Symptoms of hypothyroidism

Primary hypothyroidism, represented mainly by its "idiopathic" form, is more frequent in women 40-60 years of age. In recent decades, there has been an increase in all autoimmune diseases, including hypothyroidism. In this regard, the age range has significantly expanded (the disease is observed in children, and in adolescents, and in the elderly), and sex began to wear off. Of particular importance in terms of diagnosis, and in terms of treatment, acquired hypothyroidism in elderly patients, in which a number of general nonspecific symptoms can be mistakenly attributed to natural age involution or organ pathology.

Symptoms of severe hypothyroidism are very polymorphic, and patients present a lot of complaints: sluggishness, sluggishness, quick fatigue and decreased efficiency, drowsiness during the day and disturbance of night sleep, memory impairment, dry skin, swelling of the face and limbs, fragility and striation of the nails, hair loss, increase body weight, paresthesia, often abundant or poor menstruation, sometimes amenorrhea. Many people note persistent pain in the lower back, but this symptom disappears as a result of effective thyroid therapy, does not attract the attention of doctors and is usually regarded as a manifestation of osteochondrosis.

The severity and rapidity of the development of symptoms of hypothyroidism depend on the cause of the disease, the degree of thyroid insufficiency and the individual characteristics of the patient. Total thyroidectomy leads to a rapid development of hypothyroidism. However, even after a subtotal operation in the first year or in the future, hypothyroidism develops in 5-30% of patients operated on. The presence of antithyroid antibodies can be one of its causes.

The initial manifestations of the disease are characterized by meager and nonspecific symptoms (weakness, fatigue, decreased efficiency, pain in the heart, etc.), and patients can be observed for a long time unsuccessfully about "cerebral sclerosis", "pyelonephritis", "anemia", "angina" "Depression", "osteochondrosis", etc. When expressed hypothyroidism, the type of patients is very characteristic: periorbital edema, pale, puffy and masklike face. Ocular and enlarged facial features sometimes resemble acromegaloid. Patients are chilly and wrapped in warm clothes and at a high ambient temperature, since a low basal metabolism, a violation of thermoregulation with a predominance of heat transfer over heat production reduce the tolerance to cold. Slowing of peripheral blood flow, often associated anemia and specific edema make the skin pale, stiff, cold to the touch. Along with this, in some patients (women) against a background of general pallor appears a bright, limited blush on the cheeks. The skin is dry, scaly, with areas of keratinization, especially on the feet, the front surface of the shins, knees, elbows.

The swelling of the vocal cords and tongue leads to a slowed, fuzzy speech, the timbre of the voice decreases and coarsens. The tongue increases in volume, on its lateral surfaces are visible traces, dents from the teeth. An increase in the tongue and vocal cords causes episodes of sleep apnea. Because of the edema of the middle ear, hearing is often reduced. There is a fragility and dry hair, their thinning on the head, in the armpits, pubic, in the outer third of the eyebrows. Reduced secretion of the sebaceous and sweat glands, often jaundice of the skin, often in the form of spots on the palmar surface of the hands due to excess circulating beta-carotene, slowly transforming into the liver in vitamin A. In connection with this, an erroneous diagnosis of chronic hepatitis is sometimes made. Mialgia, decreased muscle strength and increased muscle fatigue are noted, especially in proximal groups. Muscle pain, convulsions and delayed relaxation are the most common manifestations of hypothyroid myopathy, and its severity is proportional to the severity of hypothyroidism. Muscle mass increases, muscles become dense, stiff, well contoured. There is a so-called pseudohypertrophy of muscles.

Bone lesions are not characteristic of hypothyroidism in adults. Moderate osteoporosis develops only with prolonged and severe course. Reduction of the mineral content in the bone tissue can be after total thyroidectomy, obviously, due to a deficiency of calcitonin. In adolescence and in patients with hypothyroidism from childhood, but poorly treated, there may be a defect in epiphyseal ossification, a lag in the "bone" age from chronological, a slowing of linear growth and a shortening of the limbs. Often observed arthralgia, arthropathy, synovitis and arthrosis. Disorders from the cardiovascular system are very diverse. The defeat of the myocardium with the subsequent development of the hypothyroid heart appears already at the early stages of the disease. Patients are troubled by shortness of breath, which increases even with a slight physical strain, discomfort and pain in the heart and behind the breastbone. Unlike true angina, they are often not associated with physical activity and are not always stopped by nitroglycerin, but this difference can not be a reliable differential diagnostic criterion. Specific changes in the myocardium (edema, swelling, muscular degeneration, etc.) weaken its contractility, causing a decrease in stroke volume, cardiac output as a whole, a decrease in the volume of circulating blood, and lengthening the circulation time. Myocardial damage, pericardial and tonogenic dilatation of the cavities increase the volume of the heart, which is clinically characterized by percutaneous and radiographic signs of widening its boundaries. The heart ripple weakens, the sonority of the tones is muffled.

