Thyroid Disease Facts

Thyroid Disease Facts
By:Jeffrey Medland
Lt Col, USAF, MC, SFS
Chief, Endocrinology
MGMC, Andrews AFB, MD
Capital Conference-June 2007

Outline
* Thyroid Testing
* Hypothyroidism
o Causes
o Signs/symptoms
o Treatment
* Hyperthyroidism
o Causes
o Signs/symptoms
o Treatment
* Thyroid Nodules/ Cancer
* Thyroid Disease and Pregnancy
o Hypothyroidism
o Hyperthyroidism (Hyperemesis Gravidarum, Graves’)
o Thyroiditis
* Factors affecting Thyroid function, LT4

Thyroid
Colloid
Apical Membrane
Basal Membrane
Thyroid Peroxidase (TPO)
“Iodination Reaction”
“Coupling Reaction”

Thyroid Testing
* TSH
o Best test for screening for thyroid dysfunction!
o Log/linear response w/ FT4
+ A 2-fold change in FT4 produces a 100-fold change in TSH
o Not specific for a particular thyroid disease.
+ Don’t use TSH alone for diagnosis!
o Also useful in
+ Assessing LT4 tx in 1° hypothyroidism
+ Monitoring TSH-suppressive tx in thyroid Ca
* FT4
o Testing methods:
+ Equilibrium dialysis
+ Analog assays
o Abnormal TSH check this next
o Indications:
+ In conjunction w/ TSH for diagnosing hyperthyroidism or hypothyroidism.
+ Monitoring LT4 replacement in central hypothyroidism (TSH not helpful)
+ Assessing response to tx following 131-RAIA (Graves, toxic nodules)
+ Monitoring ATD tx in pregnant females
* FT3
o Abnormal TSH + normal FT4, then check this (T3 Thyrotoxicosis)

Pituitary Hypothyroidism
Subclinical Hyperthyroidism, Autonomous nodules
Thyrotoxicosis, Thyroiditis (stage 1)
Pituitary Hyperthyroidism
Subclinical Hypothyroidism
Primary Hypothyroidism, Thyroiditis (stage 3)
Clinical Status
FT4
Overview of Thyroid Function Tests
* Thyroid Antibodies (TPO, Tg, TSI, TRAb)
* Thyroglobulin (Tg)
* Radioactive Iodine Uptake and Scan (RAIU/Scan)
* Tc99m-Pertechnetate Scan
* Fine Needle Aspiration (FNA)
* Ultrasound
* Calcitonin

Hypothyroidism
Thyroiditis
Hypothyroidism (Treatment)
Hypothyroidism (treatment in general)
Indications for LT4 replacement
Hypothyroidism + surgery
Hypothyroidism + elderly
Combined LT4/LT3 tx
Hyperthyroid Eye Disease
Does131-RAIA worse ophthalmopathy?
Graves’ Dermopathy Thyroid Dermopathy
Thyroid Acropachy
RAIU/Scan
Increased RAIU
Decreased RAIU
Surgery (sub-total thyroidectomy)
Apathetic Hyperthyroidism
Thyroid Storm
Subclinical Hyperthyroidism
Thyroid Nodules
Red Flags concerning for Cancer
FNA Results:
Thyroid Nodules “Mimickers”
Thyroid Cancer
MTC
Thyroid Disease in Pregnancy
Four factors alter thyroid function in pregnancy
1) Transient ↑ in hCG, during the 1st trimester can stimulate the TSH-R
2) E2-induced ↑ in TBG during the 1st trimester, which is sustained during pregnancy.
3) Alterations in immune function leading to onset, exacerbation, or amelioration of an underlying autoimmune thyroid disease.
4) urinary iodide excretion, which can cause impaired thyroid hormone production in areas of marginal iodine deficiency (<50 µg/d).
Known Hypothyroidism already on LT4
Stage 1 to 4
Hyperemesis Gravidarum (HG)
Hyperemesis Gravidarum vs. Graves’
Causes of Increased LT4 requirement
Drugs Affecting Thyroid Function
Somatostatin, Glucocorticoids
Dopamine
Amiodarone Effect on Thyroid Function
Amiodarone and the Thyroid
Iodine Effect
Direct Toxic Effect
* Thyroiditis (AIT type 2)
“Innocent Changes”
Jod-Basedow phenomenon (Historical)
* Definition- Hyperthyroidism induced by excess Iodine.
* Coindet (French physician) in 1821 published his cases about Hyperthyroidism.
* In the English speaking world this became known as Graves’ disease (1835), and in the German speaking world as von Basedow’s disease (1840).
* Coindet’s cases of hyperthyroidism were actually Iodine-induced, hence it came to be known as the Iodine-Basedow phenom.
* Jod is German for Iodine, hence the Jod-Basedow phenom!
* Coindet was deprived of credit for not only describing Hyper- thyroidism, but also the variant of hyperthyroidism caused by excess Iodine
* The credit was given to Dr “Jod” who never existed!

