HYPERTHYROID
What is Hyperthyroidism? It is also known as poisonous goiter or internal goiter. The condition of the thyroid gland working excessively and producing more hormones than necessary is called “hyperthyroidism”. Thyrotoxicosis, on the other hand, is an increase in the level of thyroid hormone in the blood as a result of the destruction of the thyroid gland follicles due to bacteria, viruses, drugs or auto-immune mechanisms. It is necessary to make a good distinction between the two diseases. Because the treatment of both diseases is different.
With Which Complaints Do Hyperthyroid Patients Apply to the Doctor?
It may present with weakness, irritability, palpitations, weight loss despite having a high appetite, shortness of breath, intolerance to heat, extreme irritability, menstrual irregularity, sweating, soft stools or diarrhea, and protruding eyes. In addition, in patients, nails break quickly, hair loss, fine tremors in the hands (tremor) in order to better understand this, the hands are extended forward by opening the fingers and thin tremors in the hands can be seen by placing a small piece of paper on it. The skin is thin, warm and moist. There may be redness and itching in the palms of the hands. Skin allergy called urticaria and vitiligo (discolored or white areas on the skin) are also often found together.
Eye symptoms called “ophthalmopathy” in patients are detected in 25-30% of patients with Graves’ disease. There is a forward projection of the eyes. Some patients complain of double vision. Dry eyes may occur due to visual impairment, discomfort from light, itching and burning in the eyes, and sleeping with the eyes open as a result of the inability to close the eyelids. The eyes of the patients are alive and there may be no delay and complete closure of the upper eyelid. Sometimes strabismus may also occur.
If You Have Toxic Goiter Which Doctor Should I Apply To?
If you have a toxic goiter, first of all, consult an “ENdocrine Diseases Specialist”. If there is no endocrine specialist in your area, it would be appropriate to apply to an internal medicine specialist.
Which Tests Should Be Done for Diagnosis?
The first laboratory test to confirm the diagnosis of the disease should be TSH and F-T4. When F-T4 is found to be normal, F-T3 hormone level should be checked. High levels of F-T4 and FT3, and low TSH indicate overt (clinical) hyperthyroidism. After the laboratory confirmation of the diagnosis of hyperthyroidism, the RAIU (or Tc uptake) should come first in the differential diagnostic tests for the etiology. A high RAIU supports “hyperthyroidism”, while a low value supports “thyrotoxicosis” (thyroiditis, exogenous thyroid hormone use).
Is it subclinical hyperthyroidism? The presence of low serum TSH (less than 0.5 mIU/L) and normal F-T3 and F-T4 is sufficient for the diagnosis of subclinical hyperthyroidism.
Causes of Hyperthyroidism
1- Graves’ disease: It is the most common cause of hyperthyroidism. Graves’ disease constitutes 60-90% of patients with hyperthyroidism. It is caused by a disorder in the immune system. The disease is also called “Basedow’s disease”. It is an overactivity of the thyroid gland caused by an increase in TSH receptor antibodies in the blood. In some patients, there is an enlarged eye.
2- Excess hormone secretion by hot nodules or nodules: Due to excessive secretion of thyroid hormone by hot nodules or nodules, the level of thyroid hormones in the blood increases and creates hyperthyroidism. If there is only one hot nodule, it is called toxic adenoma and the presence of more than one hot nodule is called toxic multinodular goiter.
3- Excessive intake of thyroid hormone drugs: Taking levothyroxine more than necessary increases the thyroid hormones in the blood and causes hyperthyroidism.
4- Hyperthyroidism may develop as a result of the use of certain drugs. For example, hyperthyroidism may occur due to the use of a drug called amiadorone, which regulates the heart rhythm.
5- Excessive intake of iodine causes hyperthyroidism in patients with nodules.
GRAVES – BASEDOW’S DISEASE:
Graves’ disease is the most common cause of thyrotoxicosis and can occur at any age. It is seen 5-7 times more in women than men and 1% in the society. An increase is observed in the number of Graves’ patients after iodine prophylaxis. TSH receptor stimulating antibodies (TSH-Receptor Antibody =TRAB) cause Graves’ disease.
Who Is More Common in Graves’ Disease?
Graves’ disease is the most common cause of hyperthyroidism. Although it can be seen at any age, it is most common between the ages of 20-40. While it is seen 5-7 times more in women than in men, its incidence in society is about 1%. There is a familial feature in Graves’ disease: Graves’ disease is detected in 15% of the family members of a person with Graves’ disease. For this reason, it is beneficial for people with a family history of Graves’ disease to have their thyroid tests done at regular intervals.