Bradycardia with a small and mild pulse is a typical symptom of hypothyroidism. It is observed in 30-60% of cases. A significant proportion of patients have a pulse rate within normal limits, and approximately 10% have tachycardia. The low metabolic balance of oxygen in organs and tissues, and in this connection the relative safety of the arteriovenous difference in the oxygen content, limits the mechanisms of cardiovascular failure. Inadequate therapeutic doses of thyroid hormones, which increase oxygen utilization, can provoke it, especially in elderly patients. Violations of the rhythm are very rare, but may appear in connection with thyroid therapy. Blood pressure can be low, normal and elevated. Arterial hypertension, according to different authors, was noted in 10-50% of patients. It can decrease and even disappear under the influence of effective thyroid therapy.

Wide statistical studies have shown that the age-related gradual increase in blood pressure is more pronounced in hypothyroid patients than in those with normal thyroid function. In this regard, hypothyroidism can be attributed to risk factors for the development of hypertension. This is also evidenced by post-thyrotoxic hypertension syndrome, which occurs after surgery for DTZ. However, the traditional view of the atherogenic effect of hypothyroidism, which accelerates the development of atherosclerosis, hypertension and coronary heart disease, is considered ambiguously today.

Endocrinologists observed hypertension in 14 of 47 patients (29%). The average age of the patients is 46-52 years. Most were unsuccessfully treated for hypertension in therapeutic and cardiac hospitals. Hypertension in some patients was very high (220/140 mm Hg). As hypothyroid symptoms were reduced, successful therapy reduced or normalized hypertension in most patients. Attention is drawn to the fact that the antihypertensive effect of thyroid therapy is detected quite quickly from the moment of its beginning and long before the full compensation of thyroid insufficiency. The latter excludes the association of hypothyroid hypertension with profound structural changes in the myocardium and vessels. However, in elderly people with the natural development of atherosclerosis, the hypotensive effect is small and unstable. Expressed hypertension, masking and "pushing" the hypothyroid symptomatology, is one of the frequent reasons for the untimely diagnosis of hypothyroidism and the appointment of thyroid preparations.

In the process of adequate thyroid therapy in people of different ages in the presence of hypertension and without it, often the pains behind the breastbone disappear, which are long regarded as angina pectoris. Obviously, with hypothyroidism, there are two clinically difficult to distinguish types of pain: truly coronary (especially in the elderly), which can be intensified and become more frequent even with very cautious thyroid therapy, and metabolic, disappearing during treatment.

One of the characteristic symptoms in 30-80% of patients is the presence of fluid in the pericardium. The volume of pericardial effusion may be small (15-20 ml) and significant (100-150 ml). The fluid accumulates slowly and gradually, and such a terrible symptom, as a cardiac tamponade, is extremely rare. Pericarditis can be combined with other manifestations of hypothyroid poliserozit - hydrothorax, ascites, characteristic of autoimmune lesions with severe autoaggression. With severe polyserositis, the other symptoms of hypothyroidism may not be so obvious. Observations documented by effective treatment are known when effusion into serous membranes was the only manifestation of hypothyroidism. It is believed that there is a known parallelism between the severity of hypothyroidism, the level of increase in creatine phosphokinase in the blood and the presence of pericardial effusion. The most sensitive and reliable method of detecting fluid in the pericardium is echocardiography, which also allows recording its decrease, observed after several months, and sometimes years of adequate treatment. Metabolic processes in the myocardium, pericardial symptoms, especially in the presence of effusion, and hypoxia form a complex of changes in the ECG in a largely nonspecific manner. A low-voltage electrocardiogram is observed in approximately one-third of patients. Often noted deformation of the final part of the stomach complex (decrease, biphasic and inversion of the T wave) have no diagnostic value, since they are not less typical for coronary artery atherosclerosis. It is these changes in combination with pain syndrome, and sometimes with hypertension, leading to hyperdiagnosis of coronary heart disease. The best evidence of their metabolic nature is the disappearance of pain and positive ECG dynamics during the treatment.

Deviations from the respiratory system are characterized by muscular discoordination, central regulatory disorders, alveolar hypoventilation, hypoxia, hypercapnia and edema of the mucous membrane of the respiratory tract. Patients are prone to bronchitis, pneumonia, which are characterized by a sluggish, protracted course, sometimes without temperature reactions.

