Homeopathic Perspective on Thyroid Disorder
Author : Dr. R. K. Manchanda, MD (HOM), MBA (Health Care), Deputy Director (Homoeopathy), Directorate of ISM & Homoeopathy, Government of NCT of Delhi
ANATOMY OF THYROID GLAND5
FUNCTIONS OF THYROID GLAND6
Thyroid palpation Method
DIAGNOSING VARIOUS THYROID DISORDERS
- Complete homoeopathic case taking.
- Family history of systemic disorders particularly thyroid and autoimmune disorders. It is seen that the individuals who have family history positive of thyroid dysfunction are at greater risk of developing thyroid disorders.
- Consistancy and size of thyroid gland, as it may give us some hint about the underlying pathology, e.g. firm gland are suggestive of Hashimoto's thyroiditis, goiter in high grades can induce pressure symptoms on trachea and other adjacent tissues, painful gland suggests acute or subacute inflammatory condition.
- Presence of anti thyroid antibodies, may suggest some of the thyroid dysfunction.
- Other investigations also help in arriving at diagnosis of thyroid disorders. Some of the investigations are: Radioactive iodine uptake (RAIU), Technetium scan (Tc Scan), Fine needle biopsy (FNB). These investigations are condition specific and are to be advised as per requirement of the case. The detailed description of these investigative modalities is described later in the following text.
- Estrogen therapy
- Oral contraceptive pills
- Acute viral hepatitis
- Primary biliary cirrhosis
- Hepatocellular cancer
- Collagen vascular disease
- Nephrotic syndrome
- Protein-losing enteropathy
- Critical illness/starvation
|TSH||Most reliable marker to assess thyroid dysfunction with FT4 as TSH is the precursor of release of FT3 & FT4|
|Free T3, T4||Circulating un-bound hormone assays depicts the actual level of thyroid hormones thus prognosis can further be made along with the clinical and confirmed diagnosis.|
|Antibodies: Anti-TPO, Anti-TSHr||Presence of antibodies may sometime help us to understand the natural history of thyroid functions, as their presence confirms the undergoing pathological conditions.|
|Thyroid ultrasonography||Thyroid Ultrasonography is done to see the consistency of thyroid gland. It is also done to rule out the presence of nodules. Ultrasonography can also be suggestive of congenital anomalies e.g. absence of one or both lobes of thyroid gland.|
|RAIU||Scintillation counter measures radioactivity after
I123administration. Uptake varies greatly by iodine status, e.g.
indigenous diet (normal uptake 10%).
Elevated RAIU with hyperthyroid symptoms may be presented in:
|Technetium scan (Tc Scan)||Technetium scan is also based on the uptake phenomenon of Tc by thyroid gland that is then use to differentiate various nodules and hyper functioning and hyperactive thyroid gland.|
|Final Needle Biopsy (FNB)||FNB is used to study the morphological and pathophysiology of glandular tissue. By this technique we can differentiate various types of carcinomas, dysplasia, and chronic lymphatic infiltration.|
- TSH is a good screening test to assess thyroid function in an outpatient setting.
- If TSH is abnormal, the diagnosis is confirmed with thyroid hormone levels.
- Change in thyroid binding proteins could alter total thyroid hormone levels.
- 99% of thyroid hormones are protein bound.
- In order to assess the thyroid hormone levels unaffected by the binding proteins, free thyroid hormone levels assessment is more reliable.
- T4 is the major thyroid hormone in circulation; therefore assessing T4 status alone is usually sufficient to assess the thyroid hormone status.
- In certain situations, T3 level becomes abnormal without changes in T4, as in T3 thyrotoxicosis where there are elevated levels of T3 along with normal T4 levels and low TSH level.
- Acute illnesses can alter thyroid function tests without thyroid disease as they tend to increase binding proteins, also TSH can also be influenced by stress and anxiety.
- Thyroglobulin is a good cancer marker for papillary and follicular cancer after total thyroidectomy.
- Thyroid antibodies can assess the risk of developing autoimmune thyroid diseases.
SPECTRUM OF THYROID DISORDERS7
- Endemic goiter-Areas where > 5% of children of 6-12 years of age have goiter, very common in China and central Africa.
- Sporadic goiter -Areas where < 5% of children 6-12 years of age have goiter. Multinodular goiter in sporadic areas often denotes the presence of multiple nodules rather than gross gland enlargement.
