Conditions related to hypothyroidism might be more common than dental hygienists realize.
Lynn Cortese Radziewicz
It started with a discussion of sleeping poorly among a group of hygienists on the list-serve at amyrdh.com. We discovered that many of us often awoke between 3 and 4 a.m. A common theme developed; many of us were hypothyroid and had also received a diagnosis of Hashimoto’s disease. Soon we discovered the majority of us with “Hashi’s” were seasoned hygienists. The early morning awakening made it apparent that there might be a connection to not only our age, but also to the status of our thyroid function.
What Is Hashimoto’s Disease?
Hashimoto’s is a disease that typically causes the condition of hypothyroidism, but the terms are not identical. Hashimoto’s is the most common term for the autoimmune disorder, which usually involves a slow, steady destruction of the thyroid gland. Antibodies reacting against proteins in the gland will result in this gland becoming unable to produce sufficient thyroid hormone - thus leading to hypothyroidism. Hypothyroidism results from an underactive thyroid gland. Most cases of hypothyroidism are due to autoimmune disease, a complication of an overzealous immune system, with the exception of iodine deficiency, which is rare in the United States. There are other types of thyroid problems including cancer, as well as benign nodules, but most simple hypothyroidism is immune system related.1
Named for the Japanese physician who first identified it in 1912, Hashimoto’s thyroiditis is also referred to as autoimmune thyroiditis or goitrous lymphocytic thyroiditis.2 The question is why do our immune systems go into overdrive and start destroying different parts of our bodies? Undoubtedly it is a mistake for our bodies to be attacking themselves. Once thought to be rare, it has unfortunately become increasingly common. Autoimmune disorders are found predominantly in women. In Hashimoto’s, the ratio is 50:1.3 Hormones are thought to play a part in autoimmune conditions because some illnesses are more prevalent after menopause, some improve during pregnancy with recurrence after delivery, and still others worsen during pregnancy. For those with the disorder in their families, genetics account for 25 to 50 percent of the risk.4 Often families experience clusters of autoimmune disorders, diagnosed with different disorders, but all of an autoimmune nature. One family member may have Sjögren’s syndrome, one may have fibromyalgia, and another may have Hashimoto’s disease. Additionally, other conditions can be associated with Hashimoto’s. See Table 1.2
Even accounting for genetics and hormones, what tips the balance to precipitate an immune system dysfunction? Genetic predisposition alone doesn’t cause the development of the disease, so there must be other factors that help initiate the process. According to recent research, the most likely culprits are:
- nvironmental pollutants, such as the many chemicals that are hormone blockers, hormone mimics and immune disruptors. Among these are PCB’s, dioxins, pesticides, chemicals in paints, varnishes (Alkylphenols) and Bisphenol A, used in plastic manufacturing.5
- Radiation exposure incurred, for example, occupationally, and especially for more than five years duration,6 which endangered hygienists, radiology technicians, and radiation oncology therapists.