Conditions affecting Thyroid Function
Autoimmune Polyglandular Syndromes 2
Hypokalemic Periodic Paralysis
Hyperthyroid Eye Disease
Cutis Aplasia
Cutis Aplasia Keloid
Cutis Aplasia
Thyroid Binding Globulin (TBG)
Increased TBG
Decreased TBG
Thyroid Regulation
Amiodarone the Thyroid
Amiodarone Effects on Thyroid
Thyroid Hormone
* There is no absorption from the stomach. Absorption occurs in the small bowel.
* The main absorptive sites appear to be the proximal and mid-jejunum.
* Progressively decreasing degrees of absorption occur along the distal bowel and proximal colon.
* Hypothyroidism can lead to a slight increase in absorption.

Thyroid Disease Facts.ppt

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Osteoporosis

Osteoporosis
Capital Conference 2007
By:Marc Childress, MD

Osteoporosis
* Epidemiology
* Risk Factors
* Prevention
* Screening
* Diagnosis
* Treatment
* Osteoporosis in Men
* Management
* Falls
* Acute Complications

Osteoporosis
* Average female bone mineral density peaks at age 35, slow decline thereafter
* Density loss is accelerated post-menopausally

Epidemiology
Risk Factors
Predisposing Medical Conditions
* Estrogen Deficiency
* Inflammatory Bowel Disease
* Type 2 Diabetes Mellitus
* Celiac disease
* Cystic fibrosis
* Hyperthyroidism
* Hyperparathyroidism
* Hypogonadism
* Liver Disease
* Corticosteroid use
* Heparin use
* Cyclosporine use
* Depo-Provera use
* Vitamin A (systemic retinoid) use
* No clear increase in risk with carbonated beverages
* Chronic excess thyroid hormone replacement
* diffuse nontoxic goiter
* osteoarthritis
* osteoporosis
* hyperparathyroidism
* Addison’s disease
* Hypothyroidism
* Osteogenesis imperfecta
* Anticonvulsive medication

Prevention
* Adequate total dietary calcium
* Vitamin D
* Regular weight-bearing exercise
* Additional protective factors: increased BMI, African-American ethnicity, moderate EtOH intake
* Which of the following antihypertensives agents may help preserve bone mineral density?
* Atenolol (Tenormin)
* Doxazosin (Cardura)
* Enalapril (Vasotec)
* Hydrochlorothiazide
* Nifedipine (Procardia, Adalat)
* Which one of the following is associated with a reduced risk of post-menopausal osteoporosis?
* Corticosteroid use
* Cigarette smoking
* Diuretic use
* Low BMI
* Asian Ethnicity
Screening
* USPTF/AAFP— “routine screening” above the age of 65, consider between 60-65 for increased risk
* National Osteoporosis Foundation—recommend screening above 65, or in younger with risk factors
* Difficulty with recommendations
Screening Options
* Single Photon absorptiometry
* Dual Photon absorptiometry
* Dual X-ray absorptiometry (DEXA)—MOST POPULAR
* Quantitative CT
* Ultrasound

Diagnosis
Treatment
* Raloxifene (Evista)
* is used to manage hot flashes
* increases bone density
* stimulates breast tissue
* stimulates endometrial proliferation
* raises LDL and total cholesterol levels

Osteoporosis in Men
Chronic Management
Falls
Acute Complications

Osteoporosis.ppt

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Infertility

Infertility
By:Stephanie R. Fugate D.O.
Dewitt Army Community Hospital
Department of OB/GYN

Objectives
* Define primary and secondary infertility
* Describe the causes of infertility
* Diagnosis and management of infertility

Requirements for Conception
* Production of healthy egg and sperm
* Unblocked tubes that allow sperm to reach the egg
* The sperms ability to penetrate and fertilize the egg
* Implantation of the embryo into the uterus
* Finally a healthy pregnancy

Infertility
* The inability to conceive following unprotected sexual intercourse
o 1 year (age < 35) or 6 months (age >35)
o Affects 15% of reproductive couples
+ 6.1 million couples
o Men and women equally affected
* Reproductive age for women
* With the proper treatment 85% of infertile couples can expect to have a child
* Health problems develop
* SAB
* Primary infertility
* Secondary infertility

Conception rates for fertile couples
Age and Pregnancy
Pregnancy
Age and related miscarriage
Causes for infertility

* Male
o ETOH
o Drugs
o Tobacco
o Health problems
o Radiation/Chemotherapy
o Age
o Enviromental factors
* Female
o Age
o Stress
o Poor diet
o Athletic training
o Over/underweight
o Tobacco
o ETOH
o STD’s
o Health problems

* Anovulation (10-20%)
* Anatomic defects of the female genital tract (30%)
* Abnormal spermatogenesis (40%)
* Unexplained (10%-20%)

