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Frequently Asked Questions

(Patient question) If I haven’t had goitre or thyroid surgery in the past, why would I develop hypothyroidism?

The most common cause of hypothyroidism around the world is still iodine deficiency. However, in iodine-sufficient populations, thyroiditis is the most common cause of hypothyroidism. This is due to progressive destruction of thyroid follicular cells by antibodies directed towards specific parts of the cells that produce thyroid hormones. This condition often develops very insidiously over years and may not produce any manifestations until the person becomes overtly hypothyroid.

(Patient question) What is the best way to find out if I am hypothyroid?

Diagnosis of hypothyroidism requires documentation of low levels of thyroid hormones (i.e. T4 and T3). However, the diagnosis is refined by also measuring levels of thyroid stimulating hormone (TSH), which is produced in the brain and acts on the thyroid gland to stimulate T4 and T3 production. If TSH is high, then thyroid gland hormone secretion is the primary defect. However, if TSH is low, then the defective supply of this hormone from the brain (pituitary gland) is the cause of the hypothyroidism.

(Patient question) Do I need a special test, such as thyroid ultrasound or biopsy, to know if I am hypothyroid?

A blood test to check levels of the thyroid hormones T3 and T4 and the level of a further hormone (thyroid stimulating hormone, TSH) is sufficient to diagnose hypothyroidism. There is no need to do any other test if only to diagnose hypothyroidism. However, these other tests, thyroid ultrasound or a biopsy, are used to detect the presence of thyroid abnormalities that may have led to the hypothyroidism. Thus, a physician may request them after documenting that a person has biochemically confirmed hypothyroidism so that the probable cause can be investigated.

What is the incidence of systemic disease in patients with autoimmune hyperthyroidism?

Around 50–60% of all patients with autoimmune hyperthyroidism will go on to develop systemic disease, involving their skin, eyes, heart, etc. In a large, cross-sectional multicentre study, 3286 Caucasian subjects (2791 with Graves’ disease, 495 with Hashimoto’s thyroiditis) attending UK hospital thyroid clinics were investigated for coexisting autoimmune disorders. The frequency of a further autoimmune disorder in these patients was investigated by questionnaire, and revealed a rate of 9.67% for those with Graves’ disease and 14.3% for those with Hashimoto’s thyroiditis. The most common coexisting autoimmune condition was rheumatoid arthritis, but other diseases were also present, including pernicious anaemia, systemic lupus erythematosus (SLE), Addison’s disease, celiac disease and vitiligo. Thyroid diseases are frequent in patients with SLE, particularly hypothyroidism and thyroid autoantibodies.

When investigating a patient with autoimmune endocrine disease, should a physician look for other autoimmune disorders, i.e. type 1 diabetes, systemic lupus or autoimmune gastritis?

Yes, there is a good chance that the patient will also have symptoms for another autoimmune disorder, which could be caught at an early stage and treated. Further, patients with other autoimmune disorders have an increased probability of autoimmune thyroid disease compared with the general public, and may benefit from testing.

What has been reported about the impact of thyroid antibodies (TPOAb) in pregnancy? Is there any treatment available?

Thyroid antibodies (TPOAb) increase the risk of miscarriage. In a study with 552 women who presented to their obstetrician in the first trimester of pregnancy, miscarriage rate was doubled in women who were euthyroid with TPOAb compared with women who tested negative for TPOAb. Thyroid autoantibody-positive women miscarried at a rate of 17%, compared with 8.4% for the autoantibody-negative women. Levothyroxine treatment in euthyroid pregnant women with autoimmune thyroid disease decreased the rate of obstetric complications in a study of 984 pregnant women. In a meta-analysis of 12,126 women, the cohort studies showed an increased risk of miscarriage in TPOAb+ women (odds ratio [OR] 3.90, 95% confidence interval [CI] 2.48–6.12; P

Is a Bethesda III cytological result always an indication for a second thyroid fine needle aspiration biopsy?

The risk of malignancy in atypia/follicular lesions of undetermined significance (AUS/FLUS) included under the Bethesda III category is 3–15%. A second fine needle aspiration biopsy (FNAB) is recommended in these patients because in 75–80% of cases, the nodules with cytology Bethesda III will be reclassified as Bethesda I, II, IV, V or VI, modifying the diagnosis towards a category that displays less controversy. However, these figures may vary among studies. Other possible strategies include simple observation, surgery after the first FNAB based on clinical or ultrasound findings, the use of molecular markers that define benign from malignant nodules and core needle aspiration, which provides more material for cytological analysis.