- Hashimoto's thyroiditis
- Early stages only, late stages show atrophic changes
- May present with hypo, hyper or euthyroid states
- Graves' disease - Due to chronic stimulation of TSH receptor
- Diet - Brassica (cabbage, turnips, cauliflower, broccoli), Cassava, Lithium prevents release of hormone, causes goiter in 6% of chronic users
- Chronic Iodine excess - Iodine excess leads to increased colloid formation and can prevent hormone release. If a patient does not develop iodine leak, excess iodine can lead to goiter.
- Palpable: 4-7%
- Non-Palpable: >50%
- Cancer in nodules: 5%
- Women affected more than men
- Most subjects are euthyroid and/or asymptomatic
- Prevalence is less than 1% with thyrotoxicosis
- Historical Red Flags are defined as:
- Extremes of age (<20 or >65)
- Rapid Growth
- Symptoms of local invasion (hoarseness, dysphagia, neck pain)
- History of radiation to the head or neck dispose an individual to develop nodules
- Family history of Thyroid Cancer or Polyposis
SOLITARY THYROID NODULE
- More likely to be malignant in men, patients over 60 and patients with a h/o head or neck irradiation are at more risk.
- No growth for years almost always indicative of benign nodule as it is not a nodule that appears suddenly (likely a cyst or adenoma hemorrhage)
- Malignant nodule develops in weeks to months.
- Virtually all patients with thyroid carcinoma are euthyroid as are those with benign nodules. Nodule of >1.5 cms., are usually detectable on examination and are confirmed in the Ultrasonography. Lifetime risk for developing a nodule is 5-10%. Studies show 50% of people during autopsy have either single or multiple nodules. 5-10% of clinically detectable hypofunctioning (cold) nodules can be malignant. The laboratory/imaging techniques used are: TSH, Calcitonin, Ultrasound, FNB for characterization of Nodules, Nuclear Scan to see whether nodule is "Hot" or "Cold." If FNB is suggestive of malignancy then surgery is advised, and if it is suspicious or negative then a follow up of few months is given to the patient with repeat investigations. In case there are indeterminant reports then FNB is repeated, if still indeterminant, surgery is recommended.
- Worldwide - iodine deficiency is most common cause.
- Iodine depleted areas - chronic autoimmune thyroiditis is commonly present in these areas.
- Associated with elevated serum cholesterol, CPK, AST and LDH
- Also referred to as central or hypothyrotropic hypothyroidism.
- Caused by either pituitary or hypothalamic diseases.
- Very uncommon.
- TSH is usually low or inappropriately normal.
Symptoms of hypothyroidism
- Low FT4, High TSH (Primary, antibodies estimation suggested)
- Low FT4, Low TSH (Secondary or Tertiary, TRH stimulation test, MRI)
- It is the most common cause of hypothyroidism.
- It is due to action of auto- antibodies to TPO, TBG thus by inhibiting/diminishing the production and secretion of thyroid hormones.
- Commonly presents in subjects from 30-50 yrs, female affected more than males.
- It is usually non-tender and asymptomatic.
- Lab values
- High TSH
- Low T4
- Anti-TPO Ab, Anti-TBG Ab
SILENT THYROIDITIS (POST-PARTUM THYROIDITIS)
SUBACUTE THYROIDITIS (DEQUERVAIN'S, GRANULOMATOUS)
- It starts with pain and thyrotoxicosis (3-6 weeks) followed by asymptomatic euthyroidism.
- Then there is period of hypothyroid state(weeks to months).
- It is followed by phase of recovery (complete in 95% after 4-6 months).
- Elevated ESR
- Anemia (normochromic, normocytic)
- Low TSH, Elevated T4 > T3, Low anti-TPO/Tgb
- Low RAI uptake (same as silent thyroiditis)
- Graves' disease may occasionally develop as a late sequellae
- 68% Bacterial (S. aureus, S. pyogenes)
- 15% Fungal
- 9% Mycobacterial
- Warm, tender, enlarged thyroid
- FNA to drain abscess, obtain culture
- RAIU normal (versus decreased in DeQuervain's)
- CT or US if infected TGDC suspected
- Thyroid antibodies are present in 2/3
- Painless goiter "woody"
- Open biopsy often needed to diagnose
- Associated with focal sclerosis syndromes (retroperitoneal, mediastinal, retroorbital, and sclerosing cholangitis)
- TSH, T4, T3 to establish toxicosis
- RAIU scan to differentiate toxic conditions
- Anti-TPO, Anti-TSAb, FT3 if indicated
|RAIU in Hyperthyroid States|
|High Uptake||Low Uptake|
|Graves'||Sub acute Thyroiditis|
|Toxic MNG||Iodine Toxicosis|
|Toxic Adenoma||Thyrotoxicosis factitia|
- Dynamic- Euthyroid autoimmune thyroiditis.
