The disease doctors still miss

A large number of people have a thyroid disorder, but only half know it. Here are the symptoms to look for, and the test you should demand today, says RONNY FRISHMAN.

SHORTLY after her May 1998 wedding, Michelle Chiaro could not shake the blues. "The first six months of marriage were a nightmare," says Chiaro, 41, a social worker from West Chester, Pennsylvania. She was exhausted, gaining weight, and her libido was waning. Chiaro suspected depression - a reaction to a year in which she lost her mother and had a breast-cancer scare. A psychiatrist agreed, and put her on Prozac.

But Chiaro still felt foggy and forgetful. She finally went to her internist and a blood test revealed hypothyroidism, an underactive thyroid. She began daily medication, weaned herself off Prozac and got her life back. "I am clear-headed and there are no signs of depression," says Chiaro.

In 1991 Kelly Hale, now 43, was working in the administrative office of a Houston hospital when she developed what felt like an ongoing caffeine high: She was jittery, had tremors and could not sleep. Her doctor diagnosed anxiety disorder and prescribed tranquilisers.

Over time, Hale's symptoms worsened. Her eyes bulged and she dropped three dress sizes. "I was having difficulty getting through my days," says Hale, who quit her job and moved in with her parents. "My brain was racing so fast, I could not remember anything." Someone noticed her nervousness and bulging eyes and suggested that Hale might have Graves' disease, an autoimmune disorder that stimulates the thyroid. Two days later, a specialist confirmed it with a blood test. Hale started hyperthyroid therapy and was able to stabilise her condition. Because of her experience, she founded the American Foundation for Thyroid Patients to help patients get the right diagnosis and support.

Thyroid disorders affect 13 million people in the United States, including Tipper Gore, who recently had surgery to remove benign thyroid nodules, and former President George Bush and his wife, Barbara, who were both diagnosed with Graves' disease while in the White House.

Though highly treatable, thyroid disease is elusive - only half the people with this problem know it. Because symptoms tend to mimic those associated with other conditions, such as depression, stress and menopause, a malfunctioning thyroid can easily be missed. Runner and Olympic gold medallist Gail Devers was misdiagnosed repeatedly after her health took a nosedive in 1988. It was not until her weight plummeted 38 pounds and she suffered severe heart palpitations, weakness and hair loss that she was finally diagnosed with and treated for Graves' disease.

Worries about undetected disease and needless suffering have led to increased awareness and more testing by doctors. That is particularly important for women, who are five to eight times more likely than men to develop thyroid disease, a risk that increases with age.

The thyroid is a small gland below or beside the Adam's apple that wields considerable power over the body's metabolism. It secretes two hormones - thyroxine (T4) and triodothyronine (T3) - that circulate throughout the body, telling cells and tissues how fast to work.

The thyroid gets its orders from the pituitary gland, the master gland that monitors T4 and T3 hormones in the blood and adjusts levels by releasing thyroid-stimulating hormone (TSH). When thyroid hormone levels are normal, only a small amount of TSH is present. When supplies run low, the pituitary sends more TSH, signalling the thyroid to step up production; when hormone levels get too high, TSH secretion stops.

Several factors may help throw the thyroid off balance, most notably any underlying autoimmune disorder. Though researchers do not know what causes autoimmune diseases, they do know that the illnesses occur more often in women.

Thyroid dysfunction has been linked to premature graying, hair loss, dyslexia, lefthandedness, chronic hives and vitiligo (a skin pigmentation disorder). But those at greatest risk are people with a family history of thyroid disease.

Most people with thyroid problems either have an overactive or underactive thyroid. Hyperthyroidism occurs when the thyroid releases too much hormone, causing metabolism and other organ functions to accelerate. The most common cause is Graves' disease. The illness generally strikes women between the ages of 30 and 40. Onset may be gradual, with such symptoms as weight loss, insomnia and irritability. Inflamed, protruding eyes are a hallmark of Graves', though not everyone develops eye disease. Untreated, hyperthyroidism can lead to heart failure and osteoporosis.

Hashimoto's thyroiditis, also an autoimmune condition, is the primary cause of hypothyroidism, the most common thyroid abnormality. In this disease, antibodies gradually destroy the thyroid, causing a slowdown in the body's systems. One in 10 women will develop Hashimoto's; women over 40 are the most likely to have the condition. Many women dismiss symptoms of fatigue and "the blues" as part of aging or perimenopause. However, failure to treat an underactive thyroid can cause anemia, high cholesterol and heart disease.

Postpartum thyroiditis is an inflammation of the thyroid that occurs in five to 10 per cent of women following pregnancy and probably is responsible for most postpartum depression. The problem usually resolves on its own.

Some people develop painless lumps on the thyroid. Most of these nodules are harmless, but a doctor will perform a biopsy to evaluate the cells for cancer. An imaging test can also help diagnose the nodules.

Only 10 per cent of people with thyroid problems have thyroid cancer. Most malignancies first appear as a lump or nodule on the thyroid, but sometimes the first sign is a swollen lymph gland in the neck, a hoarse voice or difficulty swallowing. Most cases are curable with removal of the thyroid gland and follow-up therapy.

A physician can detect whether you have an enlarged thyroid - often the first sign of an overactive or underactive gland - by physically examining your neck. The best tool for diagnosing thyroid dysfunction is a simple blood test that measures TSH. Abnormal results usually are followed with a test to measure T4 and T3 levels, and possibly other blood tests that would indicate an autoimmune disease or an iodine absorption test.

The usual treatment for hypothyroidism is daily medication to replace the lost T4 hormone, which corrects the condition and relieves symptoms. There is evidence that some people fare better when taking a combination of T4 and T3, but this regimen needs more study.

There are three options for treating hyperthyroidism. A doctor may prescribe anti-thyroid drugs that reduce hormone production. More effective is therapy with radioactive iodine, which is taken orally and generally destroys the thyroid gland. Less common is surgical removal of the thyroid gland. Once the gland is destroyed or removed, patients then need hypothyroid medication.

Though treatment sounds straightforward, it is not. Because people react differently to shifts in thyroid balance, the dosage that pushes one person's TSH back into the normal range may not produce the same effects in someone else. THe AACE recommends monitoring patients every few weeks until the TSH is normal, followed by checkups every six months to a year.

Doctors disagree about whether to treat people who have TSH levels indicating low-grade thyroid disease but no symptoms. Most endocrinologists (doctors who specialise in the glands and hormonal system) argue that starting thyroid medication early can prevent misery and provide unseen benefits, such as keeping cholesterol in check. Other physicians say early treatment is not necessary.

Being assertive about testing and alert to the symptoms of thyroid disease are important to maintaining good health. But perhaps more crucial is finding a knowledgable, attentive physician. "Get as much information as you can," says Kelly Hale. "If you do not feel you have a good relationship with your doctor, find someone you can work with."

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