SUBCLINICAL HYPOTHYROIDISM (To Be Treated or Not To Be Treated) (Dr.

AMIT ARORA) Keywords: Subclinical hypothyroidism and homoeopathy, mild thyroid failure, elevated TSH Abstract: Subclinical hypothyroidism is a condition in which there is an elevated thyroid-stimulating hormone (TSH) with normal serum free thyroxine (T4). It is often asymptomatic but may be present with symptoms seen in overt hypothyroidism. Studies shows that it is a risk factor for cardiovascular diseases and high low density lipoprotein level. The condition is to be treated with proper medicine so as to check the progress of this functional disorder to structural level. Thyroid Gland The thyroid gland is one of the largest endocrine gland situated in throat just inferior to the larynx. It is a bi-lobed gland, the right and left lateral lobe of gland lie on either side of trachea. The lobes are connected to each other by isthmus. It was once a sex gland and is frequently called the third ovary since it is always involved in ovarian cases in lower vertebra. In lower vertebra it is connected with ducts of sexual organ. Dr. Louis Berman says that the relation is lost. The thyroid migrated more and more to head region to become a great link between sex and brain. Dr. I G Cobb tells Only 31/2 grain of thyroid secretion stand between intelligence and idiocy Dr. Berman says "Without thyroid there can be no complexity of thought, no learning, no education, no habit-formation, no responsive energy for situations, as well as no physical unfolding of faculty and function and no reproduction of kind, with no sign of adolescence at the expected age, and no exhibition of sex tendencies thereafter. The thyroid secreted two hormones namely (1) Thyroxine (T4) and (2) Tri-iodothyrnine (T3). The hormonal output from the gland is regulated by Thyroid Stimulating Hormone (TSH) from pituitary which itself is regulated by Thyrotropin Releasing Hormone (TRH) from hypothalamus. Functions Thyroid gland is keystone of endocrine system of body. It is a great catalyst of energy in body. Its hormones control the basal metabolic rate of each and every cell of body. More the thyroid hormones more the metabolism rate, more will be the catabolism of proteins, fat and carbohydrates. After removal of the thyroid gland, excess amounts of water, salts, and protein are retained within the body, blood cholesterol also goes up. It also has the effect on cardiac function, neuromuscular functions, cognitive function, gynecological and sexual functions. Tests for thyroid function assessment Tests for thyroid functioning involves the assessment of (1) Serum Free T4, (2) Serum Free T3 (3) Serum TSH

(4) Antithyroid antibodies for evidence of autoimmune diseases that may be damaging the thyroid gland Most of thyroid hormone in circulation remains in bounded form to globulin, theses are the free hormones which are more biologically active, so free hormone assay is more reliable indicator. SUBCLINICAL HYPOTHYROIDISM Subclinical hypothyroidism is a condition in which there is an elevated thyroidstimulating hormone (TSH) concentration with normal serum free thyroxine (T4) and normal serum free tri-iodothrionine (T3). Though the levels of T4 and T3 are normal but elevated TSH represent that somewhere the gland is less functioning. If the level of T4 and T3 falls, a signal is sent to hypothalamus and then to pituitary gland which produces more TSH so as to stimulate the thyroid gland to produce more hormones. In subclinical hypothyroidism the elevation of TSH levels reflects the sensitivity of the hypothalamic-pituitary axis to small decreases in circulating thyroid hormones where the free T4 level has fallen only slightly (i.e. toward the lower normal range) but is still within the normal range. Causes Subclinical hypothyroidism is caused by the same disorders that cause overt hypothyroidism. These are Chronic autoimmune thyroiditis (Hashimoto's disease), which is commonly associated with increased titers of antithyroid antibodies, such as Thyroid peroxidase antibodies(TPOAb) and antithyroglobulin antibodies (TgAb). This condition is associated with thyroid gland enlargement but but antithyroid antibodies may also be associated with atrophy of the thyroid and hypothyroidism. Previous radioiodine therapy, thyroid surgery, and external radiation therapy can also result in mild thyroid failure. Physical and mental stresses. Symptoms: The condition is often asymptomatic but some patients may experience nonspecific physical and psychiatric symptoms. In the Colorado Thyroid Disease Prevalance study, the patients with only mild TSH elevations had slight symptoms present as compared to euthyroid control. The symptoms are Dry skin Poor memory Slow thinking Muscle weakness Fatigue Muscle cramps Cold intolerance Puffy eyes, puffy face Non pitting edema in legs

