An overview of subclinical hypothyroidism and homoeopathic management

Dr Ashna.E

ABSTRACT
The thyroid gland is an endocrine gland which is situated in the lower part of the front and sides of the neck with rich blood supply. Thyroid gland disorders are the most abundant disorders worldwide next only to diabetes mellitus. Subclinical hypothyroidism is the term used to describe this condition, which has a high TSH level and normal free T4 and T3 level. Patients are commonly presented with symptoms like slowness of thinking, muscle cramps, memory impairment, tiredness, muscle weakness, feeling colder, dry skin, puffy eyes, hoarseness of voice, and constipation. Management of the cases can be done using homoeopathic medicines.

INTRODUCTION
Subclinical hypothyroidism is characterized by abnormal thyroid stimulating hormone (TSH) levels in presence of normal total free thyroxine (T4) or triiodothyronine (T3).¹

Thyroid gland disorders are the most abundant disorders worldwide next only to diabetes mellitus.² It has been estimated that about 42 million people in India suffer from thyroid disease.³The prevalence of subclinical hypothyroidism in south India is around 9.4%.¹

Subclinical hypothyroidism (SCH) is divided into two groups according to the elevated level of  serum thyroid stimulating hormone (TSH). These are mildly increased TSH levels (4.0–10.0 m U/l) and more severely increased TSH value (>10m U/l).⁴

Mild levels of increased thyroid stimulating hormone (4 to 10mIU/l) are seen in 90% of patients with Subclinical Hypothyroidism. The consequences of Subclinical Hypothyroidism include increased risk of cardiovascular diseases such as coronary artery diseases, dyslipidemia, neuropsychiatric symptoms, liver diseases and it may lead to miscarriages, sub fertility and low birth weight. Patients with Subclinical Hypothyroidism are frequently presented with symptoms like slowness of thinking, muscle cramps, memory impairment, tiredness, muscle weakness, feeling colder, dry skin, puffy eyes, hoarseness of voice, and constipation.⁵

RISK FACTORS FOR DEVELOPING SCH^6,7

• Gender: Higher prevalence in women than in men.
• Estrogen: Increased level of thyroid binding protein and TSH are seen in postmenopausal women with hormone replacement therapy.
• Age: Prevalence of SCH increases with increasing age.
• Excess iodine intake: SCH is more common in iodine sufficient areas. Normal thyroid function is reduced due to excessive iodine intake via a direct toxic effect or via immunological alterations
• Racial difference: Serum TSH concentrations are higher in whites than in blacks.
• Cigarette smoking: Active smokers have low levels of TSH. Cigarette smoking was negatively associated with SCH.
• Seasonal variations: Increased in cases of cold weather.
• Hashimoto thyroiditis: Inflammation of thyroid gland produced by antibodies against thyroid cells.
• Recent pregnancy and child delivery.
• Treatment of irregular heart rhythm with amiodarone.
• Treatment with lithium.
• Recent treatment with radioactive iodine, interferone alfa, and interleukin 2.

AETIOLOGY OF SUBCLINICAL HYPOTHYROIDISM⁸

Causes of subclinical hypothyroidism are;

• Chronic autoimmune thyroiditis.
• Persistent TSH increase in subacute thyroiditis, painless thyroiditis, postpartum thyroiditis
• Thyroid injury: Radioactive iodine therapy, external head and neck radiotherapy, partial thyriodectomy, or other neck surgery.
• Iodine and iodine-containing drugs (amiodarone, radiographic contrast agents), lithium carbonate, cytokines (particularly interferone), aminoglutetimide, ethionamide, sulfonamides,and sulfonylureas are among the pharmaceuticals that affect thyroid function.
• Inadequate replacement therapy for overt hypothyroidism – Inadequate dosage, noncompliance, drug interactions (iron, calcium carbonate, cholestyramine, dietary soy, fiber, etc), increased T4 clearance (phenytoin, carbamazepine, Phenobarbital etc), malabsorption.
• Thyroid infiltration – Amyloidosis, sarcoidosis, hemochromatosis, riedel’s thyroiditis, cystinosis, AIDS, primary thyroid lymphoma.
• Central hypothyroidism with impaired TSH bioactivity
• Toxic substances, environmental and industrial agents.
• TSH receptor gene mutations

PATHOPHYSIOLOGY OF SUBCLINICAL HYPOTHYROIDISM⁹

• The direct iodine toxicity to thyrocytes caused by oxidative stress is the postulated mechanism of SCH. The thyroid peroxidase enzyme quickly oxidizes the elevated iodine concentration in the dysplastic thyrocytes, resulting in the production of oxidative intermediates of iodine. Due to the interaction of proteins, lipids, and nucleic acids, these oxidative intermediates become too reactive and harm thyrocytes and the mitochondrial membrane by generating iodo compounds. These reactive intermediates’ production results in oxidative stress, which leads to thyrocyte necrosis. Therefore, consuming too much iodine triggers the apoptotic or death process in thyrocytes and results in thyroid autoimmunity.