Why Does Graves’ Disease Occur?
Graves’ disease occurs as a result of a disorder in the immune system. For an unknown reason, proteins called antibodies are formed against proteins called receptors, to which TSH hormone binds to the thyroid gland. It is not yet known why these antibodies occur. The increased TSH receptor antibodies in the blood, just like the TSH hormone, stick to the thyroid gland, causing it to work harder and make an excessive amount of thyroid hormone. As a result, increased thyroid hormones accelerate our metabolism (palpitations, sweating, etc.) and Graves’ disease occurs.
What are the Signs and Symptoms of Graves’ Disease?
Three common features of Graves’ disease are goiter, elevated thyroid hormones in the blood, and eye symptoms. There is often an enlargement of the thyroid gland, that is, goiter, and there is hardly any nodule in the gland, there is a flat growth. The symptoms in the eye are called “ophthalmopathy” in medical language. Two other less common features are inflammation of the skin of the legs and cambering of the fingertips, called clubbing, in the fingers. These two symptoms are very rare
Hyperthyroid-specific weakness, irritability, palpitations, weight loss despite high appetite, shortness of breath, intolerance to heat, extreme irritability, menstrual irregularity, sweating, soft stools or diarrhea, protruding eyes (in one or both eyes). The thyroid gland is usually enlarged bilaterally, a murmur can be heard when listening to the thyroid gland with a stethoscope. There may also be skin lesions (redness and itching on the hands and feet), the skin is thin, warm and moist. Nails break quickly, hair loss, fine tremors in the hands are seen. In order to better understand the tremors in the hands, the hands are extended forward by spreading the fingers and thin tremors in the hands can be seen by placing paper on the fingers. The onset of these complaints is slow, usually developing over weeks or months. However, rapid onset may be seen in some patients. Heart palpitations are present in most of the patients, the pulse rate is increased even at rest. The disease may also cause gynecomastia in the breasts of some men.
Graves (Basedow) Disease Is More Common in Who?
Graves’ disease is the most common cause of hyperthyroidism. Although it can occur at any age, it is most common between the ages of 20 and 40. Its incidence in the community is about 1%, it is seen 5-7 times more frequently in women than in men.
Why Does Graves’ Disease Occur?
Graves’ disease occurs as a result of a disorder in the immune system. For an unknown reason, proteins called antibodies are formed against proteins called receptors, to which TSH hormone binds to the thyroid gland. It is not yet known why these antibodies occur. The increased TSH receptor antibodies (TRAB) in the blood adhere to the thyroid gland, just like the TSH hormone, causing it to work harder, that is, to produce an excessive amount of thyroid hormone. As a result, increased thyroid hormones in the blood accelerate our metabolism (palpitations, sweating, etc.) and reveal the disease.
Is Graves’ Disease a Genetic Disease?
Yes, the disease is inherited. Because Graves’ disease is detected in 15% of other members of the family of a person with Graves’ disease. People with a family history of Graves’ disease are at risk, and genetics or heredity have been found to be the most important factor in the development of the disease.
For this reason, people with Graves’ disease in their family should have their thyroid tests done at regular intervals
Who is at Risk for Graves’ Disease?
Stress, sadness, smoking, eating too much iodized salt and some drugs can cause this disease. Graves’ disease occurs most often during the warm seasons of the year. The reason for this seasonal feature is not known exactly. While the eye symptoms are more severe in smokers, the severity of eye disease increases in those who continue to smoke. Graves’ disease is more common in people with allergies or allergic rhinitis. Excess iodine intake also exacerbates the mild disease.
Treatment of Graves’ Disease.
Graves’ disease or hyperthyroidism can be treated in 4 ways.
1. Drug therapy,
2.Atom (Radioactive iodine=RAI) therapy,
3. Operation (surgery).
4. Supportive treatment
1. Drug Treatment: It is the treatment to reduce the thyroid hormone synthesis (production) in order to normalize the thyroid hormones that are high in the blood. The effect of the drug in the treatment begins to be seen after an average of 6-8 weeks. For this reason, the patients are called for control again 4-6 weeks after the start of the treatment, the hormone values are checked, and the dose of the drug is adjusted according to the status of the hormone values. In this way, check-ups are made with 1-1.5 month intervals, and drug treatment is continued for at least 1-1.5 years. If the treatment is stopped earlier, the chance of recurrence of the disease increases. It will be of great benefit for patients to use non-iodized salt during this period.