- Stress has a strong effect on immune system balance, either intense short term stress, or lower grade chronic stress lasting more than one year.7
Other causes for development of hypothyroidism itself include:8
- Exposure to radiation from medical treatments (radiation treatment to the face, neck or chest, or in the 40s to 60s for treatment of acne, tonsillitis, adenoids, thymus gland problems)
- Environmental factors like those experienced by people who lived near the nuclear accident areas of Chernobyl, Hanford, and Tokaimura
- Overconsumption of isoflavone-intensive soy products such as soy protein capsules, and powders (soy-based infant formulas are considered to be a risk for later development of thyroid problems)
- Certain drugs, such as lithium and the heart drug cordarone
- Surgical treatments for thyroid cancer, nodules or goiter
- Radioactive iodine treatment (RAI) for Graves disease and hyperthyroidism, an overactive thyroid condition for which the treatment itself can cause hypothyroidism
- Overconsumption of uncooked “goitrogenic” foods such as Brussels sprouts, broccoli, rutabaga, turnips, cauliflower, cabbage, radishes, kale and kohlrabi
Autoimmune Thyroiditis Attacks
Dr. Steven Langer, author of the book Solved: The Riddle of Illness, refers to thyroiditis as “arthritis of the thyroid.” Just as arthritis can assault the joints with pain and inflammation, thyroiditis can mean the thyroid gland becomes inflamed, causing anxiety, panic attacks, heart palpitations, difficulty swallowing, and commonly, problems sleeping. Dr. Langer notes thyroiditis attacks typically happen in the middle of the night, which helps explain the inability to sleep well through the night. Some nutrients are known to have a sedative effect. He prescribes calcium and magnesium before bedtime along with either buffered aspirin or ibuprofen to relieve inflammation. About two-thirds of his patients found some relief from their nighttime thyroiditis attacks with this regimen.9
Some studies have shown those with autoimmune thyroiditis can reduce elevated antibody levels with the mineral selenium in doses of 200 mcg per day.8 Doses of more than 200 mcg per day have not been shown to be beneficial, and could, in fact, be harmful. A recent study in the Journal of Clinical Endocrinology and Metabolism also noted that selenium during pregnancy and the postpartum period reduced thyroid inflammatory activity and incidence of hypothyroidism.10
Signs and Symptoms Of Hypothyroidism
Some of the symptoms more commonly associated with hypothyroidism include sensitivity to cold, unexplained weight gain or inability to lose weight, and the tendency to become easily fatigued. As seen in Figure 1, many other signs and symptoms can stem from this condition.11
Lab values for the normal range of TSH (thyroid stimulating hormone) have been updated since 2003. With these changes, it is believed that many more people will be added to the already growing number of those diagnosed. According to the American Association of Clinical Endocrinologists (AACE), until Nov. 2002 many physicians relied on the range of normal for TSH as .05 to 5.0.12 Unfortunately, today, most labs still note the older reference range, leading to continued under-diagnosis.
In their January 2003 press release, AACE stated: “...AACE encourages doctors to consider treatment for patients who are outside the boundaries of a narrower margin based on a target TSH level of 0.3 to 3.0. AACE believes the new range will result in proper diagnosis for millions of Americans who have suffered from a mild thyroid disorder, but have gone untreated until now.”12
Hygienists should encourage people with any thyroid history or symptoms to acquaint themselves with the newer guidelines and speak with their health-care practitioners concerning the lowered values for normal TSH. Many physicians and nurse practitioners in primary care medicine may still be following outdated guidelines, since the majority of laboratories still use the older range of .30 to 5.50 IU/L. (My blood-work done in December 2006 came back with that outdated reference range printed on it.)
It appears that this condition becomes significantly more common in women during the peri-menopause and menopausal years. Over 25 percent of menopausal women in the United States are diagnosed with thyroid dysfunction.11 In addition, low thyroid often goes unnoticed for far too many women with menopause difficulties, according to Drs. Richard and Karilee Shames. These practitioners, authors of the book Thyroid Power, have been treating people with hypothyroidism for over twenty-five years. They further note that not only does low thyroid become more common as women mature, but also with perimenopausal and menopausal changes the levels of thyroid hormone needed may change.8
The late John R. Lee, MD, a well-known author on menopause, believes estrogen dominance and hormone imbalances between progesterone and estrogen are responsible for many of the midlife cases of hypothyroidism. When estrogen is dominant, it blocks the action of thyroid hormone, causing it to be ineffective. The laboratory tests may show normal thyroid hormone levels, because the thyroid gland itself is not faulty.11