There are a number of gastrointestinal disorders: decreased appetite, nausea, flatulence, constipation. Reducing the tone of the musculature of the intestine and biliary tract leads to stagnation of bile in the bladder and promotes the formation of stones, the development of a megacolon and sometimes intestinal obstruction with a picture of an "acute abdomen."

The excretion of fluid by the kidneys is also reduced due to low peripheral hemodynamics, and as a result of an increased level of vasopressin; Atony of the urinary tract favors the development of infection. Sometimes there may be light proteinuria, reduced filtration and renal blood flow. Severe disorders of renal hemodynamics usually do not happen.

Disorders of the peripheral nervous system are manifested by paresthesias, neuralgias, slowing of tendon reflexes; the rate of passage of the pulse along the Achilles tendon with hypothyroidism slows down. The symptoms of polyneuropathy can be not only with obvious hypothyroidism, but also with latent hypothyroidism.

This or that degree of mental disorders is observed in all patients, and sometimes they dominate in clinical symptoms. Characteristic lethargy, apathy, memory impairment, indifference to the environment; the ability to concentrate attention, acuity of perception and reaction is reduced. The sleep is distorted, the sick are disturbed by sleepiness during the day and insomnia at night. Along with mental indifference, there may be increased irritability and nervousness. With long-term untreated disease, a severe hypothyroid chronic psychosyndrome develops, up to psychosis, which in its structure approximates endogenous (schizophreniform, manic-depressive psychosis, etc.).

Hypothyroidism may be accompanied by certain manifestations of ophthalmopathy, but they are much less common than with thyrotoxicosis, and do not tend to progress. Usually observed periorbital edema, ptosis, refractive anomalies. Changes in the optic nerve and edema of the retina are very rare.

Disturbances in the blood are more or less found in 60-70% of patients. Achlorhydria, a reduction in absorption in the gastrointestinal tract of iron, vitamin B12 and folic acid, and suppression of metabolic processes in the bone marrow are at the heart of "thyreogenic" anemia, which can be hypochromic, normochromic, and even hyperchromic. Anemias of autoimmune genesis are associated with severe autoimmune forms of hypothyroidism; In this case, there may be both a disproteinemia and a decrease in the total protein in the blood in connection with its release from the vascular bed as a result of increased vascular permeability. Patients are prone to hypercoagulable processes due to increased plasma tolerance to heparin and an increase in the level of free fibrinogen.

The fasting blood sugar content is usually normal or slightly reduced. As a rare complication, even hypoglycemic coma are described. In connection with the slow absorption of glucose in the intestine and its utilization, the glycemic curve with the load can be flattened. The combination of diabetes mellitus and hypothyroidism is rare, usually with polyendocrine autoimmune lesions. When decompensating hypothyroidism, the need for insulin in patients with diabetes mellitus can be reduced, and in conditions of full-fledged substitution therapy - to increase.

Hypothyroidism is accompanied by an increase in the synthesis of cholesterol (its level sometimes increases to 12-14 mmol / l) and a decrease in its catabolism; inhibition of metabolism and clearance rate of chylomicrons, an increased increase in the amount of common triglycerides and triglycerides of low-density lipoproteins. However, in a number of patients, the lipid spectrum is not significantly disturbed, and the cholesterol content in the blood remains normal.

In recent years, interest has increased in the syndrome of primary hypothyroidism of galactorrhea-amenorrhoea. The level of diagnostics of this pathology and its differentiation from others, similar in many respects to the clinic, but fundamentally different in the pathogenesis of syndromes with a primary disruption of the central regulation and secretion of prolactin and gonadotropins (Chiari-Frommel syndrome, Forbes-Albright, etc.), has increased. The peculiarity of the syndrome made it possible to isolate it into a clinical form known as the Van Vika-Henness-Ross syndrome.

In 1960, JJ Van Wyk and MM Grambah reported an unusual course of primary hypothyroidism in 3 girls (7, 8 and 12 years old), combined with macromastia, galactorrhea and sexual dysfunction (premature menarche and metrorrhagia in the absence of sexual pilosis). Noting the normalization of the general condition and the regression of the symptoms of premature sexual development with a return to the pre-abortative state, the halalectomy and the restoration of the structure and size of the previously enlarged Turkish saddle, the authors proposed a pathogenetic concept of the nonspecific hormonal "cross" that has not lost its significance to this day. They also indicated a secondary mechanism of development of the pituitary adenoma with a long-term untreated mixdeem. U. Hennes and F. Ross observed the postnatal course of primary hypothyroidism with lactorrhea and amenorrhea, and sometimes metrorrhagia, but without changes in the Turkish saddle. Discussing the mechanisms of the hormonal "cross" at the level of the pituitary gland, when the decrease in the peripheral level of thyroid hormones through stimulation of TRH increases the release of not only TSH but also prolactin, the authors assumed that, along with the stimulation effect, suppression and prolactin inhibiting factor (PIF) and LH -rilling factor. The latter breaks the secretion of gonadotropins and sex hormones. In the "cross" may involve and non-traditional links, for example, hyperpigmentation due to excess melanin-stimulating hormone and metrorrhagia as a result of excess gonadotropins.