Things to consider during drug treatment
a) If you have a fever and sore throat during drug treatment, you should consult your doctor immediately. This may be due to the very decrease in white cells (leukocytes) in the blood. If this very rare condition occurs, the drugs are discontinued and surgical treatment or atomic (RAI) treatment is recommended.
b) Since the liver may be affected during treatment, there may be slight elevations in the levels of liver-related enzymes in the blood. However, this may also be due to the effect of hyperthyroidism. For this reason, liver enzyme levels called SGOT (AST) and SGPT (ALT) should be monitored frequently, and if the enzyme levels gradually increase with treatment (2.5-3 times higher than the upper normal), the drugs used should be discontinued and surgery should be recommended to the patient or atomic therapy should be started.
c) One thing that patients with hyperthyroidism should pay attention to is not to eat iodized salt. Therefore, patients should eat non-iodized salt.
d) Since the disease is difficult to heal in smokers and eye disease occurs, the patient should quit smoking.
Does Graves’ Disease Recur After Treatment Is Completed and Stopped?
Since the disease may recur at a rate of 30-50% in the first 6 months after the treatment is completed and stopped, it is necessary to go for control again after the drug is stopped. In patients whose disease relapses after drug treatment is stopped, surgery or atomic therapy is performed after hormone levels are brought back to normal with drugs.
Recurrence of Hyperthyroidism is More in Who?
1. Those with large thyroid gland,
2. Young patients,
3. Those with severe disease at the beginning,
4. Initial ophthalmopathy (in the eye) throwing out),
5. Smokers,
6. Those who use iodized salt or drink a lot of iodized cough syrup,
7. TSH receptor antibody (TRAB) in the blood in patients with high levels
9. In patients with a short treatment period (less than 1.5 years), the recurrence of the disease is high.
2.Atom (Radioactive iodine=RAI) therapy,
The aim is to reduce the hormone production of the gland that produces excess thyroid hormone. Atomic therapy is given in organized Nuclear Medicine units. Although the name of RAI treatment is frightening, it does not have a carcinogenic or harmful effect on the reproductive system. However, women are allowed to become pregnant for at least 6 months after receiving RAI treatment. Compared to drug treatment, the effect of hypothyroidism is delayed. On average, hypothyroidism develops 3-3.5 months after RAI treatment is given. 4-6 weeks after atom therapy is given, thyroid hormones should be checked and whether the given treatment is effective or not. Permanent (hypothyroidism) thyroid gland insufficiency develops in 80-90% of patients receiving Atom therapy within the first 5 years and they need to take thyroid hormone medication (such as Levothyron, Tefor or Euthyrox) for life. Patients should know and accept this from the beginning.
3.Surgical (Surgery) Treatment:
Almost all or all of the thyroid gland is surgically removed. Thyroid hormone levels, which were high before surgery, should be brought back to normal with drug therapy. After surgery, patients should use thyroid hormone therapy for life. It is beneficial to inform the patients about this before the operation. It is beneficial to have the operation performed by surgeons experienced in thyroid surgery. Because the incidence of postoperative complications such as hoarseness and hypoparathyroidism decreases.
Surgical Treatment for Whom?
Surgery is recommended for patients who are resistant to drug therapy or have relapsed despite drug therapy, have advanced ocular findings, have a large goiter, and have a nodule in the thyroid gland that compresses the esophagus or trachea, or is suspected of cancer.
How Should Postoperative Follow-up Be Done?
Approximately 4-6 weeks after the operation, serum TSH and free T4 (FT4) hormone levels should be measured in the patient. After a successful operation, the patient’s serum TSH level should increase and the FT4 hormone should decrease. In this case, lifelong thyroid hormone treatment is applied to the patient to ensure that the serum TSH level remains between 1-2 mIU/L.
4. Supportive Treatment:
In patients with complaints such as palpitations, sweating, anxiety, irritability and heat intolerance, beta-blocker group drugs can be given in the initial period of the disease.
What Happens If Hyperthyroidism Is Not Treated?
If a patient with hyperthyroidism is not adequately treated, the patient continues to lose weight; arrhythmia in the heart, thyroid storm due to heart failure, shock and death occur. Therefore, hyperthyroidism is a disease that must be treated. In addition, hyperthyroidism accelerates bone resorption (osteoporosis), especially in postmenopausal women, making the bone more fragile.
What are the Common Diseases with Graves’ Disease?
Type 1 diabetes (diabetes), muscle disease called myasthenia gravis, pituitary gland inflammation and laxity of the mitral valve with heart murmur can be seen together with Graves’ disease. This is because these patients have a defect in the “immune system”
