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Hashimoto's disease

Overview

Hashimoto's disease is a condition in which your immune system attacks your thyroid, a small gland at the base of your neck below your Adam's apple. The thyroid gland is part of your endocrine system, which produces hormones that coordinate many of your body's functions.

Inflammation from Hashimoto's disease, also known as chronic lymphocytic thyroiditis, often leads to an underactive thyroid gland (hypothyroidism). Hashimoto's disease is the most common cause of hypothyroidism in the United States. It primarily affects middle-aged women but also can occur in men and women of any age and in children.

Doctors test your thyroid function to help detect Hashimoto's disease. Treatment of Hashimoto's disease with thyroid hormone replacement usually is simple and effective.

Thyroid gland

Your thyroid gland is located at the base of your neck, just below the Adam's apple.

Symptoms

You might not notice signs or symptoms of Hashimoto's disease at first, or you may notice a swelling at the front of your throat (goiter). Hashimoto's disease typically progresses slowly over years and causes chronic thyroid damage, leading to a drop in thyroid hormone levels in your blood. The signs and symptoms are mainly those of an underactive thyroid gland (hypothyroidism).

Signs and symptoms of hypothyroidism include:

  • Fatigue and sluggishness
  • Increased sensitivity to cold
  • Constipation
  • Pale, dry skin
  • A puffy face
  • Brittle nails
  • Hair loss
  • Enlargement of the tongue
  • Unexplained weight gain
  • Muscle aches, tenderness and stiffness
  • Joint pain and stiffness
  • Muscle weakness
  • Excessive or prolonged menstrual bleeding (menorrhagia)
  • Depression
  • Memory lapses

When to see a doctor

See your doctor if you develop these signs and symptoms:

  • Tiredness for no apparent reason
  • Dry skin
  • Pale, puffy face
  • Constipation

You'll also need to see your doctor for periodic testing of your thyroid function if:

  • You've had thyroid surgery
  • You've had treatment with radioactive iodine or anti-thyroid medications
  • You've had radiation therapy to your head, neck or upper chest

If you have high blood cholesterol, talk to your doctor about whether hypothyroidism may be a cause.

And if you're receiving hormone therapy for hypothyroidism caused by Hashimoto's disease, schedule follow-up visits as often as your doctor recommends. It's important to make sure you're receiving the correct dose of medicine. Over time, the dose you need to adequately replace your thyroid function may change.

Causes

Hashimoto's disease is an autoimmune disorder in which your immune system creates antibodies that damage your thyroid gland. Doctors don't know what causes your immune system to attack your thyroid gland. Some scientists think a virus or bacterium might trigger the response, while others believe a genetic flaw may be involved.

A combination of factors — including heredity, sex and age — may determine your likelihood of developing the disorder.

Risk factors

These factors may contribute to your risk of developing Hashimoto's disease:

  • Sex. Women are much more likely to get Hashimoto's disease.
  • Age. Hashimoto's disease can occur at any age but more commonly occurs during middle age.
  • Heredity. You're at higher risk for Hashimoto's disease if others in your family have thyroid or other autoimmune diseases.
  • Other autoimmune disease. Having another autoimmune disease — such as rheumatoid arthritis, type 1 diabetes or lupus — increases your risk of developing Hashimoto's disease.
  • Radiation exposure. People exposed to excessive levels of environmental radiation are more prone to Hashimoto's disease.

Complications

Left untreated, an underactive thyroid gland (hypothyroidism) caused by Hashimoto's disease can lead to a number of health problems:

  • Goiter. Constant stimulation of your thyroid to release more hormones may cause the gland to become enlarged, a condition known as goiter. Hypothyroidism is one of the most common causes of goiters. Although generally not uncomfortable, a large goiter can affect your appearance and may interfere with swallowing or breathing.
  • Heart problems. Hashimoto's disease also may be associated with an increased risk of heart disease, primarily because high levels of low-density lipoprotein (LDL) cholesterol — the "bad" cholesterol — can occur in people with an underactive thyroid gland (hypothyroidism). If left untreated, hypothyroidism can lead to an enlarged heart and, possibly, heart failure.
  • Mental health issues. Depression may occur early in Hashimoto's disease and may become more severe over time. Hashimoto's disease can also cause sexual desire (libido) to decrease in both men and women and can lead to slowed mental functioning.
  • Myxedema (miks-uh-DEE-muh). This rare, life-threatening condition can develop due to long-term hypothyroidism as a result of untreated Hashimoto's disease. Its signs and symptoms include drowsiness followed by profound lethargy and unconsciousness.