Dr. Lee and Christiane Northrup, MD, another well-known researcher on menopause, recommend women with persistent menopause difficulties should be tested and treated for hidden low thyroid. Testing should consist of free T3 and T4 tests in addition to thyroid antibody tests, which may give a better indication of actual thyroid status than testing only TSH levels. With autoimmune hypothyroidism, thyroid function decreases gradually.11
A recent study showed the value of treatment with levothyroxine for people with Hashimoto’s who had normal TSH levels. The researchers found it to be effective in not only reducing autoantibody levels but also in goiter size, which could ultimately reduce the progression to overt autoimmune hypothyroidism.18
Hypothyroidism and Depression
The effects of hypothyroidism on mood have been well documented. T3 is the most active of the four thyroid hormones the thyroid gland produces. It is a neurotransmitter regulating the actions of serotonin, norepinephrine, and GABA (gamma aminobutyric acid), an inhibitory neurotransmitter that is important for quelling anxiety. Large quantities of T3 are found in the limbic system, the area of the brain that is responsible for emotions such as fear, anger and panic.11 If T3 levels are deficient or its action blocked, the normal cascade of neurotransmitters will probably be affected, likely leading to depression and changes of mood and energy. It’s no surprise that autoimmune thyroid can have the profound effect on mood and depression shown in recent research.13,14,15
As a person with thyroid disease, I have found it of utmost importance to be a strong advocate for myself in the treatment of my condition. When I was in my middle 40s, physicians had already identified estrogen replacement as the cure for bone and heart health. At my annual physical I reported my concerns regarding mood and sleep disturbances to my internist. She adamantly believed that peri-menopause was causing my difficulties and sent me home with a prescription for estrogen-replacement and an antidepressant. I could not believe that was the answer to my problems and only took the medications for a few months. After two more years, a nurse practitioner really listened to what I saying. I was finally diagnosed using proper blood tests that showed I had hypothyroidism. I have discovered that my thyroid status is very much tied to my mood. Unlike others with this condition, I have rarely had the common hypothyroid complaints of feeling unusually cold or fatigued.
After much research, I ask for additional labwork with my periodic blood-work, based on my knowledge that the standard TSH value is not the only value necessary for a thorough evaluation. Taking control of my own health, I requested copies of my lab reports so I could see how the lab values correlated with how I was feeling. I quickly realized that I felt my best when my TSH was 1.0 or lower. One physician I spoke with agreed that the TSH should be low, because it means the body is getting sufficient hormone and the thyroid gland isn’t constantly being told to make more. I believed that I should have been feeling better, so I appealed for a change in the brand of my thyroid hormone prescription. Synthroid® or Levoxyl®, synthetic hormones (generically called levothyroxine) containing only T4 thyroid hormone, were not working well enough for me.
Many physicians assume that T4 supplementation is what most patients need. The rationale is that the body takes what it needs of the T4 and converts it into T3. Many people do this quite well. However, some people don’t make that conversion as easily.
For those people, an alternative can be a natural hormone such as Armour®, extracted from porcine thyroid glands. Armour contains T3 and T4 and also contains other things to enhance T4/T3 conversion like calcitonin, T1, and T2 hormones, much the same as our own thyroid glands produce. Thyrolar® is a T3/T4 hormone that is synthetic, or there is also a T3 hormone (for example, Cytomel®, generically called liothyronine) that can be taken in addition to Synthroid or Levoxyl type medications.
What Role Can Hygienists Play?
Thorough head and neck evaluation continues to be of great importance. During this exam, palpate the thyroid gland to check for evidence of nodules or goiter. If you note any kind of thyroid supplementation in the health histories, you should assess the condition of their hair, nails, and any unusual complaints of feeling cold or hoarseness. If the patients are taking any medications for depression, anxiety, pain or even cholesterol-lowering drugs, their thyroid levels and/or medications are not allowing them to feel as well as they could. Hygienists would perform a true professional service by suggesting that these patients explore the possibilities of thyroid dysfunction with their physicians and nurses.
Some physicians believe that fibromyalgia is, in fact, most closely related to under-treated thyroid.16,17 A good friend of mine has had a long standing problem with pain in her muscles, especially around her hips and back. She has some complaints of confusion and lack of mental clarity, commonly described by many people with hypothyroidism as brain fog. I’ve wondered for some time if some of these things could be related to her thyroid levels. Recently her docter increased her dosage of thyroid medication by a small amount to see if she improved. She was happy to note how much her pain levels decreased and how much sharper and clearer her mind felt after this adjustment.
