To listen to Lisette Mancini, a 40-year old Walpole audiologist and mother of three, you might be tempted to conclude that thyroid troubles are a blessing.
Years ago, as a student at Boston College, her metabolism was cranked so high she “flew through school because I had so much time to study. I never slept. I was never tired,” she recalls. She got all A’s, carried a double major, and did an honors thesis.
Sure, she was always hungry. But that meant she could eat three dinners a night and not get fat. She was always hot, but she’d just open the window and wear T-shirts while her roommate bundled up.
But this was no blessing. Mancini’s heart raced even when she lay down. Her periods were erratic. She was elated one minute, catatonic the next. Her skin was so greasy she needed two showers a day — but she never worried about any of it, like millions of others whose thyroid problems creep up on them.
Finally diagnosed with hyperthyroidism, she had surgery to remove most of the butterfly-shaped gland in her neck that was producing too much thyroid hormone, which is crucial for basic metabolism. The tiny bits left supplied normal levels — and she was fine for years.
But then, like many women, she developed problems from too little thyroid after her first pregnancy. Now she had hypothyroidism and felt like “a total zombie.”
Mancini’s problems may seem extreme, but the trouble she — and some of her doctors — had in spotting the warning signs is so common that the American College of Physicians and the American Society of Internal Medicine recently issued new guidelines calling for thyroid screening for all women over 50.
The American Association of Clinical Endocrinologists, who specialize in hormone problems, goes even further. Since 1995, that group has urged not just screening but treatment for patients whose thyroid tests are abnormal, even if they have no symptoms, says Dr. Stanley Feld of Dallas, a past president.
An estimated 11 million Americans, many of them women over 50, have hypothyroidism, or an underactive thyroid, which results in fatigue, forgetfulness, depression, chilliness, weight gain, elevated cholesterol and goiter, an enlarged thyroid gland. Many more people are never diagnosed because the symptoms are chalked up to aging or “the blues.”
Another 2 million Americans, many of them women aged 20 to 40, have hyperthyroidism, or an overactive thyroid, which causes nervousness, weight loss, intolerance to heat and goiter.
Hyperthyroidism is also often underdiagnosed, especially in older people with subtle symptoms, says Dr. Mark Helfand, an internist at Oregon Health Sciences University in Portland.
Both hypothyroidism and hyperthyroidism can result from a misguided attack by the body’s immune cells and antibodies on the thyroid gland — in the first case, inhibiting or destroying the gland, in the second, kicking it into high gear.
With hypothyroidism, the most common cause is an auto-immune syndrome called Hashimoto’s thyroiditis, which often runs in families; with hyperthyroidism, the most common cause is an auto-immune condition called Graves’ disease, which also tends to run in families, though here, too, not everyone with a family history of thyroid troubles is at risk.
The screening now widely recommended is a blood test for TSH, or thyroid stimulating hormone, which is made by the pituitary gland. When the pituitary senses the body is not making enough thyroid hormone, TSH levels rise, signalling the thyroid gland to make more. The test picks up minute fluctuations in TSH.
If your TSH is abnormal, doctors add another test to detect blood levels of thyroid hormone itself. It’s a clear sign you need treatment for hypothyroidism if your TSH is elevated and your thyroid hormone levels are low. You need treatment for hyperthyroidism if the reverse is true — low TSH and high thyroid hormone levels.
Where things get tricky is with “subclinical” disease, particularly hypothyroidism — when TSH is elevated but thyroid hormone is normal, says Dr. Robert D. Utiger, an endocrinologist and deputy editor of the New England Journal of Medicine.
Many specialists, Feld among them, recommend treatment even for subclinical disease because patients with subtle symptoms often feel better.
But the data are “unimpressive,” says Utiger. According to the American College of Physicians, studies of people who have subclinical disease and symptoms are inconclusive, and people with no symptoms have not been shown to benefit from treatment.
Complicating things is the fact that patients who deny symptoms may have them nevertheless, says Dr. John C. Morris, a Mayo Clinic endocrinologist, though this may only become clear when the doctor asks more questions.
“It’s a subtle thing,” adds Feld. “You don’t wake up one day” with hypothyroidism. “You get a little bit that way, then a little more.”
The treatment for hypothyroidism is straightforward, and “great, provided you need it,” says Helfand. Thyroid supplements — chiefly, levothyroxine (which comes in generic form and in brands such as Synthroid or Levoxyl,) are safe, effective and cheap — about $20 for a three-month supply.
The catch is that doses have to be monitored lest you go from having too little thyroid hormone to too much, which can lead to osteoporosis and increased risk of a heart rhythm abnormality called atrial fibrillation.
Like hypothyroidism, hyperthyroidism can also appear in subclinical form. But it, too, is readily treatable.
One treatment is radioactive iodine (a one-time capsule) to shrink the thyroid gland. This does not seem to cause cancer, thyroid specialists say, though many patients are leery.
An alternative is the drugs Tapazole or PTU (propylthiouracil) that block production of thyroid hormone.
Yet another is surgery to remove the thyroid gland, or most of it, though this can be difficult to do without disrupting the adjacent glands that control calcium metabolism.
In many cases, once an overactive thyroid problem is treated, you will end up with hypothyroidism, which means you’ll need to take a thyroid hormone replacement drug.
Recently, there’s been growing concern that iodine deficiency in the American diet may increase the risk of thyroid problems, especially during pregnancy, says Dr. Reed Larsen, chief of the thyroid division at Brigham and Women’s Hospital in Boston.
The thyroid gland makes hormone from iodine, which is present in many foods, including salt and fish. But a recent government study of urine samples showed that between 1974 and 1994, the proportion of Americans deficient in iodine has grown from 2.4 percent to 11.7 percent. Iodine deficiency in pregnant women has also grown — from 1 percent to 7 percent.
“We thought we had cured this by putting iodine in salt,” Larsen says. It’s unclear why this deficiency is growing, but some suspect that people are using less salt and that iodine is used less often as a preservative in bread.
Pregnant women, especially if they have an auto-immune disease, should be especially alert to thyroid problems. In many women, stored thyroid hormone spills into the blood as soon as pregnancy is over, causing hyperthyroidism. After several weeks, the pituitary gland signals the thyroid gland to cut production of the hormone, which then can trigger hypothyroidism.
“You go from palpitations and fretfulness, which you think is because you’ve just had a baby. . .to feeling dragged out and tired, which you say is because you just had a baby,” says Feld, adding that doctors overlook the possibility of thyroid problems for the same reasons.
The bottom line, whether you’re young or old, female or male, recently pregnant or not, is that if you feel inexplicably tired — or wired — talk to your doctor. And ask about a TSH test.