Evaluation of the Infertile couple
* History and Physical exam
* Semen analysis
* Thyroid and prolactin evaluation
* Determination of ovulation
o Basal body temperature record
o Serum progesterone
o Ovarian reserve testing
* Hysterosalpingogram

Abnormalities of Spermatogenesis
Male Factor
Semen Analysis (SA)
* Obtained by masturbation
* Provides immediate information
o Quantity
o Quality
o Density of the sperm
* Abstain from coitus 2 to 3 days
* Collect all the ejaculate
* Analyze within 1 hour
* A normal semen analysis excludes male factor 90% of the time
* Morphology
* Motility

Normal Values for SA
Volume
Sperm Concentration
Motility
Viscosity
Morphology
pH
WBC

Causes for male infertility
Abnormal Semen Analysis
* Azospermia
* Oligospermia
* Abnormal volume

Evaluation of Abnormal SA
* Repeat semen analysis in 30 days
* Physical examination
o Testicular size
o Varicocele
* Laboratory tests
o Testosterone level
o FSH (spermatogenesis- Sertoli cells)
o LH (testosterone- Leydig cells)
* Referral to urology

Evaluation of Ovulation
Menstruation
* Ovulation occurs 13-14 times per year
* Menstrual cycles on average are Q 28 days with ovulation around day 14
* Luteal phase
* Progesterone causes
* Involution of the corpus luteum causes a fall in progesterone and the onset of menses
Menstrual Cycle
Ovulation

* A history of regular menstruation suggests regular ovulation
* The majority of ovulatory women experience
o fullness of the breasts
o decreased vaginal secretions
o abdominal bloating
* Absence of PMS symptoms may suggest anovulation
o mild peripheral edema
o slight weight gain
o depression

Diagnostic studies to confirm Ovulation
* Basal body temperature
o Inexpensive
o Accurate
* Endometrial biopsy
o Expensive
o Static information
* Serum progesterone
o After ovulation rises
o Can be measured
* Urinary ovulation-detection kits
o Measures changes in urinary LH
o Predicts ovulation but does not confirm it

Basal Body Temperature
* Excellent screening tool for ovulation
o Biphasic shift occurs in 90% of ovulating women
* Temperature
o drops at the time of menses
o rises two days after the lutenizing hormone (LH) surge
* Ovum released one day prior to the first rise
* Temperature elevation of more than 16 days suggests pregnancy

Serum Progesterone
* Progesterone starts rising with the LH surge
o drawn between day 21-24
* Mid-luteal phase
o >10 ng/ml suggests ovulation

Anovulation Symptoms Evaluation
* Irregular menstrual cycles
* Amenorrhea
* Hirsuitism
* Acne
* Galactorrhea
* Increased vaginal secretions
* Follicle stimulating hormone
* Lutenizing hormone
* Thyroid stimulating hormone
* Prolactin
* Androstenedione
* Total testosterone
* DHEAS
* Order the appropriate tests based on the clinical indications

Anatomic Disorders of the Female Genital Tract
Sperm transport, Fertilization, & Implantation
* The female genital tract is not just a conduit
o facilitates sperm transport
o cervical mucus traps the coagulated ejaculate
o the fallopian tube picks up the egg
* Fertilization must occur in the proximal portion of the tube
o the fertilized oocyte cleaves and forms a zygote
o enters the endometrial cavity at 3 to 5 days
* Implants into the secretory endometrium for growth and development

Acquired Disorders
* Acute salpingitis
* Intrauterine scarring
* Endometriosis, scarring from surgery, tumors of the uterus and ovary
* Trauma

Congenital Anatomic Abnormalities
Hysterosalpingogram
* An X-ray that evaluates the internal female genital tract
* Performed between the 7th and 11th day of the cycle
* Diagnostic accuracy of 70%

Hysterosalpingogram
* The endometrial cavity
* Fallopian tubes
* Dye should spill promptly

Unexplained infertility
Treatment of the Infertile Couple
Inadequate Spermatogenesis
Clomid
Superovulatory Medications
Anatomic Abnormalities
Assisted Reproductive Technologies (ART)
Emotional Impact
Conclusion
Test Question Case
Causes for Abnormal SA
* No sperm
o Klinefelter’s syndrome
o Sertoli only syndrome
o Ductal obstruction
o Hypogonadotropic-hypogonadism
* Few sperm
o Genetic disorder
o Endocrinopathies
o Varicocele
o Exogenous (e.g., Heat)
Abnormal Count
* Abnormal Morphology
o Varicocele
o Stress
o Infection (mumps)
* Abnormal Motility
o Immunologic factors
o Infection
o Defect in sperm structure
o Poor liquefaction
o Varicocele
* Abnormal Volume
o No ejaculate
+ Ductal obstruction
+ Retrograde ejaculation
+ Ejaculatory failure
+ Hypogonadism
o Low Volume
+ Obstruction of ducts
+ Absence of vas deferens
+ Absence of seminal vesicle
+ Partial retrograde ejaculation
+ Infection

Infertility.ppt

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