Standard drug information recommends that thyroxine be taken 30 minutes to one hour before breakfast. Recently, a study has noted TSH levels improved markedly by changing the administration times to late evening. Researchers observed increased thyroid hormone concentrations as well as a lowered TSH concentration while TSH circadian rhythms remained intact. The findings were explained as better gastro-intestinal uptake of the hormone during the night.19
Encouraging our patients to seek more information and to discuss alternatives with their health-care providers is well within our role as dental hygienists. Patients who become better informed are much more able and willing to become self-advocates in seeking more effective treatment for this complex but very treatable condition.
Oprah Winfrey noted in an interview on “Good Morning America” in mid-September that she “blew out her thyroid.” She describes what sounds like Hashimoto’s thyroiditis, as the thyroid goes though the stages of a brief period of hyperthyroidism before it slows down again and becomes hypothyroid for good. Although she has not been candid about the specifics of the type of thyroid disorder, given her age (53) and the widespread presence of autoimmune disorders in women during perimenopause and menopause, it is likely that she has had some experience with this type of thyroid problem. I hope that Oprah will use her influence to make this widespread disease more familiar to the public and increase the awareness of the prevalence in women.20
About the Author
Lynn Cortese Radziewicz, RDH, is a graduate of the University of Michigan School of Dental Hygiene and a clinician with more than 35 years experience. She is currently employed in general practice with a talented dentist in Ann Arbor, Mich. Lynn welcomes your comments at [email protected]
1. Shomon, M. “Autoimmune Hypothyroidism A Mind-Body Exploration with Drs. Richard and Karilee Shames” Thyroid-Info. April 23, 2007. Available at: http://www.thyroid-info.com/articles/shamesautoimm.htm Accessed 4/23/07.
2. Fatourechi, V. “Demystifying autoimmune thyroid disease” January 2000. Post Graduate Medicine Online. Available at: http://www.postgradmed.com/issues/2000/01_00/fatourechi.htm Accessed 3/24/07.
3. “Autoimmune Disease and Women” American Autoimmune
Related Diseases Association. Available at: http://www.aarda.org/women.php Accessed 3/24/07.
4. Rose, N. “The Common Thread” American Autoimmune Related Diseases Association. Available at: http://www.aarda.org/infocus_article.php?ID=28 Accessed 3/24/07.
5. “Endocrine Disrupting Pesticides” June 2001. Friends of the Earth. Available at: http://www.foe.co.uk/resource/briefings/endocrine_disrupting.html. Accessed 3/24/07.
6. Völzke,H., Werner, A., Wallaschofski, H., Friedrich, N., Robinson, D., Stefan, K., Kraft, M., John, A., Hoffmann, W. “Occupational Exposure to Ionizing Radiation is Associated With Autoimmune Thyroid Disease” J. Clin. Endocrinol. Metab. published May 10, 2005, doi:10.1210/jc.2005-0286. Available at: http://jcem.endojournals.org/cgi/content/short/jc.2005-0286v1 Accessed 3/24/07.
7. Wein, H. “Stress and Disease: New Perspectives” NIH Word on Health October 2000. Available at: http://www.nih.gov/news/WordonHealth/oct2000/story01.htm. Accessed 3/25/07.
8. Shoman, M. “Solved: Some Common Thyroid Problems Help from Thyroid Expert and Author, Stephen Langer, M.D.” Thyroid-Info. April 23, 2007. Available at: http://thyroid-info.com/articles/drlanger.htm Accessed 4/23/07.
9. Shoman, M. Living Well with Hypothyroidism Harper Resource 2005. Harper-Collins Publishers Inc. pp. 26-41, 145, 359-360
10. Negro, R., Greco, G., Mangieri, T., Pezzarossa, A., Dazzi, D., Hassan, H. “The Influence of Selenium Supplementation on Postpartum Thyroid Status in Pregnant Women with Thyroid Peroxidase Autoantibodies” J. Clin. Endocrinol. Metab. published February 6, 2007, doi:10.1210/jc.2006-1821. Available at: http://jcem.endojournals.org/cgi/citmgr?gca=jcem;jc.2006-1821v1 Accessed 3/25/07.
11. Northrup. C. “Thyroid: What You Need to Know. January 29, 2007. Available at: http://www.drnorthrup.com/womenshealth/healthcenter/topic_details.php?topic_id=59. Accessed 3/23/07.