- Functional- initial stages of autoimmune/Hashimoto thyroiditis, Subclinical hypothyroidism and Subclinical hyperthyroidism.
- Patho-physiological- Goitre, Hashitoxicosis, Chronic lymphocytic infiltration of thyroid, Non-malignant Nodules.
- Pathological- Hypothyroidism, Graves' disease, Thyrotoxicosis.
- Destructive- Malignancies, toxic nodules.
- Other systemic disorders e.g. Diabetes mellitus, Hypertension, Metabolic syndrome, dyslipidemia etc
- Autoimmune disorders e.g. SLE, vitiligo
- Any history of previous thyroid disorders e.g. Hashimoto thyroiditis, thyroid nodules, autoimmune thyroiditis, etc.
- Other endocrinal disorders e.g. PCOS, prolactinoma, Cushing syndrome, etc.
LEVELS OF PREVENTION OF THYROID DISORDERS
- Regular exercise
- Desirable BMI
- Health promotive measures and attitude
- Identifications and elimination of exciting or precipitating factors, if any.
- Early diagnosis and treatment.
- Reinforce primary and preventive measures.
- Identifications and elimination of exciting or precipitating factors, if any.
- Primary and secondary risk intervention.
- Secondary prevention: lipid profile within normal limits
- Aggressive and effective control of disease.
- Disability limitation
TREATMENT GUIDELINES FOR PHYSICIANS
WHEN TO CONSULT AN ENDOCRINOLOGIST
- Graves' disease
- Multinodular goiter
- Single palpable nodule
- Central disease (pituitary or hypothalamic)
- Patients resistant to therapy
STUDIES ON HOMOEOPATHY AND THYROID DISORDERS
- Does a homeopathic ultramolecular dilution of Thyroidinum 30cH affect the rate of body weight reduction in fasting patients? A randomised placebo-controlled double-blind clinical trial.(Homeopathy, 2002; 91(4):197-206 (ISSN: 1475-4916) Schmidt JM; Ostermayr B, Krankenhaus für Naturheilweisen, Munich, Germany.9
- Homeopathically prepared dilution of Rana catesbeiana thyroid
glands modifies its rate of metamorphosis. (Homeopathy, 2004;
93(3):132-7 (ISSN: 1475-4916) Guedes JR; Ferreira CM; GuimarÃ£es HM;
Saldiva PH; Capelozzi VL
Laboratory of Molecular Pathology, University of SÃ£o Paulo School of Medicine, SP, Brazil.10
- THYROIDINUM, A PROVING (HYGANTHROPHARMACOLOGY). J Am Inst Homeopath. 1964; 57:201-7 (ISSN: 0002-8967) PANOS M; ROGERS R; STEPHENSON J.11
- Pharmacologic and alternative therapies for the horse with chronic
laminitis. Vet Clin North Am Equine Pract. 1999; 15(2):495-516, viii
(ISSN: 0749-0739) Sumano LÃ³pez H; Hoyas SepÃºlveda ML; Brumbaugh GW.
Departamento de FisiologÃa y FarmacologiÃ¡, Facultad de Medicina Veterinaria y Zootecnia, Universidad Nacional AutÃ³noma de MÃ©xico, MÃ©xico DF, MÃ©xico.12
- To evaluate the efficacy of homoeopathic treatment in sub clinical hypothyroidism (SCH). A single blind case control 18 months follow-up pilot study at NHMC & Hospital and Institute of Nuclear Medicine & Allied Sciences, Delhi, India under Dilli Homoeopathic Anusandhan Parishad (DHAP) revealved remarkable results about management of children on subclinical hypothyroidism.13
- V. Leoutsakos, A short history of the thyroid gland, Dept of Surgery Athens University School of Medicine, Athens, 115 27 Greece.
- Encyclopedia Homeopathica, Version 2.2.2
- RADAR 10, Apex Version.
- Thyroid gland development and defects, Kratzsch J, Pulzer F., Institute of Laboratory Medicine, Clinical Chemistry and Molecular Diagnostics, University Hospital, Paul-List-Str. 13-15, D-04103 Leipzig, Germany.
- Grant's Atlas of Anatomy, Twelfth edition, Anne M. R. Agur
- Guyton & Hall Textbook Of Medical Physiology 11th_Edition
- Harrisons textbook of medicine, 17th edition.
- Organon of Medicine, Samuel Hahnemann, 5th edition, Publisher B. Jain.
- Homeopathic Journal :: Volume: 5, Issue: 4, Feb 2012 (New Papers) - from Homeorizon.com