21 Thyroid Function Tests

Management of thyroid disorders based on:

Accurate diagnosis
History
o
o
PE
o
Signs and symptoms
Accurate interpretation of laboratory results

Primary Hypothyroidism

Most frequently caused by chronic autoimmune

thyroiditis (Hashimotos thyroiditis)

Affects elderly and women over 40 years

Other causes

Thyroidectomy
131
Radioactive iodine ( I) therapy

Anti-thyroid agents

Head and neck irradiation

Medications

Congenital defects
Subclinical hypothyroidism (mild thyroid failure)

May be asymptomatic

Non-specific symptoms
Depression
o
o
Cognitive dysfunction
o
Weight gain
o
Fatigue
Alterations in lipid metabolism
o
o
Abnormalities in cardiac, GI, or
reproductive dysfunction
Diagnostics
American Thyroid Association recommends

thyroid stimulating hormone (TSH)

determination at 35 years and every 5 years
thereafter
TSH + FT4 = Primary hypothyroidism
(TSH 0.45 4.12 mlu/L)
TSH + (N) FT4 = Subclinical hypothyroidism +
TPOab (Thyroperoxidase Ab)
(N) TSH + FT4 = Secondary hypothyroidism or a
hypothalamic pituitary disorder
(N) or TSH + FT4 = TSH-secreting pituitary tumor or
thyroid hormone resistance
Symptomatology

History of autoimmune disease

History of Graves disease treatment/ thyroid

surgery

Family history of thyroid disease

History of heat/ neck irradiation

Depression/dementia/lithium treatment

Increased cholesterol

Increased CPK

Increased Na > 130 mg/L

Infertility/irregular menses
Cardiomegaly/ bradycardia/ low voltage ECG/

pericardial effusion

Alopecia/ coarse or thinning hair/ vitiligo

Cold intolerance/ fatigue/ hoarse voice

Suspect hypothyroidism
Measures TSH
TSH
> 4.12 mlu/L

TSH = 0.45 4.12 mlu/L

TSH
< 0.45 mlu/L

Patient
euthyroid

Measure FT4

Refer to
hyperthyroidism
algorithm

FT4
TSH-secreting pituitary tumor or thyroid
hormone resistance
(N) FT4
Test TPOab
Patient hypothyroid
FT4
Patient hypothyroid
Management

Thyroid hormone replacement therapy:

Levothyroxine sodium (1.6 ug/kg/d)
Goal of therapy:

o
Restore patient to euthyroid state
o
(N) TSH

Overdosage causes:
o
Decreased bone density
Accelerated bone turnover
o
o
Alterations in liver enzymes,
tachycardia and CV changes

Replacement therapy: lifetime

Hyperthyroidism

Thyrotoxicosis: excess thyroid hormone

o
Toxic diffuse goiter (Graves disease)
o
Toxic multinodular goiter
o
Toxic adenoma
o
Thyroiditis (painful, subacute, or silent)

Associated with:
o
Excessive pituitary TSH production
o
Trophoblastic tumor
o
Excessive ingestion of iodine or thyroid
hormone
Diagnosis
TSH + FT4
TSH + (N) FT4 + (N) FT3
TSH + FT3 + (N) FT4
TSH + FT4

=
=
=
=

Hyperthyroidism
Subclinical hyperthyroidism
T3 toxicosis
TSH secreting pituitary tumor
of familial thyroid hormone
resistance
TSH + (N) FT4 + FT3 = Euthyroid sick syndrome

rainwater@mymelody.com || 1st semester, AY 2011-2012

Goiter

Suspect hypothyroidism

Measures TSH
TSH
> 4.12 mlu/L
Hypothyroid
algorithm

TSH =
0.45 - 4.12 mlu/L

TSH
< 0.45 mlu/L

Patient
euthyroid

Measure FT4
FT4

Hyperthyroid
(N) FT4
Investigate pituitary disease
FT4
Subclinical hyperthyroidism
Symptomatology
History of autoimmune disease

History of Graves disease treatment/ thyroid

surgery
Family history of thyroid disease

Excessive iodine exposure (contrast

dyes/medications)

Goiter/ exophthalmos/ pretibial myxedema

Atrial fibrillation/ palpitations/ tremor

Depression/ dementia

Unexplained weight loss/ hyperdefecation

Vitiligo/ alopecia/ coarse thinning hair

Heat intolerance/ sweating

Management
131

Radioactive Iodine (I ) Therapy

o
Treatment of choice for Graves
disease
Recurrent hyperthyroidism after
o
antithyroid therapy
o
Toxic multinodular gland
Toxic adenoma
o

Thyroiditis (painful, subacute or silent) should

131
not be treated with (I ) but requires
symptomatic therapy (-blockade)

Goal of therapy
o
To destroy thyroid tissue (followed by
fibrosis and atrophy which leads to
thyroid failure)
o
(N) TSH
131

Complications of I therapy: hypothyroidism

Antithyroid Drugs
o
Propylthiouracil preferred in severe
or life-threatening hyperthyroidism)
(thyroid storm); inhibits conversion of
T4 to T3
o
Methimazole for patients who will
131
subsequently undergo I therapy
o
50-80% recurrence of hyperthyroidism
following withdrawal of antithyroid
drugs

Enlargement of the thyroid gland

Diffuse
o
o
Nodular
Clinically exhibits
Hypothyroidism
o
o
Hyperthyroidism

Solitary Thyroid Nodule

Occurs in 4-7% of the general population

More common in women than in men

History of head/neck irradiation is a major risk

factor

Classification
o
Benign (colloid or follicular adenomas)
o
Suspicious
o
Malignant

FNAB principal diagnostic tool

Surgical excision depends on:

o
Tumor size
o
Location
o
Presence of lymph nodes

Thyroid scan:
o
Hot (hyperfunctioning)
o
Cold (hypofunctioning): higher
probability of being malignant and
managed with surgery
Post-Partum Thyroiditis (PPT)

Transient thyroiditis developing hypothyroidism

or hyperthyroidism in postpartum women who
were euthyroid during pregnancy
Occurs in 5-8% of women

Occurs in 25% of women with DMI

Autoimmune disorder, hence increased TPO Ab

Levothyroxine sodium therapy used as

replacement therapy

25% of women with PPT develop permanent

primary hypothyroidism

At high risk of recurrence following subsequent

pregnancies

Additional Reading:
Henrys metabolism and other factors affecting thyroid
function tests (p. 339)

rainwater@mymelody.com || 1st semester, AY 2011-2012