The disease is more common in the female population and requires continuous monitoring. Understand.
Hypothyroidism is a dysfunction of the thyroid gland in which there is a decrease in the production of thyroid hormones, leading to a slowdown in metabolism. The disease can affect anyone of all ages, including newborns, but is more common in women and the elderly. Hypothyroidism affects 8% to 12% of the Brazilian population.¹
The disorder can be caused by a number of conditions, such as autoimmune diseases, surgical removal of the thyroid, radiation therapy, thyroiditis (inflammation of the thyroid), changes in the level of iodine in the body and some medications, and can also be congenital (when the person is born with the disease).² The most common cause of hypothyroidism is Hashimoto’s thyroiditis , an autoimmune disease in which antibodies produced by the body itself attack thyroid cells.
The symptoms of the disease are often nonspecific and can be confused with those of other health problems. However, in some cases, they can have a significant impact on patients’ quality of life and daily routine. Treating hypothyroidism is essential to maintain thyroid hormone levels and prevent possible complications.
Symptoms and impact on quality of life
Symptoms of hypothyroidism can include weight gain, fatigue, constipation, dry skin, intolerance to cold, muscle pain, among others.⁴ “Hypothyroidism causes a series of symptoms that can be quite serious, leading the patient to a coma and, eventually, death. However, this only occurs in individuals with very prolonged hypothyroidism and is triggered by special situations, such as extreme cold or stress,” explains Laura Sterian Ward, an endocrinologist certified by the Brazilian Society of Endocrinology and Metabolism (SBEM) and full professor at the Faculty of Medical Sciences at the State University of Campinas (FCM-Unicamp).
But most cases are not very symptomatic. “In fact, we call most [cases] subclinical hypothyroidism, because the symptoms are not very characteristic. These are symptoms that appear in a series of other diseases besides Hashimoto’s thyroiditis, which is the most common cause of hypothyroidism. These symptoms even appear in conditions related to lifestyle, mainly [because of] the agitation and stress that we live in today. For example, fatigue, tiredness, lack of energy. Complaints of dry skin, hair loss, weak nails, slow bowel movements are also common. Sometimes, during a physical examination, dry, paler skin, peripalpebral edema [swelling of the eyelids], and occasionally bradycardia [slow heart rate] are noted,” explains the endocrinologist.
However, depending on the intensity of the symptoms, the quality of life of patients can be significantly affected. According to the specialist, the symptoms can reduce the person’s physical and mental capacity, in addition to affecting mood, causing memory deficit, the so-called brain fog (in free translation, mental fog, which means a state of forgetfulness and lack of focus) and sadness, which is often confused with depression.
“Hypothyroidism can significantly affect a person’s life. Thyroid hormones regulate the functioning of several organs in the body, and in hypothyroidism these hormones are produced at insufficient levels, which affects the normal functioning of the body as a whole,” says Camila Matsumoto, medical manager at Sanofi.
Housewife Marislene Gonçalves, 33, was diagnosed with hypothyroidism in 2019, during her pregnancy. Her symptoms included weight gain, fatigue and excessive sleepiness that interfered with her daily activities, including her job at the time. “At my workplace, I often had to sit down and ‘take a nap’ because I was so sleepy. I weighed 115 kilos during pregnancy, whereas before that I weighed 97”, she says.
Diagnosis: clinical evaluation and exams
Hypothyroidism is usually diagnosed through a combination of a clinical evaluation by a doctor and blood tests. “During the consultation, the doctor may perform a physical exam, ask about symptoms and order blood tests to measure levels of thyroid-stimulating hormone (TSH) and thyroxine (T4). If TSH levels are high and T4 levels are low, the patient may have hypothyroidism. Other tests may be necessary to confirm the diagnosis and determine the causes, such as antibody tests for thyroid enzymes or a thyroid ultrasound,” explains Camila.
“TSH, the thyroid-stimulating hormone, is a hormone secreted by the pituitary gland and is a good indicator of the thyroid gland’s hormone production. This is a test that can be used to screen for hypothyroidism, but it should be ordered with caution, since the symptoms of hypothyroidism may not be caused by hypothyroidism, but rather by a series of other diseases and conditions that lead to similar symptoms,” explains Dr. Laura.
The endocrinologist explains that, although it is a very sensitive and effective test for diagnosing the disease, TSH may be altered due to factors such as the patient’s age and weight or thyroiditis that arises from viral infections, for example. She recalls that temporary changes in TSH levels were frequent during the COVID-19 pandemic in patients with severe infections. “Therefore, it is essential to remember that a single altered TSH does not establish a diagnosis, unless, evidently, it is an extremely high TSH and associated with a well-defined clinical picture. In most cases, this is not the case. We need to repeat the TSH after at least three to four months to rule out the hypothesis that it was a temporary elevation of the hormone.”