Constipation Hoarseness Weight gain Menorrhagia Decrease sex drive Depression Impaired myocardial contractility and diastolic dysfunctionat rest Increase seum levels of total cholesterol and low density lipoproteins with reduced high density lipoproteins.

Should subclinical hypothyroidism be treated? Studies show that subclinical hypothyroidism is a risk factor for cardiovascular disease like myocardial infarction, ischemic heart disease and atherosclerosis. According to a study report in May 2007 issue of The Journal of Clinical Endocrinology & Metabolism the researchers concluded that treating subclinical hypothyroidism can improve a number of heart disease risk factors, as well as certain quality of life measurements. It is associated with increase in total cholesterol and low density lipoprotein. It has been estimated that increase in serum TSh level of 1mU/L is associated with increase in total serum cholesterol concentration to 3.5 mg/dl in females and 6.5 mg/dl in males. Subclincial hypothyroidism may progress to overt hypothyroidism. Duration of TSH elevation and higher titers of antithyroid antibodies increase the probability that the condition will progress to overt hypothyroidism. So the early treatment in subclinical hypothyroidism with or without symptoms prevents the further progress of disease and improves the quality of life. Laboratory investigations: (1) Serum TSH: How much should be the reference range for normal Serum TSH is a debatable. As of 2003, the American Association of Clinical Endocrinologists (ACEE) considers TSH 0.33.0 mIU/L within normal range. However in most laboratories the normal reference range for TSH is 0.5-5.0 mIU/L. (2) Free T4 and Free T3 As T4 is the major thyroid hormone in circulation; so assessing T4 status alone is usually sufficient to assess the thyroid hormone status. TREATMENT General Guidelines If TSH is higher and T4 is normal, if possible repeat the test after 6 weeks. After the treatment is started retest for TSH after every 6-8 months till the TSH is within normal range. After TSH is within normal range the frequency of TSH measurement may be decreased to once in every 6 to 12 months.

During the course of treatment serum level of T4 should be done along with TSH. It should be in normal range but not toward the lower normal range.

Allopathic Approach If after the repeat test TSH is higher and T4 normal follow as If TSH > 10mIU/L Check antithyroid antibodies If positive start levothyroxine therapy If negative o Symptoms present start levothyroxine therapy o No symptoms consider levothyroxine therapy If TSH between 5-10mIU/L Check antithyroid antibodies If positive or symptoms present consider levothyroxine therapy. If negative and no symptoms observe patient and retest every 6 months. In 2005 Thyroid specialist panel report recommended that all patients with elevated serum TSH value be considered for levothyroxine therapy. Homoeopathic Approach: The approach in cases of subclinical hypothyroidism is to treat the patient and prevent the further progress of disease. The disease here is at functional level and with proper treatment it can be prevented to progress to structural level. Subclinical hypothyroidism is a state where there is mild thyroid failure, which may manifest with symptoms or without symptoms. Here the thyroid gland is in its early state of failure. Though it is secreting the hormones which are in normal range but the presence of elevated TSH is showing that somewhere the gland is under some stress that it is not able to function up to the extent it has to do. It is the state where if homoeopathic treatment (i.e. constitutional treatment) is offered to the person, the vital force will act by its full force under the action of well selected homoeopathic remedy so as to remove the stresses acting on thyroid gland. Homoeopathic medicines play an important role in immuno-modulation at the cellular level and can cure cases of sub clinical hypothyroidism. As Dr. Hahnemann has rightly treat the man in disease not the disease in man. Therefore, a holistic approach is needed to treat the patients. A detailed case taking with psychosomatic approach should be adapted in case taking. It should include investigation of the emotional and psychological factors (which if present play a great role in disturbing the internal environment of man) along with other factors like past and family history and physical aspects. Some specific rubrics in repertory: In synthesis repertory (1) External throat complaints of external throat Thyroid gland (2) Generals obesity children in- thyroid gland ; from dysfunction of (3) Chest Heart complaints accompanied thyroid