Van Vika-Henness-Ross syndrome (the authors list this sequence in chronological order) is a combination of primary hypothyroidism, galactorrhea, amenorrhea, or other disorders of the menstrual cycle with or without pituitary adenoma. In the syndrome, a juvenile version of Van Vika should be distinguished (having some age specificities, when some of the maturation parameters are ahead of age and some are absent) and postnatal variant - Henness-Ross. The "cross" syndrome testifies to the absence of a narrow specialization of both hypothalamic and hypophysial mechanisms of negative feedback. In the pituitary gland, the reserve of not only TSH, but also prolactin (PRL), as well as STH, can be dramatically increased, which is most demonstratively revealed in the trial with tiroleiberin. Obviously, this syndrome develops in patients with primary hypothyroidism when a decrease in the level of peripheral thyroid hormones leads the entire lactogenic system (TGH, TTG, PRL) into an extreme strain state. The same mechanism of combined central hyperactivity of thyrotrophs and lactotrophs by their hyperplasia and adenomatous transformation more often than in the general group of patients with primary hypothyroidism stimulates the secondary adenoma of the pituitary gland. In long-term untreated patients, the adenoma of the pituitary gland can acquire features of autonomy and not respond to either the TRH or the level of peripheral hormones. X-ray and computer-assisted scanning reveals adenomas of the pituitary gland, which in some cases extend beyond the Turkish saddle. Often there are defects in the fields of vision, mainly central (compression of the chiasma). Correction of defects in the visual fields, and sometimes regress of some radiologic symptoms of the pituitary adenoma occurs in a few months or years of thyroid therapy. The disease is provoked by pregnancy and especially childbirth with their natural physiological hyperprolactinemia and depression of the gonadotropin cycle. After childbirth, the pathological galactorrhea, caused by hypothyroidism, can be summarized, which could be hidden for a long time, and physiological, postpartum. This situation leads to the manifestation of hypothyroidism, and on the other hand, it masks the true nature of the disease, making it difficult to diagnose it timely. Postnatal and hypothyroid symptoms simulate panhypopituitarism, but the fact of lactorrhea and hyperprolactinemia excludes it.

There are no significant clinical differences between the expressed forms of primary and secondary hypothyroidism. However, the presence in the thyroid gland of the basal, non-stimulated secretion of thyroid hormones somewhat softens the clinical manifestations of secondary hypothyroidism. The classic form of secondary thyroid insufficiency is hypothyroidism in patients with postpartum pan-hypopituitarism (Shien syndrome). Thyroid insufficiency with various hypothalamic-pituitary diseases (hypophysial nanism, acromegaly, adiposogenital dystrophy) is combined with impaired growth, sexual development, abnormal fat metabolism, diabetes insipidus.

The most severe, often fatal complication of hypothyroidism is the hypothyroid coma. This complication usually occurs in elderly women with undiagnosed or long-term untreated, as well as poorly treated hypothyroidism. Provoking moments: cooling, especially in combination with hypodynamia, cardiovascular failure, myocardial infarction, acute infections, psychoemotional and muscle overload, various diseases and conditions contributing to hypothermia, namely gastrointestinal and other bleeding, intoxication (alcohol, anesthesia, anesthetics, barbiturates, opiates, tranquilizers, etc.). The most important clinical reference points: dry, pale yellow, cold skin, sometimes with hemorrhagic eruptions, bradycardia, hypotension, sharp breathing, oliguria, decrease and even disappearance of tendon reflexes. Hypothyroid polyserositis with accumulation of fluid in the pericardium, pleura and abdominal cavity associated with the most severe forms of hypothyroidism, combined with true cardiovascular insufficiency, rarely observed with hypothyroidism and more often with coma, create certain differential diagnostic difficulties. Laboratory tests reveal hypoxia, hypercapnia, hypoglycemia, hyponatremia, acidosis (including by increasing levels of lactic acid), high cholesterol and lipid spectrum disorders, an increase in the hematocrit and blood viscosity. Critical to the diagnosis may be low levels of thyroid hormones (T ₃, T ₄ ) in the blood and high - TSH, but the urgent implementation of these studies is not always possible.

[1], [2], [3], [4], [5], [6], [7]