CATEGORIES OF SUBCLINICAL HYPOTHYROIDISM⁴

According to the elevation of serum thyroid stimulating hormone, subclinical hypothyroidism is considered in two categories:

1. Mildly increased TSH levels (4.0-10.0mU/l)
2. Severely increased TSH value (>10mU/l)

CLINICAL FEATURES OF SUBCLINICAL HYPOTHYROIDISM¹⁰

         Table no.1: Signs and symptoms of subclinical hypothyroidism¹⁰

Signs	Symptoms
Hoarseness     Constipation     Cognitive dysfunction     Generalized swelling     Weight gain      Lower amplitude of stapedial reflex	Slow thinking     Muscle weakness     Poor memory     Muscle cramps     Depression     Fatigue     Anxiety     Cold intolerance

DIAGNOSIS OF SUBCLINICAL HYPOTHYROIDISM¹¹
When assessing thyroid function, the WHO recommends sensitive TSH assays as the first line of investigation. Free T4, free T3, and anti-TPO antibodies for differential diagnosis of thyroid diseases. TSH assays are crucial for determining the presence or absence of symptoms in subclinical hypothyroidism, which is characterized by an isolated increased serum TSH level in the context of a normal blood T4 level.

Figure No.1 Diagnostic strategy with increased serum TSH¹¹.

COMPLICATIONS OF SUBCLINICAL HYPOTHYROIDISM^12,13

1. Dyslipidemia
2. Cardiovascular endothelial dysfunction
3. Progression to overt hypothyroidism
4. Cardiac dysfunction
5. Coronary heart disease
6. Psychiatric and cognitive dysfunction
7. Infertility, recurrent miscarriage
8. Preterm delivery, pregnancy loss

DIFFERENTIAL DIAGNOSIS OF SUBCLINICAL HYPOTHYROIDISM⁸

Only persistent or progressive subclinical hypothyroidism should be considered an early stage of thyroid disease. It could be challenging to differentiating between transient thyroid gland dysfunction and mild thyroid failure.

• Laboratory analytical problem (heterophilic antibodies, assay variability).
• Impaired renal function.
• After withdrawal of thyroid hormone therapy in euthyroid patients.
• Untreated adrenal insufficiency.
• Isolated pituitary resistance to thyroid hormone.
• TSH secreting pituitary adenoma.
• Recovery phase of euthyroid sick syndrome.

TREATMENT¹⁴

The typical daily replacement dose of levothyroxine for those with overt hypothyroidism is 75 to 125g, or 50 to 100g for older people, or around 1.6g per Kg per day.TSH assessment are frequently recorded at intervals of six to eight weeks, and treatment is typically started with 25 to 50g.Lower starting dosages and more gradual dosage increases are advised for individuals who are elderly, or who have heart problems.

Due to the mild thyroid hormone deficiency, patients with subclinical hypothyroidism may be managed with total daily doses of levothyroxine as low as 25 to 50g. This starting dose should be kept up for six to eight weeks before a TSH measurement is done to help with dosage adjustment. The objective is to keep the TSH level within normal ranges; levothyroxine dosage should be increased if the TSH level remains above the normal and decreased if the TSH level decreases.¹⁴

ADVERSE EFFECT OF LEVOTHYROXINE THERAPY¹⁵

Treatment related risks have primarily been linked to over treatment, which is observed in 14% to 21% of subclinically hypothyroid people receiving thyroxine replacement therapy. Atrial fibrillation, angina pectoris, congestive heart failure, and symptoms associated with excessive thyroid hormone, such as nervousness and palpitation, are the potential side effects from thyroxine. An increase in the risk of fracture and decrease in bone mineral density can come from over treatment.¹⁵

LIFESTYLE MODIFICATION^16,9

A community based cross-sectional study was conducted by Epidemiological survey of Thyroid disease in Fujian provine, China, to analyze the relationship between the lifestyle and thyroid function in subclinical hypothyroidism. It was found that subclinical hypothyroidism was directly associated to lifestyle factors like sleep, smoking, nutrition, and exercise. Staying up late on weekends, smoking, exercise, and iodine excess were effect the thyroid function in subclinical hypothyroidism.

