Thyroid and comorbid conditions, menopause , depression, infertility , dyslipidemia , newborn , diabetes , CKD women pregnancy

1. Thyroid and comorbid conditions
Dr. Jyoti Agarwal
Dr.Sharda Jain
Dr. Jyoti Bhaskar

2. Dr. Sharda Jain / Dr Jyoti Agarwal
Life Care Centre has a over 200 ppt on shildeshare.net
For benefit of Medical fraternity.
use it yourself & share among your friends

3. www.drsarma.in 3
Knowledge is
essential
When applied, is
wisdom
Wisdom is Happiness

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HYPOTHYROIDIM
And Comorbidities

5. Major Comorbid Conditions
AACE medical guidelines for clinical practice for the evaluation and treatment of hyperthyroidism and hypothyroidism, 2006:1-13

6. Autoimmune diseases that occur
concurrently with hypothyroidism
• Diabetes mellitus
• Vitiligo,
• Rheumatoid arthritis
• Addison’s disease
• Coelic disaese
• Pernicious anemia
• Autoimmune diseases
are associated
with autoimmune
thyroiditis

8. Diabetes Mellitus
• Hashimoto’s thyroiditis
is associated with 10%
of patients with type 1
diabetes mellitus
• Approximately one-fourth
of female patients with
type 1 diabetes mellitus
develop postpartum
thyroiditis

9. AACE recommends that
All Diabetic patients
• Examine for goiter
• Assess TSH levels regularly especially in the
presence of a goiter or other autoimmune
disorders

10. 10
• Increased estrogen
production.
• Defective
spermatogenesis.
• Low sperm count with
• sperm motility defect.
Thyroid and InfertilityThyroid and Infertility
FEMALES MALES

11. Subclinical overt hypothyroidism has been
reported to be linked with insulin resistance.
In patients on treatment for both thyroid
disorders and diabetes, thyroid status
should be kept in mind while titrating ant
diabetic therapy .
11Reference : Kalra S et al. The hypoglycemic side of hypothyroidism.
Indian Journal of Endocrinology Metabolism 2014;18(1)1.3.
Diabetes

12. Image infertility
12

13. Impact on Female Fertility
• Over 50 % of hypothyroid patients have menstrual
irregularities
• one third of subfertile patients have thyroid disease
• 46 % of infertile patients with hypothyroidism have
hyperprolactinaemia
Thyroid dysfunction is associated with
short luteal phase, failure to sustain a
fertilized egg, and loss of early pregnancy.

14. Impact on Female Fertility
• Controlled ovarian hyperstimulation leads to
increase in estradiol, which in turn has an
adverse effect on thyroid hormones
• In presence of autoimmune thyroid disease ,
the impact of controlled ovarian
hyperstimulation becomes more severe
Treatment with LT4 replacement therapy restores
normal menstrual cycle and fertility

15. In males infertility starts in childhood
• Thyroid failure in the pre-pubertal period is
associated with testicular enlargement and
alterations in sexual hormones
• There is macro orchidism without virilization
• Longer the hypothyroidism persists, greater
is the degree of damage to the testes
• If adequately treated these boys progress through
puberty normally

16. Always suspect Hypothyroidism
1. Amenorrhea
2. Oligomenorrhea
3. Menorrhogia
4. Galactorrhea
5. Premature ovarian failure /
early onset of menopause
6. Infertility
7. Decreased libido
8. Precocious / delayed
puberty
16

17. Infertility tip
An Endocrine society clinical practice guideline
Screening of Hypothyroidism is recommended in
women suffering from infertility
Reference : De Groot L et al. Management of thyroid dysfunction during
pregnancy and postpartum an endocrine society clinical practice guideline J Cline
Endocrinal Metab. 2012;97(8);2543-65

19. Depression
• Diagnosis of overt or
subclinical hypothyroidism
should be considered in
every patient with
depression
• Periodic evaluation for
thyroid function should be
performed in patients
receiving lithium therapy
because lithium is known to
induce goiter and
hypothyroidism

20. Depression
• All depressed patients
should be evaluated
for thyroid dysfunction
• Antidepressants may
be less effective if
thyroid functions are
not normalized
• Occasionally thyroxin
is given with
antidepressants even in
euthyroid patients

22. Dyslipidemia and cardiovascular sequelae
comorbid with overt hypothyroidism
Dyslipidemia is
characterized by
• Increased levels of
total cholesterol
• Increased LDL and
deranged lipid profile
If untreated leads to severe
cardiovascular sequelae
• Pericardial effusion
• Congestive heart failure
• Coronary artery disease

23. HYPOTHYROIDISM AND
DYSLIPIDEMIA TIP
All patients with elevated lipid levels
should be screened for
Hypothyroidism.
Reference : Tandon N. et al. Management of hypothyroidism in adults. J Assoc
Physicians India.

