Autoimmune Thyroid Disease
According to the American Thyroid Association, women are five to eight times more likely than men to be diagnosed with thyroid disease. Since two of the most common thyroid conditions are autoimmune in nature, their symptoms may often be confused with other health problems, which can make reaching a diagnosis for some a long and puzzling process. Today the diagnostic journey of autoimmune thyroid disease, the symptoms, the risks, and how– due to advances in testing– one result just might provide the missing piece you’ve been looking for.Despite its small size, the thyroid gland plays a huge role in determining how our body functions and ultimately how we feel. Too much or too little of its hormones can have a major impact on our health and well-being.
The most common causes of thyroid malfunctions are autoimmune disorders, which means instead of your immune cells protecting your thyroid tissue, they attack it and interfere with hormone production. Because the thyroid has an impact on every part of our body, sometimes the symptoms can be vague and difficult to make a diagnosis. So often patients are being treated specifically for individual symptoms, such as depression or sleeping problems, heart problems, such as palpitations, so they go in this path of being on antidepressants or being referred for sleep studies, or being told they need to just exercise more and eat less, and the thyroid is really not thought of as the unifying cause of these symptoms. It can be quite a diagnostic journey for people.
Many patients are seeking care and answers from specialists for individual symptoms that arise early in the disease process or being dismissed without help, due to vague symptoms and are likely walking around undiagnosed. Autoimmune thyroid disease is the most common thyroid problem we see– Graves disease is the most common reason people have an overactive thyroid and that’s when the immune system attacks the thyroid and tricks it into making too much thyroid hormone. Whereas Hashimoto’s is the most common cause of an underactive or hypothyroidism, so the immune system attacks the thyroid and destroys the normal thyroid gland and patients then have underactive thyroid.
When the thyroid’s under active or slow, people have brain fog, they have depression sometimes, fatigue, exercise intolerance, feelings of shortness of breath, they’ll retain some fluid and gain a little bit of weight, become constipated, and get cold easily, have dry skin, and sometimes hair thinning. On the other end of the spectrum the immune system tricks the thyroid or stimulates it into making too much thyroid hormone– everything is sped up so people have anxiety, insomnia, they get fidgety, they’re shaky, they have heart palpitations, again exercise intolerance, feelings of inefficient breathing, or shortness of breath, muscle weakness, sweating, and weight loss. Because the metabolism is revved up. So patients individually, can have both attacks at the same time, so that’s why we think of it as a spectrum and not an either/or, but all those symptoms are not specific to thyroid– so in diagnosing a thyroid problem we have to look at the whole picture; family history, physical exam, the patient’s symptoms, other medications they might be on, because at times it’s not as straightforward as it would seem and it needs a very thorough investigative look.
What standard thyroid tests may not be telling you
Diagnosing thyroid disease is a process that incorporates numerous factors including a clinical evaluation, and imaging tests, however, blood tests for thyroid function provide some of the most crucial evidence for doctors. What are they testing for, and what are the results telling us? So when first seeing a patient with suspected thyroid problems, we order a test called TSH or thyroid stimulating hormone– that’s a hormone that comes from the pituitary which is the master gland in the brain that communicates with hormone producing glands, such as the thyroid– So that TSH gives us great insight into the thyroid balance status of the body. So if a TSH is normal then in a broad sense that patient should have normal thyroid function. If the TSH is abnormal, then we look at the actual thyroid hormones that the thyroid is producing, so that’s T4, which is the predominant hormone that’s produced by the thyroid that gets converted into T3, which is the more active thyroid hormone. So those are the base options options for what else can I test hormone wise to see how severe either the over activity, or the under activity might be.
There’s been some debate on what the reference range should be, so on a lab report you’ll have a result and then there’ll be a range that your doctor looks at but sometimes that individual result might be at the lower end of a range or the higher end of the range– even though it may not be flagged as abnormal, I begin to ask more questions; do you have a family history of thyroid problems, do you have any thyroid symptoms, do you have any thyroid enlargement, have you had a miscarriage, are you trying for pregnancy, all of these things that trigger the need to explore more. The problem is the underlying autoimmune disease and that can exist even if the TSH is normal, so we need to look deeper into options for testing and identifying those patients who may be at risk for autoimmune thyroid disease and not know it.
HOW TO UNDERSTAND YOUR ISSUES
So because autoimmune thyroid disease is what is causing the thyroid function problem, we have to look at what the immune system is doing so we have to look beyond those basic tests. The diagnosis of autoimmune thyroid disease can be elusive, leaving patients questioning their symptoms even after they leave the doctor. According to the guidelines published by the American Thyroid Association, measurement of thyroid antibodies for confirmatory diagnosis of autoimmune thyroid disease is recommended. In order to understand what is going on, you must look at antibodies. In fact, there are antibodies in the blood that through innovations and testing, can be detected to confirm Hashimoto’s and Graves disease before it may even be reflected in a patient’s TSH.
There are different types of thyroid antibodies in the blood some of them will stimulate the thyroid to make excess thyroid hormone– and we see that in Graves disease– some of them will block the thyroid and decrease the thyroid hormone production causing hypothyroidism, some of them will destroy or damage the thyroid, and those are the thyroid peroxidase and thyroglobulin antibodies that we see typically in Hashimoto’s. There are times where the TSH test is normal but the thyroid is already under attack by the immune system, so the times we think about that would be if there’s a strong family history, if there’s some symptoms suggestive of thyroid or previous history of thyroid TSH results that fluctuate a little bit, very importantly if there’s a young woman who has had trouble becoming pregnant, or who has had miscarriages, screening with a TSH is not enough, looking at thyroid antibodies is very important to explain those reproductive problems and, which, are quite treatable with today’s technologies.
Other times we see patients with thyroid eye disease, so the eyes become bulging, the vision becomes impaired the eyes can ache, or be irritated, seemingly– maybe eye allergies or something else– but that can be Graves disease, where those antibodies that attack the thyroid, the TSH receptor antibodies also attack the fat and muscle behind the eye and caused the bulging and that can occur with a normal TSH. So test results can be deceptive and note normal thyroid function even though something is wrong.
Remembering that Graves disease is the immune system attack, where the thyroid is tripped and stimulated into making excess thyroid hormone, if we can measure something that’s very specific as a stimulating immune system attack, that would give us a definite diagnosis of Graves disease, but there are different types of tests. So the older tests looked at these TSH receptor antibodies, but didn’t tell us exactly if it was stimulating or blocking, and now we have a test that’s a bioassay, meaning we’re measuring the exact cause of Graves disease, so that’s the TSI or TSH stimulating immunoglobulin that we can measure directly to confirm a diagnosis of Graves disease, and at that same time determine how active the immune system is against the thyroid. So if we know why the thyroid is misbehaving then we can guide treatment better and we can make predictions on outcomes and prognosis.
In my experience with the treatment and management of thyroid disease, patients do very well in large part due to these new innovative tools we have to recognize the autoimmune etiology of thyroid disease, and manage these patients better. So my advice to people who think they might have a thyroid problem is simply talk to your doctor. Call the office, make an appointment, explain what symptoms you’re having, and ask whether or not thyroid testing would be appropriate. I’ve build my practice on helping people with un-diagnosed or mis-diagnosed thyroid issues. If you’re struggling for answers and aren’t feeling quite like yourself, it’s important to talk to your doctor and ask about testing your thyroid. For more information on the antibody tests discussed here today, schedule a time with myself or one of our doctors. We’ll discuss your current situation and talk about the next steps to take.