    A myxedema coma may be triggered by exposure to cold, sedatives, infection or other stress on your body. Myxedema requires immediate emergency medical treatment.

  • Birth defects. Babies born to women with untreated hypothyroidism due to Hashimoto's disease may have a higher risk of birth defects than do babies born to healthy mothers. Doctors have long known that these children are more prone to intellectual and developmental problems. There may be a link between hypothyroid pregnancies and birth defects, such as a cleft palate.

    A connection also exists between hypothyroid pregnancies and heart, brain and kidney problems in infants. If you're planning to get pregnant or if you're in early pregnancy, be sure to have your thyroid level checked.

Diagnosis

In general, your doctor may test for Hashimoto's disease if you're feeling increasingly tired or sluggish, have dry skin, constipation, and a hoarse voice, or have had previous thyroid problems or goiter.

Diagnosis of Hashimoto's disease is based on your signs and symptoms and the results of blood tests that measure levels of thyroid hormone and thyroid-stimulating hormone (TSH) produced in the pituitary gland. These may include:

  • A hormone test. Blood tests can determine the amount of hormones produced by your thyroid and pituitary glands. If your thyroid is underactive, the level of thyroid hormone is low. At the same time, the level of TSH is elevated because your pituitary gland tries to stimulate your thyroid gland to produce more thyroid hormone.
  • An antibody test. Because Hashimoto's disease is an autoimmune disorder, the cause involves production of abnormal antibodies. A blood test may confirm the presence of antibodies against thyroid peroxidase (TPO antibodies), an enzyme normally found in the thyroid gland that plays an important role in the production of thyroid hormones.

In the past, doctors weren't able to detect an underactive thyroid (hypothyroidism), the main indicator of Hashimoto's disease, until symptoms were fairly advanced. But by using the sensitive TSH test, doctors can diagnose thyroid disorders much earlier, often before you experience symptoms.

Because the TSH test is the best screening test, your doctor will likely check TSH first and follow with a thyroid hormone test if needed. TSH tests also play an important role in managing hypothyroidism. These tests also help your doctor determine the right dosage of medication, both initially and over time.

Treatment

Treatment for Hashimoto's disease may include observation and use of medications. If there's no evidence of hormone deficiency, and your thyroid is functioning normally, your doctor may suggest a wait-and-see approach. If you need medication, chances are you'll need it for the rest of your life.

Synthetic hormones

If Hashimoto's disease causes thyroid hormone deficiency, you may need replacement therapy with thyroid hormone. This usually involves daily use of the synthetic thyroid hormone levothyroxine (Levoxyl, Synthroid, others).

Synthetic levothyroxine is identical to thyroxine, the natural version of this hormone made by your thyroid gland. The oral medication restores adequate hormone levels and reverses all the symptoms of hypothyroidism.

Treatment with levothyroxine is usually lifelong, but because the dosage you need may change, your doctor is likely to check your TSH level about every 12 months.

Monitoring the dosage

To determine the right dosage of levothyroxine initially, your doctor generally checks your level of TSH after a few weeks of treatment. Excessive amounts of thyroid hormone can accelerate bone loss, which may make osteoporosis worse or add to your risk of this disease. Overtreatment with levothyroxine can also cause heart rhythm disorders (arrhythmias).

If you have coronary artery disease or severe hypothyroidism, your doctor may start treatment with a smaller amount of medication and gradually increase the dosage. Progressive hormone replacement allows your heart to adjust to the increase in metabolism.

Levothyroxine causes virtually no side effects when used in the appropriate dose and is relatively inexpensive. If you change brands, let your doctor know to ensure you're still receiving the right dosage.

Also, don't skip doses or stop taking the drug. If you do, signs and symptoms will gradually return.

Effects of other substances

Certain medications, supplements and some foods may affect your ability to absorb levothyroxine. However, taking levothyroxine four hours before or after other medications could remedy the problem. Talk to your doctor if you eat large amounts of soy products or a high-fiber diet or if you take any of the following:

  • Iron supplements, including multivitamins that contain iron
  • Cholestyramine (Prevalite), a medication used to lower blood cholesterol levels
  • Aluminum hydroxide, which is found in some antacids
  • Sucralfate, an ulcer medication
  • Calcium supplements

Is a combination of hormones needed?

