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Hashimoto’s Thyroiditis

Brief Overview: Hashimoto’s thyroiditis is a chronic autoimmune disorder in which the immune system attacks the thyroid gland, leading to progressive thyroid dysfunction. Over time, this results in hypothyroidism (underactive thyroid) as the gland loses its ability to produce sufficient thyroid hormones. It is the most common cause of hypothyroidism in iodine-sufficient regions. Management focuses on thyroid hormone replacement, symptom monitoring, and long-term follow-up.

Prevalence: According to UpToDate, Hashimoto’s thyroiditis “occurs in up to 10 percent of the population.”

Etiology: According to UpToDate, “The cause of Hashimoto's thyroiditis is thought to be a combination of genetic susceptibility and environmental factors.” Hashimoto's thyroiditis is an autoimmune condition. 

Risk Factors:

  • Female
  • Pregnancy
  • Excessive iodine intake
  • Environmental radiation exposure
  • Genetics

Commonly Associated Conditions:

  • Hypothyroidism
  • Goiter
  • Other autoimmune diseases:
    • Type 1 diabetes
    • Rheumatoid arthritis
    • Celiac disease
    • Pernicious anemia
    • Systemic lupus erythematosus
  • Depression and anxiety
  • Hyperlipidemia

Common Medications:

Treatment is aimed at replacing deficient thyroid hormone once hypothyroidism develops.

  • Levothyroxine (T4) – first-line and most commonly used therapy
  • Liothyronine (T3) – rarely used; selected cases under specialist guidance
  • Combination T4/T3 therapy – Armour Thyroid
  • Key medication considerations:
    • Taken daily on an empty stomach for best absorption
    • Requires periodic dose adjustment based on TSH levels
    • Lifelong therapy is often required

Common Labs, Imaging, and Tests:

  • Thyroid-stimulating hormone (TSH) – primary monitoring test
  • Free T4 (and sometimes Free T3)
  • Thyroid antibodies:
    • Anti-TPO antibodies
    • Anti-thyroglobulin antibodies
  • Lipid panel (hypothyroidism may elevate cholesterol)
  • Thyroid ultrasound (if goiter or nodules are suspected)

Common Symptoms: Symptoms often develop gradually and may include:

  • Fatigue and low energy
  • Cold intolerance
  • Weight gain
  • Constipation
  • Dry skin and hair loss
  • Depression or cognitive slowing (“brain fog”)
  • Menstrual irregularities
  • Voice hoarseness
  • Neck fullness or goiter

Common Treatments:

  • Thyroid hormone replacement therapy (see ‘Medications’ above)
  • Regular laboratory monitoring (TSH-guided dosing)
  • Management of associated conditions (hyperlipidemia, depression)
  • Patient education on lifelong management
  • Endocrinology referral for complex cases

Physical Findings:

  • Enlarged, firm, or irregular thyroid (goiter)
  • Bradycardia
  • Dry, cool skin
  • Periorbital puffiness
  • Delayed reflexes
  • Weight gain

Potential Complications and Contraindications:

  • Potential complications:
    • Severe hypothyroidism (myxedema)
    • Cardiovascular disease due to dyslipidemia
    • Infertility or pregnancy complications
    • Cognitive impairment
    • Goiter progression
  • Contraindications / cautions:
    • Overtreatment can cause hyperthyroidism (palpitations, bone loss)
    • Drug interactions affecting levothyroxine absorption (calcium, iron, PPIs)
    • Caution in elderly patients or those with coronary artery disease

General Health and Lifestyle Guidance:

  • Take thyroid medication consistently at the same time daily
  • Separate levothyroxine from calcium, iron, and fiber supplements. Take levothyroxine first thing in the morning on an empty stomach with a full glass of water. Wait 30-60 minutes before eating, drinking, or taking any other medications/supplements.
  • Maintain regular follow-up lab testing
  • Encourage balanced nutrition; avoid excessive iodine intake
  • Monitor for symptom changes
  • Reinforce adherence even when symptoms improve

Suggested Questions to Ask Patients:

  1. Have you noticed changes in energy, weight, or cold tolerance?
  2. Are you taking your thyroid medication daily and correctly?
  3. Any missed doses or difficulty with timing?
  4. Have you experienced palpitations or anxiety symptoms?
  5. Any neck fullness or difficulty swallowing?
  6. When was your last thyroid blood test?
  7. Are you taking supplements that might interfere with absorption?

Suggested Talking Points:

  • Hashimoto’s is an autoimmune condition that commonly leads to an underactive thyroid.
  • Thyroid hormone replacement helps restore normal body function.
  • Medication timing and consistency are key for effective treatment.
  • Most people feel much better once hormone levels are stabilized.
  • Regular blood tests help ensure the dose stays appropriate.

Sources:

This content was created with the assistance of AI. Any AI-generated content was reviewed by a Nurse Practitioner.