SAN FRANCISCO — Hyperthyroid disease can be deceptively symptom free or mildly symptomatic, especially in the elderly, Dr. Hossein Gharib said at Perspectives in Women's Health sponsored by OB.GYN. NEWS.
Common symptoms of hypermetabolism include warm, moist skin, fine hair, physically stimulated or nervous mannerisms, possibly a goiter present on palpitation, and perhaps symptoms such as eye asymmetry, a typical hyperthyroid “stare,” and lid retraction.
Elderly patients with hyperthyroidism, however, may complain instead about lethargy, fatigue, or depression. They also have cardiac disease, or atrial fibrillation.
“It is easy to miss the diagnosis [in elderly patients],” said Dr. Gharib, professor of medicine at the Mayo Clinic in Rochester, Minn.
Biochemical tests make the diagnosis. The first step is to order a serum TSH; if it's low, especially if less than 0.1 mIU/L, the patient has hyperthyroidism until proven otherwise, he said.
Next, order total T4 and free T4 fractions; if these are high and the TSH is low, that confirms the diagnosis of hyperthyroidism.
For high suspicion of hyperthyroidism in a patient, test both the TSH and thyroid hormone levels at the same time, he added.
Finally, conduct a radioiodine uptake test, which will differentiate between Graves' disease (which accounts for 70%–80% of hyperthyroidism and requires treatment) and thyroiditis (which is less common and usually subsides spontaneously), Dr. Gharib said.
For most hyperthyroid adults, radioiodine therapy is the treatment of choice. Follow up within 2 months or sooner. Patients will become hypothyroid sooner or later and will require lifelong thyroxine therapy.
For pregnant women who have hyperthyroidism, the antithyroid thionamides are the first choice in treatment. Follow total T4 and free T4 levels in patients on medical therapy and aim for high-normal levels, Dr. Gharib advised. Antithyroid drugs are safe during breast-feeding.
Surgery is a treatment option starting in the second trimester if there's an experienced surgeon in your area. However, surgery for benign thyroid disease is rare enough that finding an experienced surgeon can be difficult, he said. Surgery typically is reserved for toxic nodular goiters, large symptomatic goiters, children with hyperthyroidism, or pregnant patients.
An estimated 0.5%–1% of adults have hyperthyroidism, which is more common in women.
Dr. Gharib has no association with the companies that make the treatments he discussed. OB.GYN. NEWS is published by the International Medical News Group, a division of Elsevier.