12. “Over 13 Million Americans with Thyroid Disease Remain Undiagnosed” January 2003. American Association of Clinical Endocrinologists. Available at: http://www.aace.com/newsroom/press/2003/index.php?r=20030118. Accessed 3/23/07.
13. Benevicius, R., Peceliunience, J., Mickuvieneb, N., Benevicius, A., Pope, V., Girlera. S. “Mood immunity assessed by ultrasonographic imaging in a primary health care” Journal of Affective Disorders. Available at: www.jad-journal.com/article/PIIS0165032706002618/abstract. Access 3/23/07.
14. Fountoulakis, K.Iacovides, A. Grammaticos, P, St. Kaprinis, G. Bech, P. “Thyroid function in clinical subtypes of major depression: an exploratory study” March 15, 2004. BioMed Cenral. Available at: http://www.biomedcentral.com/1471-244X/4/6 Accessed 3/25/07.
15. Pop, V., Maartens, L., Leusinik, G., Van Son, N., Knottenerus, A., Ward, A., Metcalfe, R., Weetmen, A. “Are autoimmune thyroid dysfunction and depression related?” Journal of Endocrinology and Metabolism 1998 Available at: http://jcem.endojournals.org/cgi/reprint/83/9/3194.pdf Accessed 3/25/07.
16. Lowe, J., Honeyman, G., Yellin, J. “Lower resting metabolic rate and basal body temperature of fibromyalgia patients compared to health controls” Thyroid Science 2006. Available at: http://www.thyroidscience.com/experimental.studies/papers.2006.pdfs/Lowe.Honeyman.Yellin.2nd.RMR.FM.Study.pdf. Accessed 3/25/07.
17. Moore, E. “The firbromyalgia/hypothyroidism link” Available at: http://www.suite101.com/article.cfm/fibro_friends/107625 Accessed 3/25/07.
18. Shomon, Mary “Treating Hashimoto’s When the TSH is Normal: New Research Says It Can Help” September 7, 2005. Available at http://thyroid.about.com/od/hypothyroidismhashimotos/a/treatmentnormal.htm?nl=1 Accessed 5/6/07.
19. Bolk, N., Visser, T. J., Kalsbeek, A., van Domberg, R. T., Berghout, A. “Effects of evening vs. morning thyroxin ingestion on serum thyroid hormone profiles in hypothyroid patients” January 2007. Clinical Endocrinology. Available at http://www.blackwell-syngergy.com/doi/full/ten.1111/j.1365-2265.2006.02681.x?cookieSet=1. Accessed 5/6/07.
Conditions Associated With Increased Incidence Of Autoimmune Thyroiditis
- Alopecia areata
- Autoimmune polyglandular syndromes (e.g. Addison’s disease, hypoparathyroidism, Type 1 diabetes, ovarian failure)
- Bipolar disorder, independent of lithium exposure
- Celiac disease
- Chronic ulcerative colitis
- Crohn’s Disease
- Down Syndrome
- Hepatitis C infection
- Idiopathic thrombocytopenia
- Idiopathic thrombocytopenic purpura
- Klinefelter’s syndrome
- Mixed connective tissue disease
- Myasthenia gravis
- Polymyalgia rheumatica
- Primary biliary cirrhosis
- Rheumatoid arthritis
- Sjögren’s syndrome
- Systemic lupus erythematosus
- Turner’s syndrome
Additional Signs and Symptoms Of Hypothyroidism11
- Puffy face, hands and feet
- Dry skin and hair
- Hoarse voice
- Elevated cholesterol levels
- Muscle aches, tenderness and stiffness, especially in shoulders and hips
- Pain and stiffness in your joints, swelling in your knees, or small joints of hands and feet
- Tingling in the fingers
- Shortness of breath
- Depression and irritability
- Sleep disturbances
- Problems with attention span or concentration
- Excessive or prolonged menstrual bleeding (especially early in the disease)
- Scarce or absent menstrual flow (later in the disorder)
- Slowed reflexes