“In clinical hypothyroidism, in addition to elevated TSH, free T4, which is the circulating hormone, is also altered. Typically, TSH rises and free T4 falls. And so we have clinical hypothyroidism. But most of the cases we currently diagnose are subclinical hypothyroidism, in which TSH is elevated, but free T4 is normal,” he adds.
After presenting symptoms of the disease, it was through these tests that Marislene confirmed that she had a thyroid dysfunction. “I was diagnosed by the obstetrician during my pregnancy. I did the tests that confirmed the malfunctioning of the thyroid. Later, I was referred to the endocrinologist. I did all my prenatal care as a high-risk baby, and the doctor even told me that my son only didn’t die by a miracle. But thank God, everything went well. The birth was also calm. Today he is five years old and healthy,” she says.
It is worth noting that hypothyroidism can affect fertility and, without proper treatment, can be associated with complications during pregnancy and problems for the baby.
Treatment carried out with hormone replacement therapy
Hypothyroidism is treated by replacing thyroid hormones. Dr. Laura emphasizes that in cases of subclinical hypothyroidism, the doctor needs to evaluate several factors – such as age and cardiovascular risk, for example – before recommending hormone replacement and the appropriate dosage for the patient.
“Hormone replacement therapy for patients with hypothyroidism is relatively simple, widely available and relatively inexpensive. What all medical societies recommend is the administration of the hormone that the thyroid produces in the form of a daily tablet. With the hormone properly ingested – that is, it has to be taken on an empty stomach because the tablet needs to be disintegrated and dissolved in the stomach in order to be absorbed by the intestine – the patient’s TSH levels return to normal and all symptoms disappear. It is a very effective treatment,” he says.
After taking the medication on an empty stomach (it is recommended to always take it with water and not with other drinks, nor to take any other medication at the same time), the patient must wait at least 30 minutes to have breakfast. To make sure you don’t forget to take it, the tip is to establish a routine and create a strategy, such as setting a reminder on your cell phone at the same time every day, leaving the pills on the table next to the bed, or even next to the toothbrush.
“But follow what your doctor has advised. Don’t keep changing brands and never change the dose of the hormone, because this dose was calculated based on your age, weight and physiological conditions. And there are several conditions in which the dose can be increased, because the need increases, for example, during pregnancy, or in children during growth; while in elderly individuals the dose is usually reduced because the need [for the hormone] decreases”, he explains.
The disease is usually monitored by an endocrinologist, but other specialists may also be involved, such as a general practitioner and gynecologist, who often participate in the initial diagnosis and monitor the treatment, as explained by Camila, from Sanofi. “In some cases, when hypothyroidism is associated with depression or anxiety, a psychiatrist or psychologist can offer support in controlling psychological symptoms. Other health professionals can also support the patient in their treatment journey. The pharmacist can answer questions and provide guidance on how to take the medication correctly and ensure better adherence to treatment, nutritionists and physical educators can offer guidance on lifestyle and diet changes,” she says. Sanofi has the Conecta channel , a website with various educational content on health and well-being, aimed at health professionals, patients and the general public.
Importance of adherence to treatment
Hypothyroidism is a chronic condition. As such, its treatment is usually lifelong. Therefore, it is essential that patients adhere to treatment and follow-up of the disease.
“Unfortunately, daily practice is not that simple. As with all chronic diseases, taking a pill every day, and usually for the rest of your life, is complicated. We know from Brazilian data, published in a high-impact international journal, that around 40% of our patients are not in what we call the therapeutic target, that is, they are not being adequately treated. They are taking an insufficient dose of the hormone, or even worse, an excessive dose,” warns Dr. Laura.
The specialist emphasizes that, without adequate treatment (that is, using the appropriate dose of hormone, as prescribed by the doctor following the case), the patient is subject to complications of the disease, such as a greater risk of cardiovascular problems – such as heart attack and stroke – and bone changes, such as loss of bone mass and even fractures.
“Knowing your symptoms, the importance of treatment and how the medication works can help patients understand the importance of following the treatment correctly,” says Camila.
Furthermore, treatment tends to become easier over time. At first, it may be necessary to return to the doctor more frequently, until the ideal adjustment of the hormone dose is made to normalize TSH levels. “By returning to the doctor in a shorter period of time, the doctor can ensure that TSH levels are at the desired target more quickly and also that the patient is adhering and taking the medication correctly, which allows symptoms to be controlled more quickly. After this initial adjustment in treatment, follow-up visits can be spaced out every six months and once the treatment is stabilized, to once a year,” adds the spokesperson.
Today, Marislene continues to receive medical care and takes daily hormone replacement therapy to keep the disease under control. “The problem is currently stable. I have regular check-ups with an endocrinologist. I feel much better, more energetic and my sleep has also improved a lot,” she says.