Lifestyle modifications are;

• Regular exercise.
• Limiting the goitrogenic food (Cruciferous vegetables like cauliflower, cabbage and broccoli).
• Proper sleep.
• Eating healthy diet containing adequate amount of iodine.
• Distress the mind with Yoga, Meditation and deep breathing.

HOMOEOPATHIC CLINICAL TRIALS

• According to exploratory randomized placebo controlled single blind study conducted by B.R.Sur Homoeopathic Medical College, Hospital & Research Centre, New Delhi, India to evaluate the efficacy of individualized homoeopathic medicine in Subclinical Hypothyroidism, where 15 medicines are commonly used to treat 86 patients , in that serum thyroid stimulating hormone returned to normal limits in 85.94% of subjects. The study also shows that it prevent the progression into overt hypothyroidism.¹⁷
• A clinical study was conducted on 37 patients who were diagnosed with subclinical hypothyroidism, to assess the effect of Thyroidinum on thyroid peroxidase antibody. The study was concluded that homoeopathic remedy Thyroidinum3X has potential to treat subclinical hypothyroidism and may prevent the patients from progressing to overt hypothyroidism, with a significant decrease in anti-TPO Ab titers.¹⁸
• In a case report, two cases of subclinical hypothyroidism were treated using Individualized Homoeopathic medicine. After proper case taking individualized homoeopathic medicine Ignatia was prescribed for both cases. Ignatia effectively manage these cases and are effective in decreasing the TSH level into normal range. The study indicates that individualized holistic approach gives a good result to subclinical hypothyroid cases.¹⁹

REPERTORIAL APPROACH

SYNTHESIS REPERTORY²⁰

CHAPTER – GENERALS

RUBRIC – HYPOTHYROIDISM

Alum, am-br, ange-s, arg-n, ars, bacls-7, bar-c, calc, calc-I, calc-met, calc-sil, carc, con, cortico, cortiso, flor-p, gels, graph, hist, hypoth, Iod, kali-, kali-I, levo, Lith-met, lith-s, luf-op, lyc, merc, Nat-m, nux-v, penic, psor, puls, rib-ac,sep, sulph, thala, thiop, Thyr

CHAPTER: EXTERNAL THROAT

RUBRIC: THYROID GLAND complaints of

Adren, am-c, am-m, apis ars, aur-s, bad, Bar-I, Bell, Brom, calc, calc-f, calc-I, caust, chr-s, cist, cortiso, Crot-c, des-ac, diph-t-tpt, diphtox, ferr, ferr-s, Fl-ac, flav, Fuc, glon, hep, Hydr, hydr-ac, influ, Iod, Iris, jab, kali-c, kali-I, kali-s, Lap-a, Lith-I, lyc, lycps-v, mag-p, Mang-I, merc, Merc-i-f, nat-I, nat-m, phos, phyt, pineal, psor, puls, sil, spect, spong, strept-ent, sulph, thal-met, thyr, Thyroiod, v-a-b, Zinc-i.

ROBIN MURPHY²¹

CHAPTER: Glands

RUBRIC: THYROID, gland

aloe, ambr, bad, bell, Brom, bufo, CALC, calc-f, CALC-I, calc-p, calc-s, caust, cist, con, ferr-i, fl-ac, form, graph, IOD, kali-c, KALI-I, Lach, Lyc,lycps-v, nat-act, nat-c, NAT-M,  nat-p, nat-s, phos, SEP, sil, SPONG, thuj, THYR

HOMOEOPATHIC THERAPEUTICS^22,23

CALCAREA CARB

• Its chief action is centered in the vegetative sphere, impaired nutrition being the keynote of its action, the glands, skin, and bones, being instrumental in the changes wrought.
• A jaded state, mental or physical, due to overwork
• Pituitary and thyroid dysfunction.
• Great sensitiveness to cold; partial sweats.
• Forgetful, confused, low-spirited.
• Anxiety with palpitation.
• Obstinacy; slight mental effort produces hot head.
• Averse to work or exertion.
• Painless hoarseness, worse in the morning.
• Menses too early too profuse too long with vertigo toothache and cold, damp feet, the least excitement causes their return. Menses late in fat, flabby girls with palpitation, dyspnea and headache.

GRAPHITES

• Tendency to obesity.
• Constipation; large, difficult, knotty stools united by mucus threads.
• Menses too late, with constipation; pale and scanty, with tearing pain in epigastrium, and itching before.
• Defective animal heat from defective oxygenation,(anemic so less oxygen in the body so cold) always cold indoors or out. Chlorotics
• Forgetful, makes mistakes in speaking and writing. Child impudent, teasing, laughing at reprimands.
• Cold feeling in precordium. Pulse slows during day, fast in the morning
• Dry, rough, irritable, that breaks easily and exudes a gluey moisture.

