothyroidism causes hyperlipidemia, which is detected by increased levels of low-density lipid (LDL). LDL, which is considered as ‘bad cholesterol’ is one of the primary causes of plaque formation. This is especially true of the small sized LDL particles. Consequences of this lead to atherosclerosis and other related cardiac problems .
Mental Health Issues
Depression is another common symptom of Hashimoto’s disease which can be worsened in untreated patients. Another concern that can be noted is a decreased libido in both men and women, which also reduces mental functioning (who knew!) .
Chronic hypothyroidism due to untreated Hashimoto’s disease can cause dermatological complications i.e. Myxedema. Myxedema refers to the deposition of mucopolysaccharides in the skin, resulting in swelling of the affected area. Other clinical symptoms of Myxedema include drowsiness, lethargy, and in severe cases, unconsciousness. Some triggering factors such as exposure to cold, infection, stress or administration of sedative drugs may cause myxedema coma, which is an emergent condition that requires immediate medical attention .
Complications in Pregnancy
Untreated Hashimoto’s disease during pregnancy can damage the neurological growth of the fetus due to a decreased availability of maternal thyroxine hormone during early gestation . Thyroid hormones and anti-bodies should be monitored closely in early pregnancy to prevent complications.
Now that you have a thorough grasp on the diagnosis of Hashimoto’s and hypothyroidism it is time to understand how to begin to feel better! The first step in this is to pick up my guide on Reading your Thyroid Labs – the Optimal Reference ranges. This will help you to better understand how well your condition is managed. Additionally, don’t forget to stay tuned next week for part 3, the treatment section.
Sign up now to get your guide to optimal thyroid health!
Have Questions or Comments for me? I would LOVE to hear them. Send them my way on Facebook!
- How does the thyroid work? – PubMed health – national library of medicine – PubMed health. . Retrieved from https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0072572/
- Lewis E. Bravemman, Sidney H. Ingbar, Keinwem Sterling; Conversion of Thyroxine (T4) to Triiodothyronine (T3) in Athyreotic Human Subjects; The Journal of Clinical Investigation Volume 49 1970; https://www.ncbi.nlm.nih.gov/pmc/articles/PMC535757/pdf/jcinvest00221-0019.pdf
- Amy C. Schroeder, Martin L. Privalsky; Thyroid Hormones, T3 and T4, in the Brain; Front Endocrinol (Lausanne) 2014; 5: 40. Published online 2014 Mar 31. doi: 10.3389/fendo.2014.00040; https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3978256/
- David Sarne, Effects of the Environment, Chemicals and Drugs on Thyroid Function; Medical Director, Endocrinology and Metabolism Clinics University of Chicago; Last Update: September 27, 2016; https://www.ncbi.nlm.nih.gov/books/NBK285560/
- Olivieri O, Girelli D, Stanzial AM, Rossi L, Bassi A, Corrocher R.; Selenium, zinc, and thyroid hormones in healthy subjects: low T3/T4 ratio in the elderly is related to impaired selenium status; Biol Trace Elem Res. 1996 Jan;51(1):31-41. https://www.ncbi.nlm.nih.gov/pubmed/8834378
- Hypothyroidism – national library of medicine – PubMed health. . Retrieved from https://www.ncbi.nlm.nih.gov/pubmedhealth/PMHT0022776/
- Dimitry A Chistiakov; Immunogenetics of Hashimoto’s thyroiditis; J Autoimmune Dis. 2005; 2: 1. Published online 2005 Mar 11. doi: 10.1186/1740-2557-2-1; https://www.ncbi.nlm.nih.gov/pmc/articles/PMC555850/
- Hashimoto’s disease – national library of medicine – PubMed health. . Retrieved from https://www.ncbi.nlm.nih.gov/pubmedhealth/PMHT0025658/
- Wang Z; [Diagnosis and treatment in 45 patients with Hashimoto’s thyroiditis associated with throat symptoms]; Lin Chuang Er Bi Yan Hou Ke Za Zhi. 2003 Feb;17(2):81-3; https://www.ncbi.nlm.nih.gov/pubmed/12833688