In Boericke repertory (1) Generalities Location of glandular affections Thyroid

A CASE OF SUBCLINICAL HYPOTHYROIDISM This is a case of female of 33 yr of age with symptoms of weight gain and some disturbance in menses. The value of T3 and T4 was normal since beginning and TSH was little high. So on the basis of slight increase of TSH and symptomatology of patient she was diagnosed as Subclinical hypothyroidism CASE: A female patient named Mrs. Harpreet, aged 33 yrs presented with following complaints: (1) Weakness (2) Weight gain. Feels as if body is swelling. There is 4 kg gain in weight in last 6-7 months. (3) Menses at regular interval but flow is increased. (4) Acne are appearing. The complaints started 1 year back with slight weakness and mild swelling in the body. Gradually the intensity of complaints increased. Generals: Weakness. Weight: 55Kg Height: 155cm Emotional aspect: On interrogation it was found that patient was under lot of familial stress. While telling there was appearance of tears in her eyes with sighing. The stress is continuing since last 2-3 years. Prescription: On the basis, the IGNATIA was prescribed. Started with Ignatia 30, then 200 and later 1M. The repeated doses were given all the time. Gradually the patients improved symptomatically and her weight again came back to 51 (as earlier). Her reports are as:

Report 1

Report 2 (Report 1 and 2 Before treatment)

Report 3

Report 4

Report 5 (Report 3, 4 and 5 after treatment) Acknowledgement Dr. Archana Narang, (Reader, Presently posted at Dr. B.R. Sur Homoeopathic Medical college and Hospital), whose guidance helped me in writing this article. Bibliography Books: 1. Khan, L.M, 2003, Pleasure of Prescribing, Ist edition, B. Jain Publishers (Ltd), New Delhi. 2. Cooper, David S, 2010, Medical Management of Thyroid Disease, 2nd edition, Informa Healthcare, New York, London

3. Aggarwal, Y.R, 2004, Materia Medical of Glandular Medicine, 3rd revised edition, Vijay Publications, Delhi. 4. Boericke,W,2006, New Manual of Homoeopathic Materia Medica and repertory, 9th edition, B Jain Publishers Pvt Ltd, New delhi Software: 1. Radar 10 software, Encyclopedia homeopathica 2.2.1, ARchibel S.A.Belgium Websites 1. http://www.lucistrust.org:8081/obooks/node/272 2. http://www.tuberose.com/Thyroid.html 3. http://www.aafp.org/afp/1998/0215/p776.html 4. http://en.wikipedia.org/wiki/Hypothyroidism 5. http://jcem.endojournals.org/content/86/10/4585.full 6. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2664572/ 7. http://www.ncbi.nlm.nih.gov/pubmed/22191793 8. http://hpathy.com/scientific-research/homeopathic-perspective-of-thyroiddisorders/ 9. http://thyroid.about.com/od/heartdisease/a/subclinical.htm 10. http://www.ncbi.nlm.nih.gov/pubmed/8197271 11. http://www.thyroidinstitute.org/brochures/are_you_sick_and_tired.pdf

By Dr. Amit Arora (Sr. Medical Officer at Directorate of ISM and H, GNCT of Delhi and Lecturer in Dr. B.R. Sur Homoeopathic Medical College and Hospital)