Hypothyroidism - primary

Primary and secondary hypothyroidism

Thyroid gland

Definition:
Primary hypothyroidism is a condition of decreased hormone production by the thyroid gland.
Causes, incidence, and risk factors:
The thyroid gland is an important organ that regulates metabolism. It is located in the front of the
neck just below the voicebox (larynx). The thyroid gland secretes two forms of thyroid hormone
thyroxine (T4) and triiodothyronine (T3). The secretion of T3 and T4 by the thyroid is
controlled by a feedback system involving the pituitary gland, a small organ at the base of the
brain, and the hypothalamus, a structure in the brain.
Hypothyroidism caused by the inability of the thyroid gland to make T3 and T4 is called primary
hypothyroidism. Worldwide, the most common cause of primary hypothyroidism is deficiency of
the element iodine. In the US, the most common cause is destruction of the thyroid gland by the
immune system, a condition called Hashimoto's thyroiditis.
Other causes of primary hypothyroidism include surgical removal of part or all of the thyroid
gland, radioactive iodine used for treatment of hyperthyroidism (overactive thyroid), radiation
exposure to the neck, X-ray contrast agents, and certain drugs such as lithium. In some cases the
cause of hypothyroidism is unknown.
Since the thyroid gland is regulated by the pituitary gland and hypothalamus, disorders of these
organs can cause the thyroid gland to produce too little thyroid hormone as well. This condition
is called secondary hypothyroidism.
Primary hypothyroidism may cause a variety of symptoms and affects the whole body. Its
normal rate of functioning slows, causing mental and physical sluggishness. Symptoms may
vary from mild to severe. The most severe form is called myxedema coma and is a medical
emergency. Risk factors for hypothyroidism include age (older than age 50), female gender,
obesity, thyroid surgery, and X-ray or radiation treatments to the neck.
Symptoms:
Early symptoms:

weakness
fatigue

cold intolerance

constipation

weight gain

depression

joint or muscle pain

thin, brittle fingernails

thin, brittle hair

paleness

Late symptoms:

slow speech
dry flaky skin

thickening of the skin

puffy face, hands, and feet

decreased taste and smell

thinning of eyebrows

hoarseness

menstrual disorders
Signs and tests:
Physical examination may reveal a smaller than normal gland, though sometimes the gland is
normal in size or even enlarged (goiter). Other physical findings include pale, yellow, and dry
skin; thin, brittle hair; loss of the edges of the eyebrows; coarse facial features; firm swelling of
the arms and legs; and slow muscle relaxation when reflexes are tested. Vital signs may reveal a
slow heart rate, low blood pressure, and low temperature.

A chest X-ray sometimes reveals an enlarged heart.

Laboratory tests to determine thyroid function include:

Free T4 test (low)

Total T3 or free T3 (low)

Serum TSH (high)

Additional laboratory abnormalities may include:

increased cholesterol levels

increased liver enzymes

increased serum prolactin

low serum sodium

a complete blood count (CBC) shows anemia

Treatment:
The purpose of treatment is to replace the deficient thyroid hormone. Levothyroxine (T4) is the
most commonly used medication, but a preparation of T3 is also available. Most people feel
their best when TSH is brought into the 1 to 2 mcIU/mL range. The lowest dose effective in
relieving symptoms and normalizing blood tests is given.

Life-long therapy is needed as relapses will occur if therapy is interrupted. Medication must be
continued even when symptoms subside.
After replacement therapy has begun, report any symptoms of increased thyroid activity
(hyperthyroidism), such as restlessness, rapid weight loss, heat intolerance, and sweating.
Myxedema coma is treated by intravenous thyroid replacement and steroid therapy. Supportive
therapy of oxygen, assisted ventilation, fluid replacement, and intensive care nursing may be
indicated.
Expectations (prognosis):
With early treatment, the condition can be completely controlled. However, relapses will occur if
the medication is not continued. Myxedema coma can result in death.
Complications:
Myxedema coma, the most severe form of hypothyroidism, is rare. It may be caused by an
infection, illness, exposure to cold, or certain medications. Symptoms and signs of myxedema
coma include:

unresponsiveness
decreased breathing

low blood pressure

low blood sugar

below normal temperature

Other complications include:

heart disease
increased risk of infection

infertility

miscarriage

pituitary tumors
Calling your health care provider:
Call your health care provider if signs or symptoms of hypothyroidism or myxedema are present

Call your health care provider if restlessness, rapid weight loss, heat intolerance, rapid heart rate,
excessive sweating, or symptoms of hyperthyroidism occur after beginning thyroid replacement.
Prevention:
Primary hypothyroidism is preventable by supplemental iodine in areas where iodine in the food
supply is low. Otherwise, the condition is not preventable. Awareness of risk may allow early
diagnosis and treatment. Some experts advocate screening laboratory testing (TSH) in certain
high risk groups (e.g., women older than 50 years).
Review Date: 4/19/2004
Reviewed By: Nancy J. Rennert, M.D., Endocrinology, Yale University School of Medicine, New
Haven, CT. Review provided by VeriMed Healthcare Network.