Levothyroxine is the synthetic form of the natural T-4. T-4 is converted into T-3 in the body. While most people are treated successfully with levothyroxine alone, some people don't feel completely normal on levothyroxine.

Researchers have investigated whether adjusting standard hypothyroidism treatment to replace some T-4 with small amounts of T-3 may offer benefit. But, the majority of studies have determined that the addition of T-3 does not offer any advantage over treatment with T-4 alone.

There is some evidence that T-3 may offer benefit to certain subsets of people, such as people who have had their thyroid surgically removed (thyroidectomy). Research is ongoing.

T-3 can be given alone as liothyronine (Cytomel) or in combination with T-4 as liotrix (Thyrolar). Taking a combination T4 and T3 ends up producing higher than normal levels of T3, especially soon after the medication is taken. This can cause a fast heart rate, anxiety and trouble sleeping.

But, for those who haven't gotten enough relief from T-4 alone, adding Cytomel to standard levothyroxine treatment for a three- to six-month trial is a long enough period to see if the combination helps you.

Alternative medicine

Standard treatment for Hashimoto's disease is levothyroxine, the synthetic form of thyroxine (T-4). However, extracts are available that contain thyroid hormone derived from the thyroid glands of pigs. These products — Armour Thyroid, for example — contain both levothyroxine and triiodothyronine (T-3).

Doctors have a number of concerns about thyroid hormone extracts such as Armour Thyroid, including:

  • The balance of T-4 and T-3 in animals isn't the same as in humans.
  • The exact amount of T-4 and T-3 in each batch of a natural extract product can vary, leading to unpredictable levels of these hormones in your blood.

Preparing for an appointment

You're likely to start by seeing your primary care doctor. Your doctor may refer you to a specialist called an endocrinologist.

Here's some information to help you prepare for your appointment and to know what to expect from your doctor.

What you can do

  • Be aware of any pre-appointment restrictions. When you make your appointment, ask if there's anything you need to do to prepare for common diagnostic tests.
  • Write down any symptoms you're experiencing, including any that may seem unrelated to the reason for which you scheduled the appointment. For example, if you've been feeling more forgetful than usual, this is important information to share with your doctor. Also tell your doctor about changes you've noticed in your physical appearance, such as unexplained weight gain or a difference in your skin.
  • Write down key personal information, including any changes in your menstrual cycle and in your sex life. Let your doctor know if your libido has changed.
  • Make a list of all medications, vitamins or supplements you're taking or have used in the past. Include the specific name and dose of these medications and how long you've been taking them.
  • Take a family member or friend along, if possible. Someone who accompanies you may remember something that you missed or forgot.
  • Write down a list of questions to ask your doctor.

Create a list of questions so that you can make the most of your time with your doctor. For Hashimoto's disease, some basic questions to ask your doctor include:

  • What's the most likely cause of my symptoms?
  • What tests do I need?
  • Is this condition likely temporary or long lasting?
  • What treatment do you recommend?
  • How long will I need to take medications?
  • What side effects could I experience from the medications you're recommending?
  • How will you monitor whether my treatment is working?
  • Will I experience long-term complications from this condition?
  • Do I need to change my diet?
  • Will exercise help?
  • I have other health conditions. How can I best manage these conditions together?
  • Should I see a specialist?
  • Is there a generic alternative to the medicine you're prescribing?
  • Are there brochures or other printed material I can take with me? What websites do you recommend?

Don't hesitate to ask other questions that occur to you.

What to expect from your doctor

Examples of questions your doctor may ask, include:

  • What are your symptoms, and when did you first notice them?
  • How have your symptoms changed over time?
  • Have you noticed changes in your energy level or your mood?
  • Has your appearance changed, including weight gain or skin dryness?
  • Has your voice changed?
  • Have your bowel habits changed? How?
  • Do you have muscle or joint pain? Where?
  • Have you noticed a change in your sensitivity to cold?
  • Have you felt more forgetful than usual?
  • Has your interest in sex decreased? If you're a woman, has your menstrual cycle changed?
  • Are you being treated or have you recently been treated for other medical conditions?
  • Do any of your family members have thyroid disease?

Last updated: November 17th, 2016

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