24. 24
Lipids in Patient with Hypothyroidism
Hypercholesterolemia
(>200 mg/dL)
Hypertriglyceridemia
(>150 mg/dL)
Hypercholesterolemia +
mild Hyper TG
Normal Lipids
N= 268
Approximately 3/4th
of patients with overt
hypothyroidism have increased cholesterol
and triglycerides

25. LDL-C Levels Increase With
Increasing Hypothyroidism Grade
0
50
100
150
200
250
C 1 2 3 4* 5†
144 133 137
168
191
246LDL-C
(mg/dL
Basal TSH (mU/L) 1.1 3.0 8.6 22.7 44.4 63.7
Hypothyroidism

26. Cardiovascular sequelae comorbid with
subclinical hypothyroidism
• Impaired diastolic function
and left ventricular
function
• Hypercoagulable state
• Increased risks of
atherosclerosis and
myocardial infarction
• Mortality in patients
less than 65 years of
age
The Cycle of Disease
Subclinical
Hypothyroidism
Emerging Risk
Factors CVD
Endothelial
Dysfunction
Cardiac
Alterations
Blood
Pressure
Hyperlipidemia
Hemostatic
Balance
Obesity

27. LT4 therapy for subclinical
hypothyroidism
• Reduces cardiovascular
risk factors
• Improves dyslipidaemia
• Minimizes
neurobehavioral changes
Decrease in total cholesterol with thyroxine replacement
therapy may be considered as an important predictor for
cardiovascular risk

29. Hypothyroidism and CKD
Please remember
Unresolved subclinical hypothyroidism in chronic
kidney disease patients can be associated with a
rapid decline in renal function.
Thyroid function should be assessed early in patients
with renal impairment.
References : Kim EO, et al. Unresolved subclinical hypothyroidism is independently
associated with progression of chronic kidney disease. Int J Med Sci.2013 Dec 20; 11
(1);52-9. doi 10.7150/ijms.7186 recollection 2014. 2. Connor A et al . Renal impairment
resulting from hypothyroidism
Nephro Dialysis Transplantation plus. 2008 : 6: 440-41.

30. www.drsarma.in 30
• Malabsorption Syndromes
• Reduced Absorption
Cholestyramine resin
Sucralfate
Ferrous sulfate
Soybean formula
Aluminum hydroxide
Colestipol hydrochloride
Drugs that affect metabolism
Rifampin
Carbamazepine
Phenytoin
Phenobarbitol
Amiodarone
Drug Interactions

31. Over-replacement risks
• Reduced bone density
osteoporosis
• Tachycardia,
arrhythmia , atrial
fibrillation and
myocardial infarction
Under-replacement risks
• Hypothyroid state
continues with
• Long-term end-organ
effects
• Increased risk of
hyperlipidemia
www.drsarma.in 31
Inappropriate Dosage

32. Learning Activity
Which of the following statements are TRUE
regarding LT4 therapy in hypothyroidism?
A.Congenital hypothyroidism is treated with LT4 at a dose of
50-100 mcg/kg orally once-daily.
B.LT4 therapy for subclinical hypothyroidism reverses cardiovascular
alterations.
C.LT4 is contraindicated in combination with antidepressants in euthyroid
patients with depression.
D.Both mild as well as overt hypothyroidism are managed by administering
levothyroxine therapy.

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CONCLUSIONS

34. Thyroid dysfunction is quite prevalent in India,
particularly in females
Women and men >35 years of age should be
screened every 5 years
Screening of hypothyroidism is recommended
in women suffering from infertility
The diagnosis of hypothyroidism must be
considered in every patient with depression.
All patients with elevated lipid levels should
be screened for hypothyroidism .
Screening should be done in peri-and post
menopausal women to prevent complications of
hypothyroidism.
Conclusion of HYPOTHYROIDISM in women

35. Diagnosis of hypothyroidism is important in
adolescence because this condition retards Growth in
height and development of secondary sexual
characteristics and delayed onset of puberty
In patients on treatment for both thyroid disorders
and diabetes,
Thyroid status should be kept in mind while
titrating anti - diabetic therapy
Increased TSH values are increasingly noted in the
elderly population.
Screening should be done I peri -and menopausal women
To prevent complications of hypothyroidism
Conclusion

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