IODUM

• Great debility, the slightest effort induces perspiration.
• Iodine craves cold air.
• Sluggish vital reaction, hence chronicity in many of its aspects.
• Anxiety when quiet. Present anxiety and depression, no reference to the future.
• Goitre, with sensation of constriction.
• Constipation, with ineffectual urging; better by drinking cold milk. Constipation alternating with diarrhoea.
• Fretful, forgets what is to be spoken or done, does not know what

KALI CARB

• The weakness characteristic of all Potassium Salts is seen especially in this, with soft pulse, coldness, general depression, and very characteristic stitches, which may be felt in any part of the body, or in connection with any affection.
• Sensitive to every atmospheric change, and intolerance of cold weather.
• Alternating moods. Very irritable.
• Great dryness of hair; falls out.
• Large, difficult stools, with stitching pain an hour before.
• Menses early, profuse [Calc.c. ] or too late, pale and scanty, with soreness about genitals;
• Delayed menses in young girls, with chest symptoms or ascites. Difficult, first menses.
• Hoarseness and loss of voice.
• Hypothyroidism

NATRUM MUR

• The prolonged taking of excessive salt causes profound nutritive changes to take place in the system, and there arise not only the symptoms of salt retention as evidenced by dropsies and oedemas, but also an alteration in the blood causing a condition of anaemia and leucocytosis.
• Great weakness and weariness
• Mouth Sense of dryness.
• Anus contracted, torn, bleeding.
• Constipation; stool dry, crumbling.
• Menses irregular; usually profuse. Vagina dry.
• Nat-m. has dry mucous membranes. Mucous membranes and skin may be dry
• Dryness and cracking about finger-nails.
• Numbness and tingling in fingers and lower extremities.
• Affects hair follicles.
• Sleepy in forenoon.

 PHOSPHORUS

• Phosphorus irritates, inflames and degenerates mucous membranes, irritates and inflames serous membranes
• Ill effects of iodine and excessive use of salt; worse, lying on left side.
• Loss of memory. Brain feels tired.
• Brain-fag, with coldness of occiput Vertigo, with faintness.
• Stool long, narrow, hard, like a dog’s.
• Difficult to expel. White, hard stools.
• Slight haemorrhage from uterus between periods.
• Menses too early and scanty-not profuse, but last too long.
• Amenorrhoea, with vicarious menstruation.
• Hoarseness; worse evenings.
• Weakness and trembling, from every exertion.
• Great drowsiness, especially after meals.

PULSATILA

• The disposition and mental state are the chief guiding symptoms to the selection of Pulsatilla.
• It is pre-eminently a female remedy, especially for mild, gentle, yielding disposition.
• Weeps easily.Timid, irresolute.
• Rumbling, watery; worse, night No two stools alike.
• Amenorrhoea, Suppressed menses from wet feet, nervous debility, or chlorosis.
• Tardy menses.
• Too late, scanty, thick, dark, clotted, changeable, intermittent.
• Capricious hoarseness; comes and goes.
• Legs feel heavy and weary.
• Numbness around elbow

LYCOPODIUM

• In nearly all cases where Lycopodium is the remedy, some evidence of urinary or digestive disturbance will be found.
• Lycopodium is adapted more especially to ailments gradually developing, functional power
• Lycopodium affects the nutrition, due to weakness of digestion.
• Best adapted to persons intellectually keen, but of weak, muscular power.
• Lacks vital heat; has poor circulation, cold extremities.
• Weak memory, confused thoughts; spells or writes wrong words and syllables.
• Cannot read what he writes.
• Great falling out of hair.
• Dryness of mouth and tongue, without thirst.
• Ineffectual urging, Stool hard, difficult, small, incomplete.
• Menses too late; last too long, too profuse.
• Numbness, also drawing and tearing in limbs, especially while at rest or at night.
• Hands and feet numb.

SULPHUR

• This is great Hahnemannian anti-psoric.
• Standing is the worst position for sulphur patients, it is always uncomfortable.
• Very forgetful.
• Difficult thinking. Irritable.
• Sulphur subjects are nearly always irritable, depressed, thin and weak, even with good appetite.
• Complete loss of, or excessive appetite.
• Frequent, unsuccessful desire; hard, knotty, insufficient.
• Menses too late, short, scanty, and difficult; thick, black, acrid, making parts sore.
• Menses preceded by headache or suddenly stopped.

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Dr.Ashna.E
PG Scholar Department of Practice of Medicine
PG Guide: Dr. Praveen Kumar. P.D (HOD of Dept of the practice of medicine)
GHMC Bengaluru