- Hashimoto’s disease. (2015, November 17). Retrieved January 12, 2017, from https://www.niddk.nih.gov/health-information/health-topics/endocrine/hashimotos-disease/Pages/fact-sheet.aspx
- Terry J. Smith.; Chapter 138Neck and Thyroid Examination; Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition; https://www.ncbi.nlm.nih.gov/books/NBK244/
- Caturegli P, De Remigis A, Rose NR; Hashimoto thyroiditis: clinical and diagnostic criteria; Autoimmun Rev. 2014 Apr-May;13(4-5):391-7. doi: 10.1016/j.autrev.2014.01.007. Epub 2014 Jan 13; https://www.ncbi.nlm.nih.gov/pubmed/24434360
- Trbojević B, Djurica S.; [Diagnosis of autoimmune thyroid disease]; Srp Arh Celok Lek. 2005 Oct;133 Suppl 1:25-33; https://www.ncbi.nlm.nih.gov/pubmed/16405253
- Clinic, M. (2016). Mayoclinic. Retrieved from http://www.mayoclinic.org/diseases-conditions/hashimotos-disease/symptoms-causes/dxc-20269764
- Chiovato L, Lapi P, Fiore E, Tonacchera M, Pinchera A.; Thyroid autoimmunity and female gender; J Endocrinol Invest. 1993 May;16(5):384-91; https://www.ncbi.nlm.nih.gov/pubmed/8320432
- Ali J Chakera, Simon HS Pearce, Bijay Vaidya; Treatment for primary hypothyroidism: current approaches and future possibilities; Drug Des Devel Ther. 2012; 6: 1–11. Published online 2011 Dec 22. doi: 10.2147/DDDT.S12894; https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3267517/
- Jacqueline Jonklaas, Antonio C. Bianco, Andrew J. Bauer, Kenneth D. Burman, Anne R. Cappola, Francesco S. Celi, David S. Cooper, Brian W. Kim, Robin P. Peeters, M. Sara Rosenthal, Anna M. Sawka; Guidelines for the Treatment of Hypothyroidism: Prepared by the American Thyroid Association Task Force on Thyroid Hormone Replacement; Thyroid. 2014 Dec 1; 24(12): 1670–1751. doi: 10.1089/thy.2014.0028; https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4267409/
- Toulis KA, Anastasilakis AD, Tzellos TG, Goulis DG, Kouvelas D.; Selenium supplementation in the treatment of Hashimoto’s thyroiditis: a systematic review and a meta-analysis; Thyroid. 2010 Oct;20(10):1163-73. doi: 10.1089/thy.2009.0351; https://www.ncbi.nlm.nih.gov/pubmed/20883174
- Levothyroxine (by mouth) – national library of medicine – PubMed health. . Retrieved from https://www.ncbi.nlm.nih.gov/pubmedhealth/PMHT0010926/?report=details
- McCONAHEY WM, WOOLNER LB, BLACK BM, KEATING FR Jr.; Effect of desiccated thyroid in lymphocytic (Hashimoto’s) thyroiditis; J Clin Endocrinol Metab. 1959 Jan;19(1):45-52; https://www.ncbi.nlm.nih.gov/pubmed/13620732
- Gregory A. Brent; Environmental Exposures and Autoimmune Thyroid Disease; Thyroid. 2010 Jul; 20(7): 755–761. doi: 10.1089/thy.2010.1636; https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2935336/
- Serena Tonstad, Edward Nathan, Keiji Oda, Gary Fraser; Vegan Diets and Hypothyroidism; Nutrients. 2013 Nov; 5(11): 4642–4652. Published online 2013 Nov 20. doi: 10.3390/nu5114642; https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3847753/
- Jagminder K. Bajaj, Poonam Salwan, Shalini Salwan; Various Possible Toxicants Involved in Thyroid Dysfunction: A Review; J Clin Diagn Res. 2016 Jan; 10(1): FE01–FE03.; Published online 2016 Jan 1. doi: 10.7860/JCDR/2016/15195.7092; https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4740614/
- Chin Lye Ch’ng, M. Keston Jones, Jeremy G. C. Kingham; Celiac Disease and Autoimmune Thyroid Disease; Clin Med Res. 2007 Oct; 5(3): 184–192. doi: 10.3121/cmr.2007.738; https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2111403/
- Markers of potential coeliac disease in patients with Hashimoto’s thyroiditis Rossella Valentino, Silvia Savastano, Maria Maglio, Francesco Paparo, Francesco Ferrara, Maurizio Dorato, Gaetano Lombardi, Riccardo Troncone; European Journal of Endocrinology (2002) 146 479–483; https://www.ncbi.nlm.nih.gov/pubmed/11916614